British Columbia has been in a public health crisis since 2016 due to escalating deaths from overdose, exacerbated during the COVID-19 pandemic, with an unprecedented six lives lost per day. A better understanding of the root causes that contribute to overdose is key to orient harm-reduction strategies and offer sustainable prevention strategies. A recent comprehensive review of the literature identified the drivers of the overdose emergency. This work is an important addition to the efforts to expand downstream overdose prevention work, and both are necessary to halt the devastating loss of life.
Laws that criminalize people for simple possession of drugs and drug use create health and social harms. Criminalization can lead individuals to use higher-risk practices to avoid detection. It can contribute to stigma and negative attitudes in the public and among health providers that can block help-seeking activities and undermine an effective systemic response. Incarceration itself is a risk factor for overdose and poor health outcomes. Access to a safer supply of pharmaceutical alternatives is necessary to separate individuals from an increasingly toxic illegal drug supply. Doctors of BC has endorsed a policy advocating for both decriminalization and safer supply as key measures to save lives.
Promoting family well-being is at the heart of overdose prevention. A 10% increase in overdose deaths parallels a 2% increase in child maltreatment and a 4% increase in child apprehension. Child removal is associated with subsequent overdose for mothers, a risk that is increased twofold among Indigenous women. Notably, losing a loved one to overdose during childhood is a marker of adversity with repercussions along the lifespan. Strengthening support for parents and families, particularly for those experiencing stress (e.g., screening for adversity, nurturing supportive relationships and resiliency, providing alternatives to apprehension), is key to mitigating the reverberating impacts of overdose now and for future generations.
Overdose is strongly concentrated in social gradients. Socioeconomic marginalization, neighborhood poverty, food insecurity, unemployment, and housing instability are correlated with overdose, with structural racism identified as a root cause of the overdose epidemic. In one US study, overdose deaths among a White rural population were likely to be precipitated by an abrupt decline in circumstances (e.g., job loss, divorce), whereas overdose deaths among racialized communities were associated with intergenerational income immobility and deprivation. Indigenous populations have used their collective strengths to buffer ongoing legacies of colonialism. Respecting Indigenous priorities and addressing stigma and racism will be key to addressing the unequal impacts of overdose on Indigenous people in BC and Canada.
Addressing comorbidities and maximizing health care interactions is essential. The likelihood of overdose increases fivefold when a substance-use disorder is present and close to fourfold when a mental illness is present, and it is highest yet for those with a dual diagnosis. A 2016 BC Coroners Service review found that one-third of youth and young adults who died by overdose in BC had a mental illness diagnosis. Transitions to or from an abstinence-based context, such as incarceration or substance-use treatment, are vulnerable periods for overdose, while access to harm-reduction services (such as supervised consumption sites) and family physicians is protective. Proactive screening and follow-up at key health care access points (e.g., primary care, mental health, emergency services) is fundamental to preventing overdose deaths.
We have to do better. Engaging people with lived and living experience is necessary to contextualize the literature and share what is needed. Interventions such as safer supply and decriminalization are imperative to provide alternatives to the toxic drug supply now. Timely access to robust, integrated population data specific to BC, encompassing rural and remote communities, is essential to focus proactive and equitable overdose response efforts throughout the health system and beyond. And elucidating pathways that may lead to overdose, including the role of adversity and social disadvantage, is critical to better supporting individuals, families, and communities in overdose prevention across the lifespan.
—BCCDC Overdose Drivers Knowledge Translation Group
This article is the opinion of the BC Centre for Disease Control and has not been peer reviewed by the BCMJ Editorial Board.
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