Benedikt Fischer is a senior scientist, Institute for Mental Health Policy Research at CAMH, and professor, department of psychiatry, University of Toronto
----------------------
Almost daily, we hear dramatic stories about Canada's latest drug crisis, the "fentanyl epidemic." We are learning that highly potent fentanyl-based opioid products – illegally produced and trafficked into Canada by overseas drug laboratories and sold for astronomical profits – have caused hundreds of deaths, all while authorities are helplessly watching. It all sounds like the many other drug "crises" – heroin, crack cocaine, methamphetamine – we have witnessed over the decades.
But this crisis is fundamentally different. It is a drug problem we created, facilitated and watched unfold in our own midst, without taking essential measures to stop. The fentanyl crisis is principally a homemade and home-sustained problem. For years, Canada has medically dispensed more opioids, far beyond fentanyl, than any other country, except for the United States (where a similar public health tragedy has unfolded). In the past decade, the amount of opioid doses dispensed in Canada has just about tripled.
Our medical system has prescribed these potent drugs to too many people, too easily and too generously – despite good evidence indicating their limited effectiveness for pain treatment, and the gradually unfolding, yet extensive, collateral harms.
More and more people began misusing prescribed opioids, ended up in emergency rooms for treatment, or died from fatal overdoses – all from drugs coming, directly or indirectly, from our own health system.
Yet decision makers took little or no action. When OxyContin, long the poster drug for the opioid crisis, was eliminated from provincial drug formularies in 2012, the main effect was that other, similarly hazardous opioids (including fentanyl) were increasingly prescribed instead. Many well-meaning measures were suggested – more awareness, prescription monitoring – but the core driving force of the crisis was neither named nor addressed: Our medical system, despite so many red flags, continued to prescribe too many opioids.
Canadian authorities have failed to recognize and implement interventions to reduce the amount of opioids fuelling this crisis. A comparable situation seems to have changed in the United States, where the Centers for Disease Control and Prevention recently released opioid prescribing guidelines. They explicitly recommend: use of non-opioid/pharmacotherapy alternatives for pain; low-dose/short-duration treatment; and intensive patient monitoring if opioids are prescribed. These guidelines are a seminal intervention to reduce opioid exposure, and thereby consequential harm, in the United States.
Unfortunately, and after too high a toll, we continue to lack such recognition of underlying dynamics, and determined action, in Canada.
The illicit, foreign part of the fentanyl crisis is mainly a consequence of a much deeper problem. Most people seeking foreign-made, clandestine fentanyl today were originally exposed to opioids from medical sources in Canada. Overseas fentanyl traffickers are feeding a demand for opioids that is mostly of our own creation. To blame the current problem on evil, drug-producing villains in foreign lands is both misguided and self-deceiving.
It will take a long time – and much continued collateral damage along the way – to undo this massive health crisis. And while suggestions such as having supervised consumption sites or increasing the availability of naloxone (the overdose-reversing drug) are benevolent, they are "after-the-fact" interventions that do not address the core causes of the problem.
Most urgently, Canada needs to rein in its medical system-induced oversaturation of opioids. This is the essential task for policy makers and medical regulators. Only when the problem's root causes are being addressed should we concentrate on other remedies. A fire can't be doused if gasoline continues to feed it.