Let’s get to the heart of the matter
Alex Paterson
Hey Upstream community, today on Bell Let's Talk Day I’m launching a new monthly blog feature called Research Roundups (#RRB) where I’ll be looking at important developments in research on the social determinants of health.
I’ll be zeroing in on specific areas of interest for you, our readers and followers. Sometimes I will simply highlight amazing research that is being done within our community. Other times, I’ll take a critical approach and push the conversation upstream, where it belongs.
Your feedback in making this blog series is very welcome, so do email at alex@thinkupstream.net with your comments, questions, feedback. If you have suggestions for a topic, please send them along.
In this first Research Roundup I’m going to dive into recent research on the opioid addiction crisis in North America. To get started on the topic, I want to take this quote from well-known addictions physician Gabor Maté and put it to the test.
"Nobody’s saying that every traumatized person becomes addicted. I’m saying that every addicted person was traumatized.” - Gabor Maté
Maté’s work focuses on the role of childhood trauma in being a driver for addiction. He thinks it is the foundation of addictive behaviour.
He writes: “All addictions—alcohol or drugs, sex addiction or internet addiction, gambling or shopping—are attempts to regulate our internal emotional states because we’re not comfortable, and the discomfort originates in childhood.”
Recent research into opioid users, overdose victims, and opioid deaths is shedding light on this problem from a population level.
Tessa Cheng et al conducted research into “risk factors” associated with illegal drug use and opioids in Vancouver. Cheng studied how different experiences or behaviours are related to illegal opioid use among street youth and adult injection drug users. She also tried to figure out whether someone misusing an opioid prescription had different risk factors than someone who started with illegal drugs.
She found within her different research cohorts that at least 57% reported experiencing childhood trauma. People who started taking illegal drugs first rather than beginning with misusing prescription drugs showed a higher prevalence of childhood trauma. At least 58% of all research participants had been incarcerated and at least 86% had been homeless, no matter how they got involved with opioids.
If more than half of every adult injection drug user or street youth has experienced childhood trauma, it makes sense to focus new research and upstream interventions in the childhood phase to prevent people from becoming traumatized in the first place. Harm reduction can hold the line and prevent deaths from occurring, but only upstream interventions can stop the generation of addiction.
We also need to really focus on asking why addiction is occuring in the first place.
Across Canada, especially on the Atlantic coast, the use of benzodiazepines, like Xanax, has a very high prevalence. It would be impossible to imagine the genesis of a rapper like Lil Xan without widespread medication of the population. Lil Xan is a rapper who takes his stage name from the anxiety medication Xanax. Benzos need to become a significant enough social phenomenon for him to construct his identity around them and for enough people to relate to this identity.
As CBC News reported, anxiety medication is intersecting with the opioid crisis. In 2017, more than 26 million prescriptions for benzodiazepines and related drugs were written in Canada, a country of 36.5 million people in 2017. That’s enough for 7 prescriptions for every 10 Canadians. That is a lot of mental suffering.
Kate Smolina et al published a paper on the patterns of opioid overdoses which shows that 88% of all women whose overdose involved opioids had been taking a sedative in the last 5 years.The population control group had a sedative prevalence of 42%.
Women had active prescriptions for benzodiazepines in 22% of overdose cases; it was 2.8% in control group. Similarly, 75% of women who overdosed had been on an antidepressant within the last 5 years, compared to 24% in the control group.
What we are seeing is the real picture of people searching for relief from mental suffering.
Tara Gomes et al studied opioid hospitalizations in Ontario, Manitoba, and B.C. between April 2015 and March 2016. They found opioid hospitalizations weren’t restricted to income—there were people from every income category—but hospitalizations were more heavily concentrated among people within the bottom two income quintiles. The opioid crisis intersects with the suffering of income class.
As Nabarun Dasgupta notes in his research commentary, looking upstream requires us to broaden our view of the opioid crisis in North America to study social and economic suffering.
The main behaviourist, or midstream, approach to understanding the source of the opioid crisis is to blame predatory pharma or irresponsible doctors, but we need to go higher up the food chain to understand the systemic factors behind the problem. The opioid crisis is a symptom of society-wide mental suffering. We should approach it as a reaction to the social and economic conditions that drive trauma, anxiety, and depression. Our interventions need to be targeted at the source.
Returning to Gabor Mate’s quote that led us off, I think it's clear that mental suffering is driving addiction, but we can’t necessarily say the roots are conclusively in childhood trauma at this time. It may well be a factor, however, so his hypothesis based on his clinical experience cannot be ruled out by recent developments in the field of addictions research on opioids.
A question I would put to the experts is: what would early childhood development and education systems look like at scale if we also valued intervention into childhood trauma and addiction as their purpose?
Cheng, T. et al. (2018), “Nonmedical prescription opioid use and illegal drug use: initiation trajectory and related risks among people who use illegal drugs in Vancouver, Canada,” BMC Research Notes, 11 (35).
Dasgupta, N., et al. (2018), “Opioid Crisis: No Easy Fix to Its Social and Economic Determinants,” AJPH, 108 (2).
Gomes, T. et al., (2018), “Comparing the Contribution of prescribed opioids to opioid-related hospitalizations across Canada: A multijurisdictional cross-sectional study,” Drug and Alcohol Dependence, 191, pp. 86-90.
Smolina, K, et al. (2019), “Patterns and History of Prescription Drug Use Among opioid-related drug overdose cases in British Columbia, Canada, 2015-2016,” Drug and Alcohol Dependence, 194, pp. 151-158.