For the purpose of this blog post, I have decided to explore the impact that the COVID-19 pandemic has had on the existing opioid crisis. With the rising rates of opioid overdoses already a national crisis in this country, COVID-19 has caused the perfect storm for our most vulnerable groups. A multilevel approach is necessary to combat the ever-growing opioid crisis and to determine the best interventions to tackle this issue. I have chosen to focus on The Social-Ecological Model of Health to explain the impact COVID-19 has had on the opioid crisis, while taking into account each level of influence presented in this model. The levels of influence in this model include…intrapersonal, interpersonal, organizational/ institutional, community and public policy (McLeroy et al., 1988).
Prior to exploring the Social-Ecological Model of Health and determining how it relates to my chosen topic, I encourage everyone to watch the video below developed by CBC News: The National. This video highlights the impact that the COVID-19 pandemic has had on the opioid crisis and how one health emergency has inevitably exacerbated the other.
CBC News: The National - Fighting an opioid overdose epidemic during a pandemic
Opioid Crisis Background
According to the Government of Canada, there are several variables that have caused a dramatic rise in deaths linked to opioids (Government of Canada, 2020). Some of these considerations include the introduction of powerful synthetic opioids such as fentanyl and carfentanil as well as the increased rate of opioid prescriptions (Government of Canada, 2020). Although opioids can be effective for pain management, opioid related harms such as addiction and overdose are now considered a growing public health concern. Opioids are a class of drugs that include:
Heroin
Synthetic drugs such as fentanyl & carfentanil
Pain relievers that are available legally through prescription, such as oxycodone, codeine, hydrocodone, morphine etc.
The Public Health Agency of Canada (PHAC) states that there were “17,602 apparent opioid toxicity deaths between January 2016 and June 2020” (Public Health Agency of Canada, 2020).
To understand the severity of the opioid crisis, I have provided a link to an infographic titled Preliminary Patterns in Circumstances Surrounding Opioid Related Deaths in Ontario during the COVID-19 Pandemic (ODPRN, 2020).
The Social-Ecological Model of Health
The Social Ecological Model of Health considers the relationship between various levels of influence including intrapersonal, interpersonal, organizational/institutional, community and public policy (Golden & Earp, 2012).
Intrapersonal age, knowledge, education, beliefs, skills and economic status
Interpersonal social networks, social supports and relationships with friends, family and others
Organizational / Institutional specific policies outlined by local organizations and institutions
Community relationships between community stakeholders, built environment and local leadership
Public Policy local, provincial, national and global laws/policies, economic and social policies (McLeroy et al., 1988).
There is a dynamic and multidirectional relationship between the various levels of this model. When looking at the opioid crisis, emphasis often focuses on individual risk, but the wider issue of social and contextual contributors, such as interpersonal connections and the environments in which people live, should also be taken into account (Jalali et al. 2020). The model outlined below depicts the layers of the Social-Ecological Model of Health and illustrates how interconnected they truly are. This model was adapted to address major factors pertaining to opioid misuse through each level of influence. When examining the effects of COVID-19 on the opioid crisis, it is crucial to address each level in order to identify appropriate response strategies to tackle this epidemic.
(Jalali et al., 2020).
Intrapersonal
The economic crisis caused by the COVID-19 pandemic will have far reaching consequences for society as a whole, but will be disproportionately harmful to people who use substances that are of lower socioeconomic status, who often rely on community supports (Cowan et al., 2021). When developing and evaluating effective strategies to combat the opioid crisis, it is important to consider risk factors that may increase vulnerability and contribute to substance use harms. Issues that may increase vulnerability include, lack of education, food insecurity, joblessness, inadequate housing and isolation (van Draanen et al., 2020). Risk factors associated with substance related harm include, family history of substance use, mental health concerns, exposure to trauma and environmental factors (Public Health Ontario, 2020). All of these factors may contribute to socioeconomic marginalization and have been shown to increase the risk of overdose (van Draanen et al., 2020). Socioeconomic marginalization is defined as “a set of conditions that contribute to exclusion from social and economic opportunities and create vulnerability” (van Draanen et al., 2020 p.1). The relationships between these factors demonstrate how different types of disparities combine to intensify vulnerability for individuals who use substances and increase the risk for overdose (van Draanen et al., 2020).
Interpersonal
The COVID-19 pandemic has significantly impacted social networks, social supports and access to community programs and services. According to the Centre for Addictions and Mental Health, COVID-19 has had a negative influence on the mental health of Canadians and many have seen stress levels increase twofold over the course of the pandemic. (Centre for Addictions and Mental Health, 2020). Social isolation is a major contributor to increased stress and has the potential to exacerbate opioid related harms. Strong connections with friends, family, and other social networks may help to protect against the health related risks of opioid use and overdose (Cowan et al., 2021). Strong network ties can help people avoid risky behaviours associated with substance use and may encourage individuals to seek supports and services. The Ontario Drug Policy Research Network (ODPRN) suggests that opioid related overdoses have increased throughout the pandemic, which may be attributed to the fact that more and more people are using alone (The Ontario Drug Policy Research Network, 2020). With social distancing and stay-at-home initiatives in place, the likelihood of social isolation increases, particularly when there is a lack of access to technology.
Organizational/ Institutional
The COVID-19 pandemic has had a major impact on organizational structures, policies, programs and services. When looking at the organization I work for, walk in services for harm reduction have been suspended and are now only accessible through mobile outreach. In person visits allowed outreach workers and public health nurses to engage clients more effectively, in order to build strong relationships and develop trust. It can take years to build lasting relationships with clients in order for them to feel comfortable accessing services. According to Public Health Ontario, The Works program in Toronto saw 3853 visits in February of last year, but only 127 in April (PHO, 2020). In person services for mental health and addictions have decreased since the start of the pandemic. Although support in the form of telemedicine and video conferencing is now widely available, many individuals may not have access to the necessary technology, while others may lack access to a secure environment in which to access those services.
Community
Community networks have been severely impacted by the COVID-19 pandemic. The community safety nets of housing, shelters, food security programs, and addictions support have all been negatively impacted by the emergence of COVID-19. As programs were disrupted, community agencies had to find new ways to deliver their own services and new ways of working together across agencies. With respect to the opioid crisis, referrals to and from agencies related to mental health services for example, have been more challenging due to the increased need.
Our communities have seen a significant increase in opioid related deaths. The Public Health Agency of Canada highlighted that last year between April and June, 1,628 apparent opioid overdose deaths occurred, marking the highest quarterly increase since national monitoring was first initiated back in 2016. (PHAC, 2020). These rising rates are a cause for concern and are likely directly associated with the COVID-19 pandemic.
(PHAC, 2020)
In March 2020, though still in the middle of an ongoing opioid crisis, the Ontario government declared a state of emergency in response to growing concerns related to COVID-19 (ODPRN, 2020). The graph below developed by the ODPRN outlines the change in opioid related deaths by public health units in Ontario pre pandemic and during the pandemic.
(ODPRN, 2020)
Public Policy
The public health pandemic response has led to the implementation of physical distancing and masking guidelines to reduce the spread of COVID-19. Public health measures have also included stay at home orders and closure of non-essential businesses. Guidelines for physical distancing and closure of non-essential businesses have contributed to diminished potential for pharmacies, outpatient services, safe injection sites, and places for harm reduction that offer treatment and supplies to people who use substances. (ODPRN, 2020). Obviously, the aim of these public health guidelines is to minimize the effects of COVID-19, but there is concern that such interventions might have unintended implications for people who use drugs (ODPRN, 2020). Somehow, we need to get back to the four pillars of the Canadian Drugs and Substances Strategy: prevention, treatment, harm reduction and enforcement (Health Canada, 2018). Hopefully we will see a decrease of COVID-19 cases with the implementation of COVID-19 vaccinations and we can reassess the implementation of public policies aimed at combating the opioid crisis.
(Health Canada, 2016).
It is evident that each level of the Social-Ecological Model of Health has been directly impacted by the COVID-19 pandemic and has only intensified the opioid crisis. On an individual level, people’s lives have been uprooted. With increased stress and exposure to trauma, the opioid crisis is continuing to worsen. On an interpersonal level, people have been affected by social isolation and lack of social supports which has directly impacted substance use harms. From a community standpoint, we must find new ways to work together and collaborate in order to increase supports for at risk communities. Lack of access to programs and services at the organizational level, is one of the driving forces behind the rising rates of opioid overdoses during the pandemic. Assuming that COVID-19 is here to stay, we must determine how best to implement public policy in relation to opioids and it is imperative that we take action in order to protect our most vulnerable communities. Interventions addressing determinants at all levels are necessary to develop sustainable solutions for at risk groups.
References
Centre for Addictions and Mental Health. (2020). Mental Health in Canada: Covid-19 and Beyond. Retrieved February 20, 2021, from https://www.camh.ca/-/media/files/pdfs---public-policy-submissions/covid-and-mh-policy-paper-pdf.pdf
Cowan, E., Khan, M. R., Shastry, S., & Edelman, E. J. (2021). Conceptualizing the effects of the COVID-19 pandemic on people with opioid use disorder: an application of the social ecological model. Addiction Science & Clinical Practice, 16(1), 4. https://doi.org/10.1186/s13722-020-00210-w
Golden, S. D., & Earp, J. A. L. (2012). Social Ecological Approaches to Individuals and Their Contexts: Twenty Years of “Health Education & Behavior” Health Promotion Interventions. Health Education & Behavior, 39(3), 364–372.
Government of Canada. (2020). Opioids and the opioid crisis – Get the facts. Retrieved February 22, 2021, from https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/get-the-facts.html
Health Canada. (2018). Pillars of the Canadian drugs and substances strategy. Retrieved March 4, 2021 from https://www.canada.ca/en/health-canada/services/publications/healthy-living/pillars-canadian-drugs-substances-strategy.html
Health Canada. (2016). Canadian Drugs and Substances Strategy: A Comprehensive, Collaborative, Compassionate and Evidence-Based Approach to Drug Policy. Retrieved March 4, 2021 from https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/publications/healthy-living-vie-saine/drugs-substances-strategy-2016-strategie-drogues-autre-substances/alt/pub-eng.pdf
Jalali, M. S., Botticelli, M., Hwang, R. C., Koh, H. K., & McHugh, R. K. (2020, August 6). The opioid crisis: A contextual, social-ecological framework. Health Research Policy and Systems. BioMed Central Ltd. https://doi.org/10.1186/s12961-020-00596-8
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An Ecological Perspective on Health Promotion Programs. https://doi.org/10.1177/109019818801500401
Public Health Agency of Canada. (2020). Opioid and Stimulant-related Harms in Canada. Retrieved February 21, 2021, from https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
Public Health Ontario. (2020). Substance Use-Related Harms and Risk Factors during Periods of Disruption. Retrieved March 3, 2021 from https://www.publichealthontario.ca/-/media/documents/ncov/main/2020/08/substance-use-related-harms-disruption.pdf?la=en
The Ontario Drug Policy Research Network. (2020). Preliminary Patterns in Circumstances Surrounding Opioid-Related Deaths in Ontario during the COVID-19 Pandemic. Retrieved February 22, 2021, from https://www.publichealthontario.ca/-/media/documents/o/2020/opioid-mortality-covid-surveillance-report.pdf?la=en
van Draanen, J., Tsang, C., Mitra, S., Karamouzian, M., & Richardson, L. (2020). Socioeconomic marginalization and opioid-related overdose: A systematic review. Drug and Alcohol Dependence, 214. https://doi.org/10.1016/j.drugalcdep.2020.108127
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