Opioid addiction is reaching crisis levels across North America. There is not a community in Canada nor in Ontario that is untouched by this complex health issue. Canada and the United States have the highest per-capita opioid consumption in the world. (Dasgupta, Beletsky, & Ciccarone, 2018) An application of Social Ecological Model offers some insight to the complexity of this health issue facing a growing number of Ontarians.
Social Ecological Model
The social ecological model is a multilevel model of health originally developed by Urie Brofenbrenner in his study of childhood development. The model organizes each context of development into five levels of external influence. The levels are categorized from the most intimate level (individual) to the broadest (macrosystem). (Psychology Notes HQ, 2013) Figure 1 below illustrates each sphere of influence in the Ontario heath system. Beginning with the individual level, each layer of opioid addiction will be explored.
Figure 1. Social Ecological Model in Ontario Health System
Individual
Individual knowledge, attitudes, and beliefs about opioid use heavily influences the rate of addiction or misuse. Mental health or attitude toward mental health is a major contributing factor as are personal and observed experiences related to opioid use of prescription and non-prescription types. (Conn & Marks, 2017) The interrelationship of social disadvantage, social isolation, and pain is a significant contributing factors for the development of dependence and addition to opioids. (Dasgupta et al., 2018) Some researchers suggest that the dopamine receptors in the brain that are responsible for pleasure are inhibited in people prone to addiction. This makes some people more likely to seek pleasure from a “high” or stimulant rather than from more typical sources like relationships and work. (Farber, 2013)
Interpersonal
Family, friends, and healthcare providers influence opioid and other addictions in many ways. Peer groups and romantic partners are particularly poised to influence individuals as they adjust behavior to fit in or be accepted by others who are using opioids. In fact, most addicts are first introduced to opioids by a friend or peer (Conn & Marks, 2017) Emotional support, affection, praise and encouragement have been identified as deterrents to substance abuse when offered by close friends, family, or romantic partners. (Branstetter, Low, & Furman, 2011) Opioid medications are overprescribed by healthcare practitioners who are uninformed about alternative pain treatment methodologies and by practitioners who work in rural areas with limited access to affordable alternative therapies. (Dasgupta et al., 2018)
Organizational
Initial opioid use often occurs in hospital settings, and patients with opiate addictions often frequent hospitals to access medical care and treatment. Inappropriate opioid prescribing is perpetuated at the hospital level by organizations that have not developed or prioritized monitoring of prescriptions for opiates. Patients discharged from Emergency Departments who had previously never been prescribed opiates have an increased likelihood of developing chronic opiate drug use. (Kim, Nolan, & Ti, 2017) Many patients with addiction to opiates are often not identified or do not receive care for their addiction when hospitalized for other medical problems. Even when they do, the transition from hospital care to the community is often poorly coordinated, resulting in poor compliance and relapse. (Kim et al., 2017)
Community
In Ontario, healthcare is administered at the local level by Local Heath Integrated Networks (LHIN). Each geographically and demographically unique LHIN has chosen to approach the opioid crisis in slightly different ways. The Central East LHIN, which encompasses the Durham, Scogog, Clarington, and Northumberland regions for example, contributing factors to the rise in opioid addictions has been attributed to a dearth of services to treat addictions. As such, a significant amount of funding is being directed to outpatient addictions and recovery therapies. ("Addictions Supports," 2018) The Durham region specifically has been hard hit by financial challenges faced by one of it’s major employers, the General Motors plant in Oshawa. An increase in mental health issues and substance abuse as a result of unemployment is a contributing factor to the rise of opiate abuse in this community. (Gilligan, 2017)
Policy
A joint statement of action to address the opioid crisis made by Health Canada in 2016 identified gaps and outlined targeted actions to address them at the federal and provincial level. The federal government developed two reports which highlighted contributing factors to opioid crisis in in Canada. The first is the Federal Action on Opioids, a report that makes more transparent the efforts made to better inform Canadians about the risks of opioids, treatment options and effort to improve the evidence base upon which policy is developed. The second report, the Health Portfolios’ Prescription Drug Abuse Strategy, highlights pharmacy inspections, monitoring and surveillance, and education programs for patients and prescribers. Provincial level as well as regulatory body and accrediting bodies for healthcare also released commitments to address the opioid crisis signaling the importance of multi-level action. Ontario has taken a bold step by investing more than $222 million to combat the opioid crisis in Ontario, including expanding harm reduction services, like naloxone kits, an antidote for opioids, hiring more front-line staff, and improving access to addiction supports across the province like opening opening Rapid Access Addictions Medicine clinics. ("Addictions Supports," 2018)
Conclusion
The Canadian Centre for Substance Abuse and Addiction ("Opioid Crisis," n.d., para. 2) has this to say about opioid addictions:
“The current opioid crisis is a result of multiple complex factors that include: a misunderstanding of the addictive risk of prescription opioids; frequent opioid prescribing and high amounts being prescribed for pain relief; lack of awareness of alternative treatments for pain; theft of prescription opioids by friends and family members; lack of access to prescription opioids leading to illicit opioid use; illegal drugs that are laced with other substances, such as fentanyl; psychological, social and biological risk factors like genetics, mental health, early life experiences, trauma, poverty, lack of secure housing and other social determinants of health; and stigma towards substance use disorders, discouraging individuals from seeking help.”
Several of these factors have been highlighted in this exploration of the Social Ecological Model above. There is much work to be done at all levels. How has your local community taken action to address the crisis? Are all levels of the system addressed in that approach? How are you engaged and involved as a consumer or provider of healthcare?
References
Branstetter, S., Low, S., & Furman, W. (2011). The influence of parents and friends on adolescent substance use: A multidimensional approach. Journal of Substance Use, 16(2), 150-160. http://dx.doi.org/10.3109/14659891.2010.519421
Conn, B. M., & Marks, A. K. (2017). An ecological approach to understanding adolescent prescription drug misuse. Journal of Adolescent Research, 32(2), 183-204. http://dx.doi.org/10.1177/0743558415589369
Dasgupta, N., Beletsky, L., & Ciccarone, D. (2018). Opioid crisis: No easy fix to its social and economic determinants. American Journal of Public Health, 108(2), 182-186. http://dx.doi.org/10.2105/AJPH.2017.304187
Farber, N. [The Human Beast]. (2013, August 28). Why some people are drug addicts [Blog post]. Retrieved from https://www.psychologytoday.com/blog/the-humanbeast/201308/why-some-people-are-drug-addicts
Gilligan, K. (2017). Opioid crisis in Durham is bad, getting worse. Retrieved from https://www.yorkregion.com/news-story/7764776-opioid-crisis-in-durham-is-badgetting-worse/
How did we get to an opioid crisis? (n.d.). Retrieved from http://www.ccdus.ca/Eng/Opioids/issue/Pages/default.aspx
Joint statement of action to address the opioid crisis. (2016). Retrieved from https://www.canada.ca/en/health-canada/services/substance-abuse/opioidconference/joint-statement-action-address-opioid-crisis.html
Kim, B., Nolan, S., & Ti, L. (2017). Addressing the prescription opioid crisis: Potential for hospital-based interventions? Drug and Alcohol Review, 36(2), 149-152. http://dx.doi.org/10.1111/dar.12541
Ontario expanding addictions supports in Durham. (2018). Retrieved from http://www.centraleastlhin.on.ca/newsandevents/Press%20Releases.aspx
Psychology Notes HQ. (2013, November 3 ). What is Bronfenbrenner’s Ecological Systems Theory? [Blog post]. Retrieved from https://www.psychologynoteshq.com/bronfenbrenner-ecological-theory/