POLICE ASSOCIATION OF NOVA SCOTIA 47 OPIOID CRISIS: NO EASY FIX Eroding economic opportunity, evolving approaches to pain treatment, and limited drug treatment have fueled spikes in problematic substance use, of which opioid overdose is the most visible manifestation. Epidemic inThree Phases 1) Rise of chronic pain In 1980, acute pain was so frequently treated with opioids. Previously, chronic pain was managed largely with cognitive behavioral therapy, even hypnosis. The Institute of Medicine reported that the rise in chronic pain prevalence in the 1990s to the following: 1) Greater patient expectations for pain relief 2) Musculoskeletal disorders of an aging population 3) Increased survivorship after injury and cancer 4) Increasing frequency and complexity of surgery. As insurers limited coverage of behavioral pain therapy, biopharmaceutical manufacturers sensed an opportunity. Pharmaceutical innovation propagated extended-release formulations, transdermal patches, nasal sprays, and oral dissolving strips. 2) Rise in prescriptions for opioids Physicians were unscrupulous, doling out opioids without adequate regard for medical need. 3) Rise of efficient global supply chains Increasingly efficient global supply chains and a sharp intensification in interdiction efforts created the conditions for the emergence of potent and less bulky products, for example, illicitly manufactured fentanyl and its analogs, which are increasing present in counterfeit pills and heroin. Between 2013 and 2016 deaths attributed to fentanyl analogs spiked by 540% nationally. The rapid acceleration of the crisis has led to its designation as a national public health emergency. Root Causes Prescription opioid overdose death rates have not yet dropped following the declining opioid prescribing: the number of outpatient opioid analgesic prescriptions dropped 13% nationally between 2012 and 2015.Yet, the national overdose death rate surged 38% during those years. In short, deaths attributable to prescription opioids have not decreased proportionally to dispensing. There are intuitive causal connections between poor health and structural factors such as poverty, lack of opportunity, and substandard living and working conditions. An alternate hypothesis suggests that an environment increasingly promotes obesity coupled with widespread opioid use may be the underlying drivers of increasing White middle-class mortality. Complex interconnections between obesity, disability, chronic pain, depression and substance use have not been adequately explored. Poverty and substance use problems operate synergistically, at the extreme reinforced by psychiatric disorders and unstable housing.The most lucrative employment in poorer communities is dominated by manufacturing and service jobs with elevated physical hazards.When sustained over years, on-the-job injuries can give rise to chronically painful conditions, potentially resulting in a downward spiral of disability and poverty. The counties with the lowest levels of social capital have the highest overdose rates. The interplay between social and genetic factors, too, is being elucidated. Individuals living in low socioeconomic neighbourhoods were more likely to develop chronic pain after car crashes, a process medicated by stress response genes. National Academy of Sciences report provides this summary: …overprescribing was not the sole cause of the problem.While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions, and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances. American Journal of Public Health. February 2018,Vol 108, No.2