The Fentanyl Fix
There are many reasons why British Columbia's overdose crisis has grown unabated over the past two years.
But one of the root causes, believe some, is the complex relationship between prescription drugs, chronic pain management and the education of doctors.
"Not everyone is going to be addicted to opioids, these are very effective drugs, certainly for people in severe pain.
But when you start using them in such a liberal manner, you're going to have a number of people who are going to start using medications and not able to stop," said UVic drug policy researcher Alan Cassels.
"A lot of discussion is about how to get safe injection sites and better use of naloxone and methadone, and that may all be well, but that's when you're dealing with people already addicted.
"One of the major advances would be to stop opioids being used routinely and inappropriately."
A 2013 United Nations report said Canada was the second-highest per capita consumer of prescription opioids in the world.
"I think the average doctor gets very little education around proper pain management and opioids management," said Cassels.
"Physicians aren't getting the proper kind of education in using these drugs. That's a dangerous combination when you've got doctors learning about prescribing opioids from their colleagues in the field."
The most exhaustive research into Canadian universities came in 2009, and found that only one-third of health science programs could identity specific hours designated for pain education — and that veterinary students received five times more training than medical students.
The first accredited pain medicine program didn't open in Canada until 2014, and the University of Alberta, which offers a certificate in pain management, says "there is little formal education devoted to pain education in health care training programs in Canada."
In British Columbia, the University of British Columbia created a Pain Medicine residency program in 2015.
Roger Wong, executive associate dean for education in UBC's Faculty of Medicine, says the scope of the problem means it's critical for the university to train a new generation of specialists that can support frontline workers and family doctors.
"We need to make sure we have that rigorous degree of improvement all the time, but with the fentanyl crisis, because of the scope of the issue, we are definitely very committed to make sure that we improve our curricula," he said.
"We've taken a holistic approach in making sure that our doctors ... are taught to be given the tools to address pain management. It's not as simple as prescribing medication. The holistic approach talks about looking after other components like the mental health components."
But changing how chronic pain is viewed and treated by doctors is one side of the coin. The other is making those alternative treatments affordable.
"Unfortunately, a lot of non-opioid alternatives have limited coverage. Physiotherapy, even for those who have employer-based benefits, a lot of them only count five to 10 sessions a year, and that to some is not enough,"said Kate Smolina, a postdoctoral fellow at UBC's School of Population and Public Health who studied how opioid use grew in B.C. ahead of the current crisis.
"It's important to recognize that the current crisis is much more than the epidemic of deaths. It's a crisis of pain, of dependence, of addiction. And not a lot of people see it like that," she said.
"The overdoses and deaths made it more visible, but it's not a new problem. There's lots more underneath the surface."