Illegal Use of Opioids - Examining from a Social-Ecological Framework

Opioids are a class of drugs that can help relieve pain, with the most common being morphine, fentanyl, and oxycodone (Health Canada, 2022). While they can be legally prescribed by a healthcare practitioner, there has been a rise in illegal use of opioids leading to an increase in opioid overdose-related deaths. In an article by the Public Health Agency of Canada (2022), it was noted that Canada has seen an increase in unintentional poisoning deaths related to opioid use from 2007 to 2014. The largest increase in opioid-related deaths occurred during the COVID-19 pandemic (Public Health Agency of Canada, 2022). The suggested cause for the spike in illegal drug use during the pandemic includes increased social isolation, lack of access to mental health supports, and difficulty in obtaining drugs from other countries, which lead to the creation of more synthetic toxic drugs (Public Health Agency of Canada, 2022).

With this crisis still prevalent today, I want to explore the various levels of influence that increase the risk of illegal use of opioids in Canada. In an article by The Centers for Disease Control and Prevention (CDC), they used the social-ecological framework to identify the levels of influence in determining the risk of illegal use of opioids. The framework has 4 levels: individual, relationship, community and societal (The Social-Ecological Model: A Framework for Prevention, CDC, n.d.). The overlapping rings in the model (pictured below) illustrate “how factors at one level influence factors at another level” (The Social-Ecological Model: A Framework for Prevention, CDC, n.d.). With this model, I will take a deeper look at these four levels and identify factors within each level that have a direct correlation to an increased risk of illegal opioid drug use.

INDIVIDUAL LEVEL:

First, I wanted to look at the biological factors and personal history of individuals who use illegal opioids. In an article by Jalali et al. (2020), the authors provide examples of individual factors that may influence the likelihood of a person developing an opioid addiction. These individual factors include:

- Race (racial minorities have less access to treatment to overcome addiction)

- Age (likely to peak in early adulthood, 18-25 years old)

- Gender (females are more likely to be prescribed opioids by their doctor)

- Presence of psychological disorders (those with anxiety or mood disorders have greater risk)

In a data review by Belzak and Halverson (2018), it was noted that there are many routes for individuals to access opioids for illegal use, including access through family members, “double doctoring”, prescription fraud/forgery, and theft. When looking at gender and age as predictors of illegal opioid use, one study found that it is 74% more common among males (compared to females) and the age bracket most likely to become addicted to illegal opioids is between the ages of 30-39 years old (Public Health Agency of Canada, 2020). So, knowing these individual factors is important when considering public health programs and campaigns aimed at reducing illegal drug use. Still, it is important to also consider other influences external to the individual, which I will explore now.

RELATIONSHIP:

In other social-ecological models, I’ve heard this level also named the “Interpersonal” level, as referenced by Jalali et al. (2020). This speaks to the influence of family, friends, and others in our social network, who have the ability through their attitudes and beliefs to impact the likelihood of someone using illegal drugs (Jalali et al., 2020). As mentioned above when discussing the individual level of influence, access to opioids is often gained through family members. In a study by Nguyen et al. (2020), they looked at youth aged 11-26 years old, and they found that over 65% of youth using illegal opioids had obtained them from a family member with a prescription. The researchers concluded that programs designed to curtail opioid use amongst youth must also incorporate adult family members (Nguyen et al., 2020). On the flipside, familial relationships can also have an impact on whether an individual seeks treatment for an opioid addiction. In a study by Jalali et al. (2020), it was shown that that family support of recovery is likely to increase the likelihood of the individual seeking treatment. So, it appears that relationships, particularly familial relationships, can have either a negative or positive influence on individuals regarding their likelihood of using illegal opioids.

COMMUNITY:

This third level of the framework looks at the interaction of the individual within the community. The article by Jalali et al. (2020) points out that geographic locations, for instance, influence the likelihood of initiating opioid use. People living in rural areas are more likely to be prescribed opioids for pain relief than urban dwelling citizens (Jalali et al., 2020). One hypothesis is that people living in rural areas tend to have more physical demanding work, such as farming (Jalali et al., 2020).

In a data review completed by Belzak and Halverson (2018), they observed that while all provinces in Canada have reports of illegal opioid use leading to death, the provinces with the highest use of illegal opioids are British Columbia, Alberta, and Ontario. So, what are the reasons for this geographical difference in illegal opioid use? In Canada, we need to look at the Indigenous population and the concentration of reservations. A study by Belzak and Halverson (2018) identified that First Nations peoples have up to three times the rate of opioid overdose deaths compared with non-Indigenous people. In a report by Alberta Health (2017), it was stated that “rates of apparent accidental opioid drug toxicity deaths per 100,000 were three times higher among First Nations people compared to Non-First Nations people from January 1, 2016, to March 31, 2017.” So, it makes sense that provinces with the largest Indigenous population (BC, Alberta, and Ontario) would experience higher rates of illegal opioid use. The article did not explore the reason the rates of use are higher amongst Indigenous peoples versus non-Indigenous. However, in the next section, I will look at the societal level of influence, and this may provide an explanation.

SOCIETAL:

This level has also been called “Public Policy” because it looks at risk factors within a larger social context (Jalali et al., 2020). In relation to opioid use, this level would explore government regulations, law enforcement, and economic conditions, among other things, to determine the likelihood of opioid abuse (Jalali et al., 2020). When we look specifically at Indigenous populations and the increased risk for illegal opioid use from a societal perspective, there are a few societal factors that play a role in illegal opioid use. In an article by Lavalley et al. (2018), they researched the factors that increase the likelihood a person who identifies as Indigenous to engage in drug-related harm. These factors included “the historical and ongoing traumas related to colonization, including the residential school experience, poverty and child apprehension and involvement in the child welfare system, as well as inadequate access to education, health services and social supports.” (Lavalley et al., 20018). They suggest that our government’s response to the opioid crisis “fails to address the underlying structural drivers of the overdose crisis amongst Indigenous Peoples.” (Lavalley et al., 2018). The authors petition that there needs to be more funding for drug-reduction programs within the Indigenous community, and there also needs to be a change in Canada’s drug policies to incorporate traditional Indigenous values (Lavalley et al., 2018).

Other societal factors, such as high unemployment rates and systemic racism, also lead to health disparities amongst minority groups in Canada (Jalali et al., 2020). So, it is necessary to address these systemic issues in order reduce the risk of illegal opioid use in our country, but this takes time. For now, all we can hope for is an upward turn in the economy, better policing for repeat opioid users, and that our public health prevention programs are effective and result in fewer people engaging in illegal opioid use.

In conclusion, using the social-ecological framework, I have demonstrated that there are multiple levels of influence that affect the risk of an individual using opioid drugs illegally. Where are we today? Well, in a statement made by the Government of Canada about the opioid crisis in March 2023, it announced “Tragically, more than 5,360 Canadians died of an overdose from January to September 2022. That is nearly 20 family members, parents, children, friends, and community members a day whose lives were cut short from substance use harms.” (Health Canada, 2023). In my opinion, even though we (as a country) have implemented great programs to prevent illegal opioid use, we must recognize that illegal opioid use is not going to stop anytime soon. So, it is imperative to look at the social-ecological framework to identify the risk factors for illegal opioid use at the individual, relationship, community, and societal level. By completing this task, we will gain a more thorough understanding of the various influences that can shape the risk of illegal opioid use, and this will allow us to plan interventions that will be effective for our community.

REFERENCES

Alberta Health and the Alberta First Nations Information Governance Centre. Opioids and substances of misuse among First Nations people in Alberta: Alberta report, 2017 [Internet]. Edmonton (AB): Government of Alberta; 2017 [cited 2017 Nov]. Available from: https://open.alberta.ca/dataset/cb00bdd1-5d55-485a-9953-724832f373c3/resource/31c4f309-26d4-46cf-b8b2-3a990510077c/download/Opioids-Substances-Misuse-Report-FirstNations-2017.pdf

Belzak, L., & Halverson, J. (2018). The opioid crisis in Canada: a national perspective. Health promotion and chronic disease prevention in Canada: research, policy, and practice, 38(6), 224–233. https://doi.org/10.24095/hpcdp.38.6.02

Centers for Disease Control and Prevention (n.d.). The Social-Ecological Model: A Framework for Prevention. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html

Health Canada. (2023, March 27). Statement from the Minister of Mental Health and Addictions and Associate Minister of Health on the Overdose Crisis. https://www.canada.ca/en/health-canada/news/2023/03/statement-from-the-minister-of-mental-health-and-addictions-and-associate-minister-of-health-on-the-overdose-crisis.html

Health Canada. (2020, March 19). Opioids: What Are They? (fact sheet). Canada.ca. https://www.canada.ca/en/health-canada/services/publications/healthy-living/opioids-what-are-they-fact-sheet.html

Jalali, M. S., Botticelli, M., Hwang, R. C., Koh, H. K., & McHugh, R. K. (2020). The opioid crisis: a contextual, social-ecological framework. Health Research Policy and Systems, 18(1). https://doi.org/10.1186/s12961-020-00596-8

Lavalley, J., Kastor, S., Valleriani, J., & McNeil, R. (2018). Reconciliation and Canada’s overdose crisis: responding to the needs of Indigenous Peoples. Canadian Medical Association Journal, 190(50), E1466–E1467. https://doi.org/10.1503/cmaj.181093

Nguyen, A. P., Glanz, J. M., Narwaney, K. J., & Binswanger, I. A. (2020). Association of Opioids Prescribed to Family Members with Opioid Overdose Among Adolescents and Young Adults. JAMA network open, 3(3), e201018. https://doi.org/10.1001/jamanetworkopen.2020.1018

Public Health Agency of Canada. (2020, March 17). National report: Apparent opioid-related deaths in Canada (December 2017). Canada.ca.

https://www.canada.ca/en/public-health/services/publications/healthy-living/apparent-opioid-related-deaths-report-2016-2017-december.html

Public Health Agency of Canada. (2022, September 27). Substance use and harms during the COVID-19 pandemic and approaches to federal surveillance and response: Canada-U.S. joint white paper. Canada.ca. https://www.canada.ca/en/public-health/services/publications/healthy-living/canada-us-white-paper-substance-use-harms-during-covid-19-pandemic-approaches-federal-surveillance-response.html