A call for broader recognition in the era of clandestine fentanyl
Perry Tompkins1 Citation: UBCMJ. 2018: 9.2 (36-37
SOURCE: Download Here
Abstract
Nonmedical prescription opioid use (NMPOU) among Canada’s rural youth is a public health problem largely overshadowed by the opioid crisis in metropolitan centres. In this commentary, the author explores the unique socioeconomic factors that underpin NMPOU among rural youth and draws attention to its potential to prime and promote exposure to increasingly prevalent clandestine fentanyl, often disseminated and disguised as common prescription opioids. In turn, the author argues for mitigating strategies to curb NMPOU, informed by greater awareness of the unique vulnerabilities of rural youth.
In 2017, the Canadian Institute for Health Information identified youth aged 15-24 as one of the fastest growing cohorts in terms of opioid-related hospitalization,1 driven in part by the increasing prevalence of clandestine fentanyl, particularly in British Columbia and Alberta.2,3 While the urban impact of this phenomenon has been widely covered, the threat to Canada’s rural communities has received less attention. This is concerning not only because of the relative undersupply of rural mental health and addictions treatment services compared to urban communities, but also owing to the higher prevalence of nonmedical prescription opioid use (NMPOU) among rural youth.4 As its name implies, NMPOU involves taking prescription opioids in any manner inconsistent with how they were prescribed or by a person for whom they were not prescribed; it can involve borrowing from friends or family, using higher–than–recommended doses, or pure recreational use.5 Apart from serving as a gateway to heroin,6 greater NMPOU may be priming Canadian rural youth to the threat posed by the spread of potent clandestine fentanyl, often masquerading as prescription pain medicine.7 Averting the attendant morbidity and mortality in rural communities will require broader recognition of the geographic disparity in NMPOU, which is also a prerequisite to developing viable public health responses. Despite its potential impact, lack of awareness of greater NMPOU among rural youth is unsurprising given the recently emergent literature on geographic differences in prescription drug misuse. While rurality has been broadly identified as a risk factor for youth prescription drug misuse, including pain medication,8,9 the most direct evidence stems from a recent analysis of the 2011-12 U.S. National Survey on Drug Use and Health† by Monnat and Riggs, which identified a 35% greater adjusted odds of past–year NMPOU in rural versus urban youth.10 This parallels Canadian data from the 2011 Ontario Student Drug Use and Health Survey‡ , which identified a 95% greater adjusted odds of past–year NMPOU among rural female students in Ontario.11 Explanations for the geographic disparity in youth prescription drug misuse, including NMPOU, generally invoke three related factors: 1) greater availability; 2) adverse economic drivers of use; and 3) social parameters that facilitate misuse.12 In the first case, rural communities are often older demographically and more reliant on physically demanding industries (e.g., agriculture or resource extraction).13 Both of these factors increase the prevalence of acute and chronic pain, for example via injury or chronic arthritis, resulting in greater overall medical opioid use and yielding opportunities for subsequent NMPOU through youth diversion.14 Also, greater use within rural populations may distort youth perception of the harms of prescription opioids, promoting normalization,15 and this may explain the earlier age of initiation noted in rural localities.16 Finally, it has been suggested that NMPOU within rural communities may be facilitated by more efficient circulation of diverted opioids, enabled by the close kinship networks less frequently found in urban settings.17 Beyond greater prescription opioid availability, economic determinants may drive NMPOU among rural youth. For example, Carpenter et al. recently noted that higher unemployment rates are associated with a greater incidence of opioid use disorder,18 and lower income status is a known risk factor for NMPOU.19 This is relevant as rural communities often exhibit higher unemployment rates,13 with geographic differences in financial stressors potentially driving differences in youth NMPOU. For example, relative to comparators, higher rates of depression, anxiety, and suicide have been noted among farming families in the U.S. struggling to maintain financial solvency and, in this context, youth NMPOU may represent a maladaptive coping strategy.20 Moreover, when misuse evolves into dependence, limited financial means can undermine access to important harm reduction strategies. For example, while buprenorphine/naloxone (Suboxone®) and methadone hydrochloride (Methadose®) for opioid substitution are eligible for full coverage under B.C. Pharmacare, they are still subject to its deductible policy.21 As such, B.C. rural youth whose families do not qualify for income assistance, while still potentially financially constrained, must fund at least part of the costs of these treatments, potentially limiting access. Apart from economic factors, unique aspects of rural life may promote NMPOU as a coping strategy for mental health adversities, or limit access to resources that might otherwise curb NMPOU. For example, data from the B.C. Adolescent Health Survey, administered every five years to youth in grades 7-12, indicate that rural youth are more likely to have family or friends that have attempted suicide, more likely to report problematic drinking, and are more likely to report a lack of mental health services in their community.22 Additionally, excessive idle time and boredom among rural youth has been identified as a driver of NMPOU, owing in part to limited extracurricular activities in their communities.23 Perhaps most problematic, rural youth may avoid seeking treatment resources, even when available, for fear of being recognized by neighbours or due to cultural prohibitions on acknowledging vulnerability, rooted in small–town value systems.24 With a fuller appreciation of possible social and economic determinants of rural NMPOU, mitigating strategies can be developed. For example, dedicated funding for life skills training programs in middle school might reduce rates of NMPOU among rural youth, a strategy proven effective in the United States.25 In conjunction, delivering joint parental–adolescent education programs, which explore the harms of prescription drug misuse, might counteract normalization of NMPOU, further limiting its incidence.26 Finally, expanding rural cultural competency training for Canadian medical leaners, adapted from successful approaches in the U.S.,27 might yield broader awareness of cultural drivers of NMPOU. This could position future rural physicians for earlier intervention. Ultimately, as Canada’s opioid crisis continues to evolve, it’s unlikely that rural NMPOU and related harms of clandestine opioids can be completely neutralized. Nevertheless, recognizing and counteracting the specific vulnerabilities of rural youth might keep a manageable problem from becoming an outright disaster.
References
Canadian Institution for Health Information. Opioid–related harms in Canada [Internet]. 2017 Sep [cited 2017 Nov 22]. Available from: https://www.cihi.ca/ sites/default/files/document/opioid-harms-chart-book-en.pdf
BC Coroners Service. Fentanyl–detected illicit drug overdose deaths January 1, 2012 to September 30, 2017 [Internet]. 2017 Nov 9 [cited 2017 Nov 22]. Available from: https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/fentanyl-detected-overdose.pdf
Kalaichandran A. National Post. ‘These drugs are killing our kids’: Why teen brains are more vulnerable to fentanyl and opioid addiction [Internet]. 2017 Apr 21 [cited 2017 Nov 22]. Available from: http://nationalpost.com/health/ these-drugs-are-killing-our-kids-why-teen-brains-are-more-vulnerable-to-fentanyl-and-opioid-addiction
McInnis OA, Young MM, Saewyc E, Jahrig J, Adlaf E, Lemaire J, Taylor S, Pickett W, Stephens M, Di Gioacchino L, Pica L, Levin D, Tonita A, Wang H, Xiong H. Urban and rural student substance use: technical report [Internet]. 2015 Sep [cited 2017 Nov 22]. Available from: http://www.ccsa.ca/Resource%20 Library/CCSA-Urban-Rural-Student-Substance-Use-Report-2015-en.pdf
National advisory committee on prescription drug misuse. First do no harm: responding to Canada's prescription drug crisis [Internet]. 2013 Mar [cited 2017 Nov 27]. Available from: http://www.ccsa.ca/Resource%20Library/Canada-Strategy-Prescription-Drug-Misuse-Report-en.pdf
Palamar JJ, Shearston JA, Dawson EW, Mateu–Gelabert P, Ompad DC. Nonmedical opioid use and heroin use in a nationally representative sample of US high school seniors. Drug Alcohol Depend. 2016 Jan 1;158:132-8.
Howlett K, Giovannetti J, Vanderklippe N, Perreaux L. Globe and Mail. A killer high: how Canada got addicted to fentanyl [Internet]. 2016 Apr 8 [cited 2017 Nov 22]; Available from: https://www.theglobeandmail.com/news/investigations/a-killer-high-how-canada-got-addicted-tofentanyl/article29570025/
Young AM, Glover N, Havens JR. Nonmedical use of prescription medications among adolescents in the United States: a systematic review. J Adolesc Health. 2012 Jul;51(1):6-17.
Pulver A, Davison C, Pickett W. Recreational use of prescription medications among Canadian young people: identifying disparities. Can J Public Health. 2014 Apr 16;105(2):e121-126.
Monnat SM, Rigg KK. Examining rural/urban differences in prescription opioid misuse among US adolescents. J Rural Health. 2016;32(2):204-18.
Fischer B, Ialomiteanu A, Boak A, Adlaf E, Rehm J, Mann RE. Prevalence and key covariates of nonmedical prescription opioid use among the general secondary student and adult populations in Ontario, Canada. Drug Alcohol Rev. 2013 May;32(3):276-87.
Rigg KK, Monnat SM. Urban vs. rural differences in prescription opioid misuse among adults in the United States: informing region specific drug policies and interventions. Int J Drug Policy. 2015 May;26(5):484-91.
Moazzami B. Strengthening rural Canada: fewer & older—the population and demographic dilemma in rural British Columbia [Internet]. 2015 Apr [cited 2017 Nov 26]. Available from: http://strengtheningruralcanada.ca/file/Fewer-Older-The-Population-and-Demographic-Dilemma-in-Rural-British-Columbia1.pdf
Cerdá M, Gaidus A, Keyes KM, Ponicki W, Martins S, Galea S, Gruenewald P. Prescription opioid poisoning across urban and rural areas: identifying vulnerable groups and geographic areas. Addiction. 2017 Jan;112(1):103-12.
Fleary SA, Heffer RW, McKyer ELJ. Understanding nonprescription and prescription drug misuse in late adolescence/young adulthood. J Addict [Internet]. 2013 Jan 28 [cited 2017 Nov 25]. Available from: https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4007747/ DOI: 10. 1155/2013/709207
16. Young AM, Havens JR, Leukefeld CG. A comparison of rural and urban nonmedical prescription opioid users’ lifetime and recent drug use. Am J Drug Alcohol Abuse. 2012 May;38(3):220-7.
Keyes KM, Cerdá M, Brady JE, Havens JR, Galea S. Understanding the rural–urban differences in nonmedical prescription opioid use and abuse in the United States. Am J Public Health. 2014 Feb;104(2):e52-9.
Carpenter CS, McClellan CB, Rees DI. Economic conditions, illicit drug use, and substance use disorders in the United States. J Health Econ. 2017 Mar; 52:63- 73.
Saha TD, Kerridge BT, Goldstein RB, Chou SP, Zhang H, Jung J, Pickering RP, Ruan WJ, Smith SM, Huang B, Hasin DS, Grant BF. Nonmedical prescription opioid use and DSM-5 nonmedical prescription opioid use disorder in the United States. J Clin Psychiatry. 2016 Jun;77(6):772-80.
Rhew IC, Hawkins JD, Oesterle S. Drug use and risk among youth in different rural contexts. Health Place. 2011 May;17(3):775-83.
BC Ministry of Health—Medical Beneficiary and Pharmaceutical Subdivision. BC PharmaCare Newsletter Edition 17-001 [Internet]. 2017 Jan 18[cited 2017 Nov 24]. Available from: https://www2.gov.bc.ca/assets/gov/health/ health-drug-coverage/pharmacare/newsletters/news17-001.pdf
Smith A, Stewart D, Poon C, Peled M, Saewyc E, & McCreary Centre Society. From Hastings Street to Haida Gwaii: provincial results of the 2013 BC Adolescent Health Survey [Internet]. 2014 [cited 2017 Nov 24]. Available from: http://www.mcs.bc.ca/pdf/From_Hastings_Street_To_Haida_Gwaii.pdf
Pulver A, Davison C, Pickett W. Time–use patterns and the recreational use of prescription medications among rural and small town youth. J Rural Health. 2015;31(2):217-28.
Pullen E, Oser C. Barriers to substance abuse treatment in rural and urban communities: a counselor perspective. Subst Use Misuse. 2014 Jun;49(7):891-901.
Spoth R, Trudeau L, Shin C, Redmond C. Long–term effects of universal preventive interventions on prescription drug misuse. Addiction. 2008 Jul;103(7):1160-8.
Spoth R, Trudeau L, Shin C, Ralston E, Redmond C, Greenberg M, Feinberg M. Longitudinal effects of universal preventive intervention on prescription drug misuse: three randomized controlled trials with late adolescents and young adults. Am J Public Health. 2013 Apr;103(4):665-72.
Schuller KA, Amundson M, McPherson M, Halaas GW. An interprofessional programme to culturally sensitise students to the needs of patients
Comments