Going Upstream to End the Opioid Overdose Emergency
Updated: Sep 2, 2022
UPDATE (16 August, 2022): "BC's Overdose Crisis Has Claimed More than 10,000 Lives: Coroner... B.C. also set a record for the highest number of overdose deaths in the first half of the year, with 1,095 deaths from January to July. "
Right now, in British Columbia (BC), there is a public health emergency and nearly 5,000 people have died since January 2020. Four years before COVID-19 entered BC, opioid overdoses and an increasingly toxic drug supply were declared an emergency (source). Unlike COVID-19, the response to this emergency has not flattened any curve:
>8 times as many people died to drug overdose in 2021 (2,265 deaths) compared to 2012 (270 deaths),
2021 was the most fatal year for drug overdoses to date, and
195 people died in May 2022 alone (see Figure 1; source).
By comparison, mortality rates among other common causes of unnatural death, such as suicide, motor vehicle accidents, and homicide, have not risen (see Figure 2).
Every one of the 11,000+ people who have died in the last 10 years was someone’s child, and each of them was just as deserving of respect and access to healthcare as anyone else.
In my work as a school counsellor, I have seen first-hand the suffering caused by the opioid overdose emergency. Every person who uses drugs, and every person who dies, affects many other people, including children. Some children have lost loved ones, some have lost caregivers, and thousands of families and communities are grieving. This emergency is affecting an entire generation of children, and, on a grand scale, what is happening right now is part of an intergenerational cycle of trauma, unaddressed needs, mental illness, substance use, and addictions. Alex’s story below is an example of this cycle drawn from multiple different cases with no reference to real people.
Why Alex Uses Drugs
Alex was born to a mother named Drew. Drew had used drugs for much of her teenaged years and young adult life but got off drugs when she learned she was pregnant. Alex's father left when they were less than 1 month old, so Drew had to work two jobs to make ends meet. She relied on her friends who lived next-door to watch Alex when she was not home. In the community, domestic violence was common, and Alex witnessed many fights between adults.
When Alex was six years old, Drew began dating Kyle. Alex liked Kyle and, for a time, family life was good. However, Kyle and Drew began using drugs again when Alex was eight. Three years later, Kyle was arrested and sent to prison, and Drew went to a detox program for six months, then re-united with her child. In middle school, Alex was excluded by their peers, and eventually made friends with a group of older teenagers who drank alcohol together outside school. When Alex was fifteen, they nearly overdosed on toxic drugs, went to hospital, and then to a residential treatment program. During treatment, Alex told their counsellor, “Sometimes, using drugs is the only way you can break down those barriers and hurts. It is easy to become addicted” (source).
Substance use disorders, like most mental health problems, begin in childhood and adolescence (source 1, source 2, source 3). Fortunately, it is possible to prevent mental health problems and adverse conditions in childhood from evolving into more serious, more expensive, future problems. This can be done by providing mental health promotion, prevention, and early intervention services to children and adolescents (source). These services are proactive, or “upstream” approaches to mental health and addictions.
What is meant by "upstream" or "downstream" approaches? Imagine you are standing beside a fast-moving river and you see a person floating downstream, calling to you for help. So, you throw them a life preserver and pull them out of the river. This is a "downstream" approach. Then, you notice another person and then another floating by. You try and try again to save the people in the river. Eventually, you walk upstream to see why so many people are drowning in the river. As it turns out, there is an old bridge without a guardrail or safety signage. So, you warn the people on the trail to stay away from that bridge and inform the park ranger of the danger. Now, people are much less likely to fall into the river. This is an "upstream" approach.
For generations, our society has taken a reactive, “downstream” approach to mental health and addictions. This approach focuses on individuals with existing mental health problems or people in emergencies, such as overdoses. The downstream approach tries to “pull people out of the river.” Unfortunately, this approach does not always work, as evidenced by the record-breaking number of deaths.
The neglect of children’s needs and lack of effective upstream services in BC are the major conditions that led to the overdose emergency. Today, the systems of care in our province are disconnected and overwhelmed. Children and families cannot access the services they need, when they need it, where they are, and unless action is taken to address this problem, we can expect the overdose emergency to continue or worsen.
How Do We Fix An Overdose Emergency?
Like many other countries, Canada has historically implemented criminal justice (“crime and punishment”) and medical-diagnostic (“sickness and treatment”) approaches to addressing the problems of drug use, substance use disorders, and addictions. These approaches have failed to solve the problem, as demonstrated by the present emergency.
Since BC is not the only place in the world with an overdose emergency (see the American “Overdose Epidemic” and Australian “Overdose Crisis”), there are health professionals, researchers, and policy makers around the world who have sought to find solutions. For instance, Portugal decriminalized possession of all drugs in 2001 (source). Since then, drug-related deaths in Portugal have decreased and remained significantly lower than the European Union average.
Because drug overdose crises are so widespread, there much research on effective, and ineffective, ways to solve the problem. Any approach implemented in BC to address the overdose emergency must utilize this evidence base when developing solutions. So, what does the research say?
Proximal and Distal Strategies to Addressing the Overdose Emergency
There are both proximal (“near, short”) and distal (“far, long”) strategies that can be taken to address the overdose emergency (source). Proximal strategies are "downstream" approaches which try to pull people out of the river; distal strategies are "upstream" approaches that try to prevent people from falling into the river.
Proximal strategies focus on immediate problems by helping people who are already struggling with substance use disorders and addictions. Research evidence shows that some proximal strategies are effective, including:
Decriminalization (see Portugal's strategy above);
Harm reduction (e.g. naloxone kits and training, needle exchange programs);
Providing a safe supply (e.g. prescribed diacetylmorphine and hydromorphone);
Public education about addictions and substances;
Treatment and recovery services including medically-assisted therapies buprenorphine, methadone, and naltrexone);
Reducing accessibility to drugs by regulating the drug supply;
Let me be very clear: we need these strategies to prevent deaths and care for the people who are already struggling with addictions. However, not everyone who uses drugs has an addiction. Some of the 10,000+ deaths in BC were first-time drug users.
If we really want to put an end to the opioid overdose emergency, we need more than just proximal strategies. If we keep pulling people out of the river and never walk upstream to try to prevent them from falling in, we will be overwhelmed as we are today in BC. In order to address the source of the problem, we also need to go upstream.
Substance use disorders are developmental disorders, which means they originate in childhood (source 1, source 2, Source 3, Source 4, Source 5). Although drug use and addictions appear later in life, their causes start much earlier. It is the complex interaction of a person’s biology (e.g. genetics), their environment (e.g. family, community, and society), and their experiences that leads to substance use disorders. Alex’s story illustrates how these different factors interact to predispose a person to using drugs and developing problems with substance use and addiction. Biology: Alex was conceived while their mother was using drugs. Environment: Alex grew up in poverty, with family members using drugs, and domestic violence in the community. Experiences: Alex's caregiver Kyle was imprisoned, leading to a prolonged separation; Alex's mother used drugs; and Alex experienced peer rejection at school.
Certain experiences, called Adverse Childhood Experiences (ACEs), are strong risk factors for substance use disorders (source). ACEs include child abuse, neglect, and family discord such as caregiver mental illness, drug use, or imprisonment. The powerful impact of ACEs is demonstrated research that shows a male child who has experienced 6 or more ACEs has a 4,600% increased likelihood of intravenous drug use in adulthood (source).
Rapid brain development during adolescence means that areas associated with emotional reactivity and reward mature much faster than those associated with decision-making, risk assessment, and planning. As a result, adolescence is a critical risk period for the development of substance use disorders, with the highest risk being among people who first use substances in their early teens (source 1, source 2).
Because substance use disorders are developmental, the approach to treating and preventing them must also be developmental (Source 1, Source 2, Source 3, Source 4). For more than 30 years, researchers studying the prevention of substance use disorders have emphasized the importance of enhancing protective factors, and reducing or mitigating risk factors, for substance use disorders (source). This supports the importance of distal strategies for addressing the overdose emergency.
Distal strategies include mental health promotion, prevention, and early intervention services (simple definitions are available here). Evidence-based distal strategies include child abuse and neglect prevention services, early identification and early intervention services, family-nurse partnerships, parent education, social-emotional learning and after-school care programs in schools, and trauma-informed practice (source 1, source 2, source 3, source 4, source 5). Since children grow up in the environments of family, community, and school, it is most effective for the services for children to be provided in these contexts, such as those described above. Services outside these contexts, such as those in clinics and hospitals, are less accessible to families from lower socioeconomic backgrounds and those living in rural areas.
Some of the approaches described above have already been implemented across BC in the different systems which serve children and families, such as child and family welfare, education, healthcare, and justice. However, these services are disconnected and there are several barriers to access, for instance:
Canadian universal health care does not cover many mental healthcare services;
Child welfare, mental healthcare services, primary care providers (e.g. doctors, nurse practitioners), schools, and researchers are disconnected from one another;
Primary care cannot meet the needs of the population, with nearly 900,000 British Columbians without a doctor (source);
Many families cannot afford private mental healthcare services; and
Public mental healthcare services (e.g. Child & Youth Mental Health, School Counsellors, etc.) are chronically understaffed and under-resourced.
Many of these issues were acknowledged by the BC Ministry of Mental Health and Addictions in “A Pathway to Hope". This official document describes our government’s commitment to improve the state of mental health and addictions services in BC, declaring child and youth wellness as their first priority. Now, it is time to take action on this commitment.
Prioritizing Healthy Child Development is the Solution
Taking action to improve the systems which serve children must be a core and essential element of any response to the overdose emergency (source). Children must have guaranteed access to the care they need when they need it, where they are. This means that the services for children must be adequately staffed and resourced in order to meet the needs of the population.
There are many kinds of professionals who work in these services, including community mental healthcare professionals, liaison and youth probation officers, primary care providers, school counsellors, social workers, youth and family outreach, and others. Currently, these professionals are not able to meet the needs of the population because they are chronically understaffed and under-resourced.
Addressing this problem is not only an issue of care, but also a matter of human rights. As outlined in the Convention on the Rights of the Child (CRC), the government must ensure that children have access to physical and mental healthcare, as well as protection from harm, to ensure their healthy development. In Canada, the articles of the CRC are law (source).
To address the overdose emergency specifically, the professionals who serve children need specialized training:
To conduct health risk assessments, including ACEs screening to identify children who are at risk and refer to early intervention services;
To develop knowledge of risk and protective factors for substance use disorders;
To implement evidence-based interventions such as motivational interviewing; and
As it stands, the services for children and families in BC are disconnected. Therefore, these services must also be linked to create an integrated system of care.
Children Need Us and We Need Children
Alex received the care they needed when they were fifteen. But...
What if Alex had a school counsellor who supported them when they were excluded by their peers in middle school?
What if a youth and family outreach worker had noticed the drug use and violence in Alex’s home and community before that?
What if Drew had received the support she needed, such as a nurse practitioner and social worker, when Alex was born?
What if Drew had received the care she needed when she was younger, experiencing her own struggles that led to drug use?
Alex’s story demonstrates how healthy child development and adult wellbeing are intrinsically linked to one another. This is especially true in the case of mothers. Children need us to care for them and protect them and to do that, we must also be healthy. Additionally, we need our children to grow up healthy to ensure the future of our society.
To address the opioid overdose emergency in BC, we must address the source of the problem by improving the “upstream” services which support the healthy development of children and adolescents. Every citizen of BC can make a difference by demanding that our government make a commitment to guaranteeing every child gets the care they need when they need it, where they are.
Yet even this is not enough. Canada must make a commitment towards a system of Universal Mental Healthcare. The healthy, sustainable development of our society depends on the wellbeing of communities, families, mothers, and, ultimately, children. In order to address the grand problems facing humanity, such as the climate emergency, we must take care of our children. And, if we truly care for our children, then we must also care for their parents and caregivers.
Please, write to your local Member of the Legislative Assembly (MLA) and urge them to make a political commitment to (1) save lives today through proximal strategies such as harm reduction and safe supply, and (2) invest in the future of BC by going upstream to end the opioid emergency through prioritizing healthy child development and guaranteeing access to mental health care for every child.
Moms Stop the Harm is a network of Canadian families who have been impacted by substance use related harms and deaths. They advocate for changes to the failed drug policies that have contributed to so many drug-related deaths in BC. Contact.
Kelty Mental Health (at BC Children's Hospital) can help families to navigate the mental health and addictions services in BC. They also provide information, peer supports, and resources on child and youth mental health. Phone: 1-800-665-1822. E-mail: firstname.lastname@example.org
Foundry BC provides people ages 12-24 with a variety of different health and wellness supports, including for abuse, bullying, grief and loss, mental health, self-injury, substance use, and suicide. There are 13 Foundry centres in BC and the province aims to expand to 23 centres by 2026. They also provide digital supports. Get support.
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