That photograph of counterfeit green OxyContin pills containing toxic bootleg fentanyl is infamous now. Virtually every news outlet in Canada has used the image in a leading story on its front page or on screen sometime over the last two years. The opioid crisis doesn't qualify as news anymore, though. Dozens of Canadians dying from overdose each week is just the new normal.
It doesn't have to be this way.
On Friday, Health Canada and Ontario's Ministry of Health will co-host an Opioid Conference "for a national dialogue." The next day is a more exclusive "Opioid Summit," bringing together "individuals and organizations that have the authorities...to combat the opioid crisis." After more than two years of intense media coverage and a decade of expert calls for urgent action, it is encouraging to finally see multiple sectors and stakeholders involving themselves in a national conversation, isn't it?
Well, maybe not.
On its surface, gathering a variety of perspectives, disciplines, and expertise seems desirable, if not necessary and long overdue. But the word "stakeholder" means "a person with an interest in something," and that itself is part of the problem. A diverse assembly of interests and biases partially explains why, when large groups convene over an important public health priority, the goal quickly becomes achieving consensus rather than solving the problem.
At this conference, pain societies and regulatory colleges may debate which opioids—illicit or prescribed—cause more harm. Harm reduction advocates may criticize those advocating reduced opioid prescribing about unintended consequences for people who use drugs. Stakeholders will jockey for resources: abstinence-based recovery programs for their work, universities for education, and addiction doctors for greater access to medication therapy. Agencies who see this issue as a way to remain relevant will look for money and attention, too.
Meanwhile, the right and left will probably argue drug enforcement policy from value positions, and those in government will surely ponder how measures they implement could influence their approval ratings. Pharmaceutical companies and their shills could even be on hand, and, who knows? They may have skin in the game too. In this context, a quote sometimes attributed to Heath Ledger seems apropos, "I can't tell you the key to success, but I can tell you the key to failure is trying to please everybody." Heath Ledger died of an overdose involving opioids in 2008.
In an urgent public health situation like this one, the singular goal must be optimizing health outcomes for the greatest number of people as safely, effectively, and efficiently as possible. Consensus undermines this goal. It is no measure of success. Saving lives is.
But even if conferences like Friday's could somehow resist the penchant to appease interests and reflect every perspective in a plan, one should still be worried. Human nature is not in their favour.
In 1968, to understand why some 38 witnesses supposedly did not come to the aid of Kitty Genovese as she was stabbed to death in public in New York City four years earlier, John Darley and Bibb Latané of Columbia University conducted a study. Subjects were placed in an environment where they believed they were either alone or with four other bystanders.
They were then asked to interview another individual via intercom. During the experiment, the subjects were made to believe their interviewee was having an epileptic seizure. Of the participants working alone, 85% rushed to inform their instructor the interviewee needed help. Of those who believed there were others present working with them, only 31 percent sought to help. This phenomenon was termed "bystander apathy," explained by "diffusion of responsibility." When there are others around, people hope, feel, and assume that someone else is on the case.
Human nature in the form of bystander apathy may explain why the "individuals and organizations that have the authorities to combat the opioid crisis" have not already acted quickly and decisively. Diffusion of responsibility can cause exactly the kind of delays that have now given us the worst drug safety crisis in history. Ironically, having too many people and organizations to consider and rely on may be the explanation for why too little has been done.
This can't continue. More talks with more "stakeholders" are not the answer.
Evidence-based solutions to the opioid crisis are already at hand. Journalists who have covered this issue over the past two years can recite them by now as easily as they can the alphabet:
- Increase the availability of the antidote, naloxone, to anyone who may witness an opioid overdose.
- Expand harm reduction programs including supervised drug consumption services, and remove legislative barriers to doing so immediately.
- Expand access to medication-assisted opioid addiction treatment.
- Address the overprescribing of opioids in order to reduce harms to patient and public safety, and provide appropriate care for those with chronic pain conditions.
- Conduct systematic public health surveillance of drug trends, harms, and deaths.
- Enact wise and humane drug policy (including decriminalization), prioritizing treatment and harm reduction over enforcement and incarceration.
These are not novel concepts. Neither is the need for a swift, nimble, and independent response by federal and public health authorities to crises. That's what every post-SARS Commission called for. It is long past time for our public health authorities to seize leadership—to plant their flag at the Opioid Summit—and put the protection of human health on their backs, which is exactly where that responsibility belongs. Ultimately, someone needs to take charge. You know, like doctors do. In emergencies. Where waiting and dithering means people die.
Hakique Virani, MD FRCPC DABAM, is a specialist in Public Health and Preventive Medicine and Addiction Medicine, and is a Clinical Assistant Professor in the Faculty of Medicine at the University of Alberta. Follow him on Twitter.