Understanding Addiction

This article was written by Sorcha DeHeer

The increasing availability of deadlier, synthetic opioids such as fentanyl and fentanyl analogues in Canada has created a complex national health crisis. Current preventative measures and treatment options are no longer sufficient tools to combat the crisis. In order to prevent a further crisis, it is necessary to shift away from the “war on drugs” method to a “social determinants of health” model. 

The federal government of Canada has labelled the opioid crisis a national health emergency. Between 2016 and 2019, 12,800 deaths resulted from apparent opioid use. While Canada has experienced drug epidemics before, the introduction of fentanyl and fentanyl analogues has shifted the dynamic.

Fentanyl is a potent opioid prescribed primarily in a hospital setting to control severe pain. Fentanyl is 50-100 times stronger than morphine, heroin and oxycodone—drugs that dominated previous epidemics. The strength of fentanyl means that a few salt-sized grains can cause a fatal overdose. The amount of fentanyl or fentanyl analogues in street drugs often varies, furthering the likelihood of overdose.

Up to 94 percent of overdoses in Canada happen by accident, with youth ages 15-24 becoming the fastest-growing demographic. The creation of fentanyl analogues; synthetic versions of the opioid, has led to a lucrative illegal market. The drug is cheap to produce because such small amounts are needed. In 2018, fentanyl was found in 85 percent of illicit drug overdose deaths in British Columbia. The illegal drug trade is a massive issue; however, its dissolution would not lead to meaningful long-term change. 

All activities and consumable goods can be addictive and lead to devastating consequences. Cigarettes, alcohol, gambling and are all examples familiar to Canadians, yet they have not equated the status of crisis in the same way opioids have. The main reason for this is the increasing deadliness of natural and synthetic opioids.

A secondary factor is visibility. The aforementioned activities have been granted a certain level of social acceptability. The over-prescription of opioids by medical practitioners has played a large part in the development of the crisis. Between 1980 and 2000, the volume of opioids being sold to Canadian hospitals rose 3000 percent. From 2000 to 2011, the dispensing rate rose 23 percent. Opioids are prescribed predominantly for chronic and acute pain management in patients as young as 10 years old.

The prescription of opioids doesn’t appear to be declining, since 1 out of 7 people in Ontario filled an opioid prescription in the 2015-2016 fiscal year. This does not count the number of prescriptions that were not filled. The availability of legal opioids further illustrates the widespread nature of the drug crisis. Opioids accumulate in the brain, making it necessary to consistently increase the dose in order to manage pain. When stopped, however, the patient can experience increased sensitivity to pain. This increased sensitivity is called Hyperalgesia and can lead to dependence within 10 days of use.

The solution to the opioid crisis cannot be fixed easily or quickly. It will require an evidence-based approach that focuses on the root cause of the problem, taking into account various socioeconomic factors such as race, class and cultural difference. Opioid addiction is considered a “lifelong chronic condition.” Like any other chronic condition, there is no cure for it. Temporary treatment options like detox and rehabilitation are necessary parts of recovery but will be unsuccessful at preventing relapse. 

In order to effectively tackle addiction, the root cause must be addressed. Acclaimed scholar Doctor Gabor Mate coined the phrase, “it’s not why the addiction, but why the pain.” Recent scholarship has overwhelmingly argued that the underlying conditions that lead to addiction relate to mental, emotional, physical and social trauma. These issues disproportionately affect racialized, minority, and impoverished groups;however, the white, suburban classes in Canadian society are not exempt.

In British Columbia, 66 percent of individuals who died from a drug overdose were employed within the past five years.The “social determinants of health (SDOH)” model integrates income and social status; social support networks; education; employment/working conditions; social environments; physical environments; personal health practices and coping skills; healthy child development; gender; and culture.

Due to stigma and a lack of adequate resources, an individual with Substance Abuse Disorder is likely to experience a further degeneration of health; making it harder to recover. Canadian reports show that in 2013, 90 percent of women in treatment for substance use experienced trauma in the past. Two forms of trauma must be addressed in relation to the Opioid crisis; trauma that occurred before drug use and trauma that occurred after experiencing Substance Abuse Disorder.  

The Center of Addiction and Mental Health notes that “getting rid of the idea that people choose to become addicted is an important step in understanding and helping people with addictions.”  Substance use is only one example of the many negative coping mechanisms used by individuals who have experienced trauma. Effective, affordable and accessible mental health services are crucial in preventing or curbing addictive behaviours. Access to mental health services is impacted by race, geographic location and class.

In 2018, 2.3 million Canadians reported not being able to have their mental health needs met, with Ontario and British Columbia having higher numbers than national averages. The Center for Addiction and Mental Health lists income as the primary barrier to accessing mental health services, through a primary care provider or otherwise. Services provided to low-income individuals are often understaffed and underfunded, making wait times long and staff stretched thin. Additional barriers to access are lack of knowledge and language fluency.

Another significant barrier to mental health services in Canada is location. Rural communities continue to lack the same resources as their urban counterparts. The situation is even worse for those living on reserves or in the territorial north.  Culturally appropriate services for Indigenous Peoples are lacking throughout the country. Western methods of addressing mental health issues can lead to misdiagnosing, inaccessibility, and improper treatment methods.  

All of the previously mentioned barriers to mental health services and primary care services are felt disproportionately by the homeless population. In Toronto, 30 percent of homeless individuals reported experiencing discrimination when attempting to access mental health services. The stigma associated with poverty and homelessness can worsen pre-existing mental health problems, increasing the likelihood of developing a Substance Abuse Disorder.  Homeless Indigenous Peoples are further removed from their communities and traditions. “Addiction cannot be understood from an isolated perspective.

It is a complex human condition, a condition rooted in the individual experience of the sufferer and also in the multi-generational history of his or her family and—not least—also in the cultural and historical context in which that family has existed. The ongoing processes of colonialism have negatively impacted the health of Indigenous communities. Intergenerational trauma relating to residential schools continues to have an impact on mental health. Stigma, racism and the loss of culture has led to social isolation, homelessness, unemployment, stress in early life, and addiction.  

Mental health is a large factor to consider when addressing addiction, however, it is not always the case. Social determinants of health focus on community and social engagement as the key to weathering hardships. Social isolation is a common feeling among youth, but can also be the result of racial stigma, previous history of substance use and living in unsafe or isolated communities. Individuals with close family structures were seen to better cope with hardships such as economic downturn, depression and substance use.

Substance Abuse Disorder, as well as homelessness, can cause social isolation, further damaging an individual’s likelihood of recovery. Individuals who developed Substance Abuse Disorder after being prescribed legal opioids can lose connections or become isolated as a result. The Lethbridge Supervised Consumption Site offers programs that help their clients build and maintain meaningful relationships without the social stigma generally associated with opioid use. 

As previously noted, the economy can have a drastic impact on people’s health. Stress, depression and anxiety are common consequences of economic hardship, and can all contribute to substance use. Unemployment can also lead to homelessness, stigma, and strain familial relationships.

A need for a Lethbridge supervised consumption facility was recognized in 2017, not long after Alberta’s unemployment rates climbed dramatically higher than the rest of the country. Alberta’s economy has failed to completely recover following the oil crash. Even in 2015, Alberta reported 27.3 opioid-related emergency department visits per 100,000 people, compared to only 17.4 in Ontario. While a variety of factors outside of the economy will influence substance use, continued hardships could lead to an increase in substance use.

Treatment options must take into consideration socioeconomic status, homelessness, familial attachment, education, and resiliency. The Canadian Centre on Substance Use and Addiction recommends that treatment be individualized to account for these factors. Treatment options are in need of expansion, from the number of intox and detox beds to the availability of methadone or suboxone.

Social supports for opioid agonist therapy is also an important aspect to consider. Community connection and skill development programs will be important areas to consider when looking at the long-term health and success of recovering people. People with regular health care providers are more likely to access mental health services. Not having time or being able to afford to go means there need to be greater concessions for paid time off work.

Safe Consumption Facilities are crucial to saving lives on a front-line basis while helping them access additional services. In order to effect long term change however, substance users must have access to treatment services that go beyond detox. Long term mental health services are necessary after detox or rehab in order to address the root causes of substance use and help deter the patient from relapsing. For individuals suffering from homelessness, dignified housing and employment services should also be a top priority. 

The Center for Addiction and Mental Health (CAMH) discusses the role of primary care practitioners in helping manage substance abuse, especially before it becomes an addiction (or Substance Abuse Disorder). CAMH found that physicians reported improved practice and lower dependence on pharmaceutical treatments when they received mental health training. Stigma can also be a large barrier for individuals accessing primary care services. In Toronto for example, 30 percent of people reported discrimination based on homelessness and poverty and 15 percent from race or ethnicity. Individuals using opioids are likely to experience additional stigma and misunderstanding from physicians. 

The problem has reached every demographic in Canada and will require a comprehensive, coordinated effort and continued support by incoming governments. Large scale changes to federal laws and programs will take years to successfully institute, not counting time allotted for further research. The areas that need to be addressed are stigma, housing, overall health and prescription opioid availability. The overarching barrier to accessing any form of service is stigma. Dr. Gabor Mate asserts that “a core assumption in the War on Drugs is that the addict is free to make the choice not to be addicted and that harsh social or legal measures will deter him from pursuing his habit.” 

University of Lethbridge students who may be struggling with substance abuse or mental health can get help at the following locations:

• Mental health: Visit us in SU020 or call 403-329-2484 and we will book you a 20-minute consultation with one of our Physicians to talk about what you’re going through so we can better understand your concerns and care needs. A mental health assessment might be completed with the Health Centre Registered Nurse if requested by the Physician.  A follow up appointment will be scheduled with the Physician to go over the results and discuss a mental health care plan.
• University of Lethbridge Health Centre (Phone: 403-329-2484 Email: health.centre@uleth.ca)
• University of Lethbridge-Emergency on Campus (Security). Phone: 403-329-2345 or 2345 from an on-campus telephone
• Alberta Health Services (AHS) Lethbridge Adult Addiction and Mental Health Community Clinic (403-381-5260) or visit albertahealthservices.ca. 
• Therapy Assistance Online at uleth.ca/counselling/therapy-assist-online-tao.

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