From history’s earliest civilizations to today societies have been faced with balancing

From history’s earliest civilizations to today, societies have been faced with balancing the medicinal properties of opiates in treating pain with the euphoric effects that have induced its misuse and abuse. Myths and misunderstandings about opioids run rampant in our society with many considering it a controversial subject. Opiates are considered to be among the oldest medications available to mankind, dating back to its initial use for relief of dysentery-induced diarrhea, which was a common problem in the early days (Webster et al., 2017). However, over the years, opiates have become available as means of treating a range of medical problems, with pain being the foremost and current focus. This paper will aim to look at the evolution and manifestation of opioids and their impact on the Canadian population, as well as conventions to control the opioid epidemic. Background Information The “natural” source of opiates was first referenced in 3400 BC in lower Mesopotamia where it was cultivated from the opium poppy and was popularly known as the “Joy plant” (Michael’s House Treatment Centers, 2019). From here on, opium was spread through countries in Europe, Asia and North America to be used as a cure for a wide variety of illnesses and psychological problems. Finally, in 1806 a German scientist by the name of Friedrich Sertürner isolated a chemical substance from opium, which he called “morphine” (Michael’s House Treatment Centers, 2019). Soon after this were the years preceding the time of the Civil War, which came the invention of the hypodermic needle. This invention permitted morphine to be administered parenterally and was commonly used as a pain killer by many soldiers (Pasternak & Pan, 2013). This led morphine becoming the mainstay of many North American doctors for treating pain, anxiety and respiratory problems. However, this was also the first time that the addictive side of opioids were really noticed, as many soldiers became dependent on morphine post war, and this addiction was commonly referred to as the soldier’s disease (Pasternak & Pan, 2013). Following this, around 1900, heroin was synthesized as a derivative of morphine and was offered as a “non-addictive” substitute in place of morphine. Heroine was commonly being supplied as a cough suppressant, however, the dependence and euphoric activity of heroine were quickly realized and by 1916 the mass production of heroin was stopped (Jones et al., 2018). Along with this, different policies and Acts were put in place such as the Harrison Narcotics Act in the USA that made opioids available only by prescription to limit recreational use (Jones et al., 2018). As well, international treaties limiting opioid trafficking were instituted. Moving forward, from the 1920s to late the 1980s, strong stigmas and increasing fears associating with opioid addiction led to the practice of only prescribing opioids to the dying for acute pain, rather than chronic pain (Webster et al., 2017). Most doctors turned their attention to surgeries such as nerve-blocking operations and other non-pharmaceutical methods in an attempt to relieve chronic pain (Webster et al., 2017). This period of era become to known as the “opiophobia” in which clinicians believed the following: (1) tolerance would lead to decreasing efficacy; (2) resulting dose increase would produce dependence or addiction; (3) opioids would impede functional rehabilitation, and were thought to promote regression in chronic use (Webster et al., 2017). However, the pendulum swung by 1990s as a result of the gowning demands and advocacy for the need of pain management and a significant increase was seen in opioid use for all types of pain. This eventually led to the wave of the opioid epidemic due to the fact that opioids were becoming readily available and prescribed liberally (Pasternak & Pan, 2013). Over the next few years and currently, the use of opiates has increased, in most areas of the world their addictive and euphoric properties have become popular and very apparent combined with significant abuse. At the same time, research has grown exponentially, and many counties are trying to adapt regulations and policies to meet growing concerns surrounding the evolution and manifestation of opioids as well as conventions to control this epidemic. Local Impact Statistics on opioid-related harms and deaths show that the opioid crisis is affecting individuals from all walks of life and all across Canada. At a national level, Canada the highest prescription opioid (PO) consumption in the world and is among the many countries that are in the midst of an opioid crisis (Opioid-Related Harms in Canada | CIHI, 2019). From January 2016 to March 2018, nearly ten people have died on average each day due to an illicit drug overdose, and opioid poisoning hospitalization rates have increased 27% over the past 5 years, resulting in an average of 17 hospitalizations each day (Government of Canada, 2018). According to the Public Health Agency of Canada, in 2017, a total of 3,996 Canadians died from an apparent opioid-related overdose and 2,066 deaths have resulted between January and June 2018; 94% were accidental overdoses where as 72 per cent involved fentanyl-related substances (Public Health Agency of Canada, 2018). In addition to this, opioid poisonings have a stronger impact on small and suburban communities with a population size of 50,000 to 99,999 (Public Health Agency of Canada, 2018) In 2017, opioid poisoning hospitalization rates in smaller communities were almost 2.5 times higher than rates in Canada’s largest cities (Public Health Agency of Canada, 2018). At a reginal level, data from public health Ontario has shown a steady increase in opioid related harms in Ontario for more than a decade. The number of deaths in Ontario residents has increased by almost 246 percent since 2013 and continues to do so as seen by figure 1.0 (Ontario Agency for Health Protection and Promotion, 2019).Figure 1.0 shows cases of opioid-related morbidity and mortality in Ontario, Canada from 2003 to 2017 (Ontario Agency for Health Protection and Promotion, 2019). In 2017 alone, 1250 Ontarians died from opioid-related causes and an increase of 73 % was seen in opioid poisoning hospitalization from which most were males between the ages of age 25 to 44 (Government of Canada, 2018). More specifically, data from January to June 2018 reveal that the 71% of suspected overdoses were among and the most common among individuals between the ages of 20 and 29 years (32%) and those 30 to 39 years (30%) (Government of Canada, 2018).Figure 2.0 represents the cases of opioid-related ED visits by age group and gender in Ontario, Canada 2017(Ontario Agency for Health Protection and Promotion, 2019).Although, opioid crisis affects all parts of Ontario, smaller more northern communities are more susceptible and substantially face higher risks of opioid overdoses (Government of Canada, 2018). This is due to a number of factors that go hand in hand with social determinants of health’s such as lower employment rates, higher poverty and lack of education. Often overlapping, Northern Ontario (NO) and First Nations communities in Ontario have extremely higher rates of prescription opioids misuse compared to non-first-nation and non-Northern counterparts (Sullivan, 2012). The well-known history of colonization, oppression, loss of culture and the resulting intergenerational trauma experienced by many First Nations individuals has had a significant impact on their wellbeing both physically and mentally, especially when it comes in terms to substance abuse (Sullivan, 2012). According to statistics provided by Canadian Research Initiative in Substance Misuse (CRISM), 26.4% of people in NO reported use of prescription opioids, which was significantly higher than the Ontario average of 22.2% (CRISM Ontario, 2016). In addition to this, the average Ontario opioid prescribing rate per 1,000 public drug plan recipients (ages 15-64) was 11,6105, in comparison, this number was much smaller to the 12,671-27,484-prescription rate for the North East (NE) Local Health Integrated Network (LHIN) and 12,240-42,201 for the North West (NW) LHIN (CRISM Ontario, 2016). According to the Non-Insured Health Benefits program, first nations in Ontario were prescribed more prescription opioids than the Ontario population in 2007; for every 1,000 Ontario FN, 898 POs were prescribed, in comparison to 756 POs for every 1,000 Ontarian respectively (CRISM Ontario, 2016).Figure 3.0: shows the rates of opioid-related emergency visits; all ages and all sexes in Ontario, Canada 2017 (Ontario Agency for Health Protection and Promotion, 2019). The Role of Public Health In the past couple of years, several measures to address the emerging opioid crisis have been initiated by Canadian authorities in healthcare politics. For example, in 2010, recommendations for prescribing practices in the Canadian guideline for safe and effective use of opioids were presented by the National Opioid Use Guideline Group, however, most of these recommendations were “softly phrased” suggestions rather than strict parameters that were to be followed (Fischer et all., 2016). In addition to this, almost all recommendations supported prescribing opioids with the use of a screening tool, monitoring analgesic effectiveness and trying a different opioid, with the very little material or direction about when not to prescribe or when to limit doses or durations (Fischer et all., 2016). Regardless, one thing that did come out of this and was beneficial to the society was that in some provinces such as Ontario, a prescription monitoring system was put in place (Fischer et all., 2016). This ensured a more secure and safe platform for dispensing narcotics and other controlled substance medications. Awareness surrounding opioids has always lacked since beginning of its time, but is coming more and more into play through media and public awareness campaigns. Currently, several programs have been put in place to meet growing concerns surrounding opioids, including greater scrutiny and laws limiting opioid doses during the first week of acute pain management. In addition to this, both at a federal and provincial level better addiction prevention, treatments, and recovery services are coming to the forefront. Recently, in 2016, naloxone which is a drug used to temporarily reverse the effects of an opioid overdose, was removed from the Prescription Drug List for emergency use outside hospital settings and has been approved to be readily available without prescription and for free through pharmacies, community organizations and provincial correctional facilities (CCSA-Canadian-Drug-Summary-Prescription-Opioids, 2017). In June 2017, Canada also approved the Canadian authorized version of Narcan; which is a naloxone nasal spray (CCSA-Canadian-Drug-Summary-Prescription-Opioids, 2017). Moreover, at a regional level, Ontario also recently announced delisting of high-strength opioid formulations from the provincial formulary, and increased access to pharmacotherapy with buprenorphine/naloxone and naloxone availability (Webster et al., 2017). Moreover, a huge focus for the last couple of years in regards to this arising epidemic has been on harm reduction strategies such as medication-assisted treatments (MATs) including medication like buprenorphine, methadone, and extended-release naltrexone (Centre for Addiction and Mental Health, 2016). Most often these medications help to reduce opioid cravings by blocking euphoria and withdrawal symptoms so the brain recovers from the addiction (CRISM Ontario, 2016). In most larger cities, methadone maintenance therapy is used as MAT. However, due to lack of physicians in remote first nations and Northern communities, this therapy is often not available and instead suboxone, a combination of buprenorphine and naloxone is offered as an alternative in these communities (CRISM Ontario, 2016) Other harm reduction strategies and programs include: (1) Needle exchange program in which free sterile harm-reduction supplies are available over 370 distribution points across Ontario and (2) fentanyl patch for patch program in which the law requires pharmacies to collect used fentanyl patches from a patient before dispensing new patches to the patient (Government of Ontario, 2018). Lastly, the federal Budget for 2018 set aside $231.4 million to tackle the opioid epidemic, with $150 million going to the provinces and territories to fight the overdose crisis (Russel, 2018)Conclusion:The rapid evolution, and the rise of the current opioid epidemic with prescription opioids and the use of illicit opioids has gained national attention. The opioid epidemic started in part from a multifaceted history of numerous industries trying to balance acceptable and vital treatment of pain against the misuse and abuse of opioid medications. Over the previous decade, a strong practice was seen associated with high-dose dispensing of prescription opioids resulting in an elevated risk of adverse outcomes and a very rapid overreliance on them. While adequate pain control is a significant health problem and an important priority, there is still efforts needed to titrate opioid use and to increase the use of multimodal pain regimens. Even though, research and support programs to control this epidemic have grown exponentially over the years, from development of the prescription monitoring system for Narcotics to approved naloxone nasal spray availability without prescription. I still think it is critical that we continue to raise awareness of the risks associated with problematic opioid use, underscoring that this crisis continues to affect Canadians of all ages, from all backgrounds. One way to raise awareness and reducing abuse rates is the deployment of programs of community education and training of health professionals, such as doctors, nurses, pharmacists, administrators and most importantly the patient himself. Patient education is a key in that they know the risks associated, and that no one else such as a child has access to their medication, as well the patient needs to know how the physiology of their medication works so they’re able to “stay ahead” of the pain without taking more than necessary. As a society, we must take mutual ownership of the opioid epidemic and understand how each of us can make a difference by being aware of critical points of intervention. This can be as simple as having a conversation about opioid use and misuse with your family and friends to identify the risk factors that are associated in your home and community.

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