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A woman holds a photo of her best friend, who died of a drug overdose in January 2017, before a march to draw attention to the opioid overdose epidemic, in the Downtown Eastside of Vancouver, B.C. (THE CANADIAN PRESS/Darryl Dyck)

How to stop overdoses? Prevent them to begin with

The Public Health Agency of Canada recently released projections that 2017 will have seen a total of more than 4,000 opioid-related deaths.

This is a catastrophic increase from the 2,861 deaths across Canada in 2016. And it confirms, tragically, that the public health emergency of fatal and non-fatal overdose and drug poisoning continues to take an unprecedented human toll across Canada.

Drug deaths are dramatically outpacing anything we have seen before. For example, British Columbia, the province hardest hit by the crisis, recorded 1,208 lives lost from January to the end of October 2017. This is an increase of 77 per cent over the same period in 2016, and 200 per cent over 2015.

And British Columbia is not alone in these dramatic increases: Data from Ontario report 336 opioid-related deaths from May to July this year, a 68 per cent increase over the same period in 2016.

Laudable responses have rightly focused on immediate health outcomes such as reversing overdoses amid a drug supply contaminated with fentanyl or fentanyl analogues such as carfentanil.

To build a truly effective response to the crisis, however, Canada must also address the socio-economic factors linked to overdose risk — including homelessness and housing insecurity, insufficient support following release from prison, severe poverty and low educational attainment.

Life-saving measures

Nationally, the percentage of all overdose deaths involving fentanyl has risen to 74 per cent in 2017 from 53 per cent in 2016.

These increases seem likely to continue unless we legalize and regulate the drugs at the centre of the crisis. This would allow people to access information about drug potency and purity, but the federal government explicitly does not support decriminalization.

A Naloxone anti-overdose kit. (THE CANADIAN PRESS/Jonathan Hayward)

In this context, other life-saving responses — including supervised consumption and overdose prevention facilities, drug testing, the distribution of overdose-reversing Naloxone and access to injection and non-injection opioid-assisted treatment — are all expanding. All are crucial in reducing death from overdose.

It is difficult to fathom the size of the death toll if these measures were not in place.

The good news is that not a single one of the 108,804 visits to the first Overdose Prevention Site on Vancouver’s Downtown Eastside has resulted in a fatality, despite 255 overdoses at the facility between Dec. 25, 2016 and Oct. 9, 2017.

Unquestionably, these efforts are saving lives.

Limited access to interventions

Access to overdose-related interventions is restricted geographically and available almost exclusively in urban centres. And the expansion of supervised injection facilities across the country has focused on urban, not rural, areas. Nevertheless, responses to the overdose crisis are gaining momentum.

The federal government is, for example, taking needed steps to support the expanded availability of heroin-assisted treatment. This enables individuals with severe substance use disorder to access medical opioids whose potency and purity is controlled. But it can be challenging to connect people living in rural areas to health services, which may limit their access to treatment.

Research links socio-economic factors such as homelessness and housing insecurity to overdose risks. (THE CANADIAN PRESS/Christopher Katsarov)

Even with an overdose-response infrastructure with adequate coverage in place, most of these efforts do not stop overdoses — they merely prevent them from becoming fatal.

To achieve meaningful reductions in overdose death we need to prevent overdoses from occurring in the first place.

Income assistance an overdose risk

The most recent BC Coroners Service report on illicit drug overdose deaths included this startling figure: During the days following income assistance payments, the rate of fatal overdose was significantly higher than at other times of the month.

In the first 10 months of 2017, this amounted to an average of nearly six fatal overdoses per day on the Wednesday to Sunday following income assistance payments, compared to 3.6 deaths per day at other times.

While this report is specific to B.C., most jurisdictions in Canada distribute income assistance in the same way: Once a month to all recipients on the same day.

This data is consistent with existing research linking income assistance to increased drug use. People have known for many years that income assistance payments — a critical component of the social safety net that reduces some of the health harms of poverty — are associated with increases in drug use and overdose risk.

Women write messages during a memorial service on International Overdose Awareness Day in the Downtown Eastside of Vancouver, B.C., in August 2017. (THE CANADIAN PRESS/Darryl Dyck)

People receiving these payments rely on monthly incomes that keep them significantly below the poverty line. The lack of financial security has negative implications for drug use, drug-related harm and overdose risk.

Trends like this signal opportunities for action. Considering how social and socio-economic conditions increase overdose risk will be essential to overdose response efforts that adopt a preventive approach.

Homelessness, unemployment, chronic pain

Socio-economic marginalization — which includes inadequate income, exclusion from the labour market, participation in illegal or prohibited income generation like drug-dealing or theft, and housing or food insecurity — is a key driver of illicit drug use and drug-related harm.

This kind of marginalization shapes whether and how people use drugs, how they experience the impacts and their access to a broad range of health and social services. It is relevant to the overdose crisis in many different ways.

For example, when someone loses their housing they may also lose the space, routines and social interactions that allow them to use opioids more safely.

Someone experiencing chronic pain may not have the resources to consistently access care and, as a result, may begin self-medicating with street drugs of unknown potency and purity.

This kind of socio-economic marginalization could also look like someone who goes through a family dissolution, who has to move quickly and often painfully to establish a new domestic situation with less financial and social stability, and who ends up using drugs in high-risk ways.

Or it could take the form of someone being released from prison, not having the resources to transition smoothly or access treatment, and relapsing in the context of a toxic drug supply.

Broadening overdose prevention

Current efforts to prevent overdose fatalities are extremely important. They are expanding nationally, as evidenced by the leap from two to 28 Health Canada-approved supervised drug consumption facilities in 2017, alongside new overdose prevention sites operating in select locations across the country.

Also critical are interventions to deal with the toxic drug supply. Ideally these would also involve the legalization and regulation of the drugs fuelling the current crisis.

Currently they include expanded drug-testing services and the recent announcement of a British Columbia pilot to distribute “clean opioids” (hydromorphone) to people at high risk of overdose.

But, as this public health emergency continues to deepen, we must also incorporate broader understandings of overdose risk into our response and prevention efforts.

Reducing the socio-economic marginalization associated with overdose risk for people who use illicit drugs will be essential. Meaningfully addressing the overdose crisis means addressing the socio-economic factors that increase overdose risk to begin with.

Read more: Solutions to Canada’s opioid crisis

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