Up to this point the opioid crisis has largely been treated from a medical model point of view. All attempts to alleviate this growing crisis seem to revolve heavily around the education of physicians and in their prescription of opioids. This has included the creation of guidelines and education regarding the tapering of drugs for this population of heavy users. To alleviate this burden, the government of Ontario should focus more on the Social Ecological model and consider more than just medicine. Non-pharmacological treatments need a starring role to truly alleviate the current burden in Ontario particularly in Northwestern Ontario.
“The Social Ecological Model (SEM) is a theory-based framework for understanding the multifaceted and interactive effects of personal and environmental factors that determine behaviors, and for identifying behavioral and organizational leverage points and intermediaries for health promotion within organizations. There are five nested, hierarchical levels of the SEM: Individual, interpersonal, community, organizational, and policy enabling environment” (Unicef, 2017). To date, the attempts to solve the opioid crisis in Ontario consists of largely ignoring other forms of treatment. Ontario’s strategy to prevent Opioid addiction and overdose released by the Chief Medical Officer of Health mentions appropriate pain management but instead of recommendations to send patients to health practitioners specializing in the non-pharmacological treatment approaches such as Physiotherapists, Chiropractors, or Athletic therapists the focus remains on comprehensive education for health care providers (Wiliams, 2016). The report further goes onto state that it is concentrating on providing better access to community-based addictions treatment (Wiliams, 2016) which is commendable but does nothing to address all levels of the crisis from a social-ecological model perspective. The report all but completely ignores the idea of prevention preferring to only interact with the aftermath. This is where non-pharmacological treatments should come in.
Figure 1: The Social Ecological Model
Ontario’s Northwest LHIN (local health integration Network) is an area that covers approximately 500,000 kilometers from the Manitoba border to just west of White River. Here the need for the implementation of physiotherapy funding as part of the SEM model regarding opioids is even more apparent. “In Northwestern Ontario, the population has poorer health outcomes yet more is spend to their healthcare that elsewhere in the province.” (Northwest Local Health Integration Network, 2012) This is a result of:
1) Higher rates of preventable diseases
2) Transitions between care settings could be more efficient and effective
3) Higher rates of acute hospital use compared to the rest of the province
4) Higher rates of hospitalization and Emergency department visits for chronic diseases
5) Higher health care costs in Northwest LHINs
(Northwest Local Health Integration Network, 2012)
These statistics are a recipe for disaster for the Opioid crisis, a lot of chronic diseases and acute hospitalizations involve the use of opioids and the use of opioid education as the prime strategy will only further opioid addictions. To break down the SEM models into its 5 hierarchal levels the current processes won’t work for this population. At ,the Individual level of the SEM it examines characteristics of an individual that influence behavior change including knowledge, attitudes, and behaviors. (Centers for Disease Control and Prevention, 2018). The current model in rural Ontario as shown in the statistics above is that if you need help or are in pain you go to the hospital. Rural towns often have restricted access to alternative treatment facilities due to a general lack of resources and availabilities. Policy changes created by the government of Ontario have furthered these beliefs that pain management should focus on the medical model vs. rehabilitation and treatment using non-pharmacological interventions. On April 1, 2005, Ontario partially delisted publicly funded community-based Physiotherapy services to save money on health care spending (Paul, et al., 2008). Whereas rehabilitation and non-pharmacological treatments can provide some control over an individuals pain delisting tells the individual that the proper course for pain relief is through medicine. This policy change affected one level of the SEM model which in turn leads to individual behavior change. Hospitals are further involved in complying with the medical model to show that patient satisfaction is high. The government of Ontario has recently instituted a Quality based funding pilot project for Ontario Hospitals entitled Link Quality to Funding (Policy and Innovation Branch Ministry of Health and Long Term Care, 2018). It is a truly noble effort to reward hospitals in terms of patient perception of care but unfortunately affects the opioid crisis negatively on the Organizational level of the SEM model. As a part of this initiative hospitals are required to ask a specific set of questions from a survey designed by the Canadian Institute for Healthcare Improvement called the Canadian Patient Experiences Survey Inpatient care or CPES-IP (Canadian Institute for Healthcare Improvement, 2018) three of these questions refer to pain management including a question about receiving medication for pain (Canadian Institute for Healthcare Improvement, 2018). This leads hospital physicians to ensure that patients have been treated for their pain during their stay in an immediate and continual way which is often medicine. This causes a devaluing of alternative treatments for pain as it does not meet the immediate needs of the patient as it’s more of a long-term solution.
What if for every stage of the SEM model the focus was on ensuring some method of alternative pain management. At the Policy/Enabling level the government would provide more public funding for non-pharmacological treatment avenues. The argument here, of course, is funding, in an article regarding health economics in JAMC the Ontario government was hoping to save $100 million by delisting physiotherapy and chiropractic services. A report commissioned by Deloitte by the Ontario Chiropractic Association predicted a 7-14% increase in the number of patients presenting at the Emergency Department and up to 3% increase in physician appointments so individuals could try to avoid paying for a chiropractor (Dales, 2005). An estimate in the article puts the delisting cost at close to $200 million as patients are diverted to more expensive and possibly less effective options (Dales, 2005).
The interpersonal level of the SEM model could be obtained through support groups or through the current Ontario opioid strategy to address community-based addictions treatment centers. It should be furthered that as soon as an individual mentions chronic pain in an appointment resources for social support should be offered. An automatic referral to a therapist, social worker, and rehabilitation or alternate pain treatment specialist should be automatic. This will also serve to improve the integration of services which is what the Northwest LHIN believes will solve the current health problems faced by individuals in Northwestern Ontario (Northwest Local Health Integration Network, 2012). But these solutions need to be available in real time and accessible whether through telehealth or greater governments support for non-pharmacological treatment plans for individuals with chronic pain.
Of course, none of these initiatives will completely solve the need for opioid use as there will be individuals in circumstances where pain relief can only be provided adequately through such means. For these individuals, they should receive help in the way that is most appropriate for them. A lot of work has been completed regarding opioid management guidelines and prescription use. It remains though that trying alternatives is lacking in our current medical models and our communities would be better served with an Social Ecological Model approach to providing non-pharmacological interventions.
References
Canadian Institute for Healthcare Improvement. (2018, June 27). Patient Experience. Retrieved June 27, 2018, from Canadian Institute for Healthcare Improvement: https://www.cihi.ca/en/patient-experience
Centers for Disease Control and Prevention. (2018, 06 17). Violence Prevention. Retrieved from Centers for Disease Control and Prevention: This model considers the complex interplay between individual, relationship, community, and societal factors
Dales, J. (2005). Delisting chiropractic and physiotherapy: False saving? JAMC, 166.
Northwest Local Health Integration Network. (2012). Retrieved June 29, 2018, from Northwest LHIN: http://www.northwestlhin.on.ca/goalsandachievements/Health%20Services%20Blueprint.aspx
Paul, J., Park, L., Ryter, E., Miller, W., Ahmed, S., Cott, C. A., & Landry, M. D. (2008). Delisting publicly funded community-based physical therapy services in Ontario, Canada: A 12-month follow-up study of their perceptions of clients and providers. Physiotherapy Theory and Practice, 24(5), 329-343.
Policy and Innovation Branch Ministry of Health and Long Term Care. (2018, February 7). Linking Quality to Funding (LQ2F). Retrieved June 26, 2018, from Ontario Hospital Association: https://www.oha.com/Bulletins/Linking%20Quality%20to%20Funding%20(LQ2F)%20-%20Introduction%20Package.pdf
Unicef. (2017, 06 15). Unicef. Retrieved from https://www.unicef.org/cbsc/files/Module_1_SEM-C4D.docx
Wiliams, D. (2016, September). Ontario's Strategy to Prevent Opioid Addiction and Overdose. Retrieved 2018, from Health Achieve: http://www.healthachieve.com/Presentations%202015/Tackling%20the%20Opioid%20Crisis%20in%20Ontario%20-%20Dr.%20David%20Williams.pdf