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I read with interest Dr. Tyndall's recent commentary in CMAJ which calls for the use of a regulated, low-barrier distribution of pharmaceutical-grade opioids to address the immediate challenges extant to today's opioid overdose epidemic. Of concern, however, is the statement that "the public health response to any poisoning epidemic should be to provide safer alternatives for people at risk." This statement follows a preceding paragraph that states that a number of "upstream" interventions are "critical to our response", but that the outcomes of these are longer-term and--to paraphrase--aren't meeting the immediate need.
The immediate thought that occurred to me was whether words "should be" might have been better phrased as "should include." Indeed, to distil down a complex problem that requires a comprehensive public health response to a single downstream intervention misunderstands the basic function of public health practice. Additionally, the pieces identified by Tyndall as being "upstream" but too far on the time horizon in fact constitute key elements of a public health response.
Public health's response to the opioid overdose epidemic must continue to be multifaceted. The response continues to be built on effective surveillance and evaluation to describe the shape and size of the issue and monitor the outcomes of interventions. Layered on this is partnership with the healthcare system and various community agencies to address the present mortality and morbidity occurring among those who choose to use opioids, which can include possible deployment of the single novel approach proposed by Tyndall. Finally, public health's work and advocacy with relevant stakeholders (government, housing, social services, law enforcement, and others) will be most critical in reversing the epidemic; while these have a long time horizon, they are what will ultimately address the antecedent factors that contribute to use and poor mental health.
To be clear, I agree with Dr. Tyndall to some extent - a public health response to any poisoning epidemic should include the provision of safer alternatives for people at risk. But it is important to not minimize the other elements of that response simply because they are difficult or lack immediacy. Our progress in reducing mortality due to road safety was not from improved post-accident trauma care alone; our successes to date around tobacco were not solely due to providing nicotine replacement therapy. Our efforts around alcohol do not solely revolve around light beer.
Hence, in calling something a public health response, particularly something as prominent as the opioid overdose epidemic, I would propose that due recognition be given to the complex nature of both the problem and solutions, with a recognition that advocacy for response and downstream interventions should not be conducted at the expense of those broader population interventions that will ultimately resolve this crisis.