This case was developed by JustenChoueiry, George Liu, Connie You and

Anne Zhao from the University of Ottawa.

Case designed by Dilpreet Bajwa

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Acknowledgements

A message from the authors….

“You are about to be presented with 3 independentcases, where each of them highlights a specific issuewithin the much broader spectrum of The OpioidCrisis. While the cases are all fictious, they arerepresentative of scenarios that can occur in real life.As you read, try to identify potential issues that canbe investigated further and ask yourself questionswhen something is not fully clear. Keep in mind thatthe specific characters and storylines are notimportant, but the issues surrounding the OpioidCrisis are.Be attentive, be skeptical, and be creative. Best ofluck to all!”

Case 1 - CONFLICTEDDr. Levesque sat in his office, crouched over, with his head in his hands.

13 of his former patients had arrived back at his hospital this month alone, allwith the same story. He had prescribed them pain medications for everythingfrom severe injuries to chronic pain to post-surgery recovery…

And then they all got addicted.

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Buttheprescriptiondrugswerejusttooexpensivetokeepupwith,sotheyturnedtothestreets.Heroin,fentanyl,morphine,andwhateverelsetheycouldfind…

He let out a heavy sigh and rubbed his temples. Why? he asked himself, somepeople walk in, get a prescription, have a smooth recovery, and never touchthe drugs again… but why are so many others getting hooked?

Dr. Levesque shook his head. He had been prescribing opioids to his patientsfor over 30 years, and many did come back with struggles of addiction. Yet, ithad never quite taken a toll on him like it was doing now. With everything inthe recent news and media about the opioid crisis, he felt more and moreresponsible for his role in the whole ordeal.

There must be another way, he thought, there ha—

His thoughts were interrupted as a nurse frantically barged into his office.“Doctor, we have a new patient, critical condition. We need you in the ERASAP.”

***AssoonasDr. LevesqueenteredtheEmergencyRoom,hegrimaced.Ayoungman,noolderthan16,layonhissideatopastretcher.Withhisjawclenchedshut,theboywasbreathingheavilyand tryingnottomove.

Hewassupporting hislowerbackwithonehand,andwithhisother,hewasclutching tightlytoawoman’s hand,presumably hismother’s.

“Terribleaccident,”anurseexplainedasshebegansorting through differenttubesandneedles.“Acouplevertebraehavebeencrushed.Thepatientisinalotofpainandweneedtoadministermorphine immediately.Justwaitingonyourorder.”

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Dr.Levesquefroze.Theyoungmanwastallandfitforhisage.Whilehisfacewasdistortedbypain,itwasstillevidentthathewasquitehandsome. ItdawnedonDr.Levesquethat thisyoungmanhadhiswholelifeaheadofhim.

Ifheadministeredthepainkillersnow,howwouldthataffecttherestofhislife…?

Themotherstoodupsuddenly.“HELLO?”sheshoutedatDr. Levesque.“AreyouevenLISTENING??Mysonisliterallyabout todieandyou’restandingtherelikeadeerintheheadlights?Aren’tyouadoctor?GiveJohnwhatheneeds!”

Johngroaned loudlyfromthestretcher.

Dr.Levesquerubbedhisforehead, letoutanotherdeepsigh,thennoddedtothenurse.“Proceedwiththedosageandprepareforsurgery.”

Theprocedurewasassmooth ascouldbe,andafewdayslater,Dr. LevesquedecidedtogocheckuponJohn.Heappeared toberecoveringwell,andofcourse,wasstillonregularmorphinedoses.

John’seyeswidenedasDr. Levesqueenteredhisroom.“Whoa…whoareyou?”Johnasked,almost inadaze.Dr. LevesquemadeamentalnotethatJohnmusthavebeengivenhismedication recently.

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“I’mDr. Levesque,howareyoudoingJohn?”

“Haha,youknowmyname.That’ cool.It’snicetomeetyou,Dr. LeVet.”Johnyawned.“I’mdoingprettydandy!Howareyou?”

Dr.Levesquesmiled,but itwassadsmile.Therewassomuchenergyinthisyoungman’seyes…buthecouldn’thelphimselffrompicturingalltheweary, sunkenlooksthat somanyofhispatientshadcomeback tohimwith…

“I’mdoingalrightJohn,”hereplied.

“Ya know,Dr. LeVet,Ilovevets.You’resocoolbecauseyou’readoctorandavet!”Johnbegantogiggletohimself.

Dr. Levesque was relieved to see that John was doing well and decidedthere wasn’t much else to say. He stood up and made his way for thedoor.

“Thanks for your help, Doc,” John called out to him.

Dr. Levesque turned.

Somethingabout theboy’s tonehadchanged…despitetheeffectofthedrugs, itwassuddenlyverycalm…moresincere…

Thentheinnocent,goofyexpressionreturned.“Whatwould Idowithoutyooou,Doc?Thankyousooooo much,Doc.You’rea reaaal lifesaver!”

Standing inthedoorway, Dr. Levesqueshifteduncomfortably. Hewanted tosaysomethingencouraging, somethinghopeful…butthewordsgotchokedupinhisthroat.Allhecouldmanage wasonemoreweaksmile.

Asheturnedand lefttheroom,asingletear rolleddownhischeek…

Don’t thankmejustyet,hethought.

Sideeffectsofopioidsincludeitchiness,sedation,nausea,

respiratorydepression,constipationand

euphoriaWhataresideeffects

ofopioidconsumptiondoctor?

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Case 2 – “CHILL”JamesscrolledlazilythroughhisInstagram feedinthebackseatofhismom’ssilverCorolla.Therewasacutedogvideohere,somefunnymemesthere.Hepausedataparticular postand frowned.

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It was another one of those Health Canada warnings about fentanyl in street drugs or something.

Hefeltlikehewasseeingthoseeverywhere…itwasreallystarting toannoyhim.

Astheypulleduptotheparty, Jamescould feelthecar seatsvibrating intandemwiththeloudthumpingbeatsofmusicfromoutside.Heopenedhisdooranddidn’tevengetboth feetonthegroundbeforehismotherbeganshoutingafterhim

“Besafehoney!Iloveyou!Remember that—”

“STOPITMOM,you’reembarrassing me!”Jameshissed

“Iknow,Mom!Youalready toldmethislikeamilliontimes.”

“Behomeby11pmsharp,youngman!”

It was Angie’s 19th birthday, her parents were out of town, and it was meant tobe one for the books. Pretty much everyone that was anyone was invited tothe party… which made James feel kind of good about himself.

As he entered Angie’s gigantic mansion, he was starkly greeted by the potentsmell of marijuana.

“Yo James, over here!” shouted Ben. Ben was one of James’ closest friendsfrom their early childhood and despite having made some very different lifechoices since then, the two were still very close. James made his way towardsBen through the packed crowd of teens.

“Ben, I didn’t know it was THIS kind of party” exclaimed James.

“Chill, bro. The party hasn’t even started yet” replied Ben, pulling out whatappeared a poorly wrapped cigarette and spinning it between his fingers.

“Look what I got off the streets today!”

Jamesshookhishead.“Dudeputthataway,youknowI’mnotintothat.”

“FineJamesLames,”Benwinkedathim.“Ifyousayso!”Benproceededtolightthejointand tookacouplepuffs.“See?AmIdeadyet?What’s theretobesoscaredof?”Benplayfullypunched Jamesinthearm.

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Marijuana

Relieves chronic Pain

Addictive and may result in fatal overdose

Jamesfrowned.Hewasneverreallythatcuriousaboutdrugs.They justseemedso…strange tohim.

Eitherthatoritwasjustthewayhewas raised.Jamesthoughtofhowhismomwouldreact ifshecaught himusingdrugs…andshuddered.Yup,definitelythewayhewasraised.

***Asthenightwenton,mostofthegrouphadeventuallymigratedtothebackyard. Someonestartedsinging“HappyBirthday” forAngieandalmostinstantly,everyoneelsechimedin.Attheend,aftersomemorelaughsandshoutsdiedout,Angiedecidedtosayafewwords.

“Thankyouguyssooo much forcoming.This isliterallythebestparty Ihaveeverhad”Angiesaid,drunkenlyslurringherwords.

Peoplebegantocheerwildlyagain,raisingsolocupsandlightingmore joints.Jamescheckedhiswatchandsaw itwasgettingdangerouslycloseto12am…itwas timetocallitanight.Hewalkedover toAngie,gaveherahug,andwishedherahappybirthday.Then, justas Jameswaswalkingback towardsthehouse,hefrozeinhistracks.

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Benwassprawledoutonalawnchair…eyesclosedandunmoving. Jamesapproached hisfriendslowly…awaveoffearsuddenlyrushingoverhim.

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Ben’sfingernailsandlipshadbothturned

“Hahaaa! Everyonelookatthat lightweightoverthere!”someoneshoutedfromthecrowd.

JamesreachedoutandcheckedforBen’spulse.Itwasabnormally slow.Benstilldidn’tmove.

Angiewalkedovertoseewhatwasgoingon,onlytogaspwhenshesawBen.“Ohmygosh!Someonehashadway toomuchalcohol!”sheshrieked.

“No,”Jamesreplied,hisvoicebeginningtoquiver.“Thisisdifferent…I…Ithinkhe’s…overdosing.”

“Butoverdosingonweedislikeimpossible!”Angieinsisted.

Jamespulledouthisphoneandscrolledback totheHealthCanadapost.Hereadthrough thesymptoms andhiseyeswidened.“Id-don’tthink…Idon’tthinkit’sweed,”Jamesstammered.HeplacedahandonBen’shand. Itwasicecold.“S-someoneneedstocall911!”

Everyoneattheparty froze.

“ISAIDSOMEONE CALL911!”

Case 3 – URGENCY

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Theambulance soonscreechedtoahalt infrontthesuburban housewheretheemergencycallwasreported.Nickgasped…itwashisaunt’shouse.Heandhispartner,Tyler,gotoutandrushed towards thefrontdoor.

Nick,knowing fullywellthathisauntneverlockedherdoors, immediatelyreached forthehandleandflungthedooropen.

“Whatareyoudo-“Tylerbegan, slightlyshockedbyNick’snervousenergy.

Withoutaword,Nickrushed insidethewell-lithome.Hepausedinthefoyer,attentivelylisteningforanysignsofhisaunt.Heheardwhathewaslookingforandran tothekitchen,Tylerfollowingcloselybehindhim.

Ontheground,groaning through grittedteeth,wasNick’saunt,Cindy.Sheclutchedthebackofherneckinonehand,andherenormousbabybellyintheother.Nexttoherwasachair thathad fallenover.Nickrushed toherside.“AuntCindy!”

“Nick,isthatyou?Pleasehelpme!I’minsomuchpain!”AuntCindycriedout.“I…Iwasreaching forsomesauceontheuppercupboard, and Ilostmybalance.Agh!”

“4033ETA?”

“4033toDispatch, 3minutesout.”

Nickheardcracklesofstaticandaburstofradioactivity, “TwoEMT’sonthescene,oneonstandby.”

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“Don’tworryAuntCindy,you’reingoodhands!”NicklookedovertoTyler.

Tylernodded.Theyquickly loadedherontothestretcherandbroughtherback totheambulance.

AsTylermannedthewheelandspedback towards thehospital,Nicksatnexttohisaunt.Witheverybumpintheroad, sheseemedtobefeelmorepain.

“Nick…”shewasstruggling totalk.

Nickheldontooneofherhands,“Cindy,it’sgoingtobeokay.We’regoingtogetyou tothehospitalandwe’regoing togetyouonsomemedication foryourpain.Everything isgoing tobeokay.”

Cindy’seyeswidened.“But…the…baby…”shegasped.Beforeshecouldsayanythingelse,theambulance joltedviolently.Tylermusthaverunoverapothole.Withasharpshriek,auntCindypassedout.

“Dang it,Tyler!”NickshoutedasheplacedAuntCindy’shandgentlybackontothestretcher.Helookeddownatherlimpbody.Whatwasshetrying tosay?hewonderedbriefly.Thenheshookhishead.Whateveritwas, I’mgoingtomakesureyougetthecareyouneed.

Afewdayslater,Nickwentback tothehospital tocheckuponhisaunt.WhenanurseinformedhimthatCindyhadgivenbirththedayprior,hebecameevenmoreexcitedandrushed intoseeher.

Assoonasheenteredherroom,however,hisexcitementfadedquickly.AuntCindywassittingupinherbed,anxiously fidgetingwithherfingers.Nickcouldtellsomethingwaswrong.

Begentlewithher,buddy, shehasahistoryoffibromyalgia, Isuspectthefalliscausingherpain toflareupaswell.”“

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Nickwalkedovertoherbedside.“Heyauntie,how’sitgoing?”

“Areyoufeelingbetter?”Nickbeganagain.

“Idon’tfeelathing…guessthemedsareworking”Cindyrepliedbluntly.Anawkwardsilence ensued”

Cindysighed“LookNick,Iappreciatewhatyoudidforme,”shebegan,“butI’mreallyconcerned about—"

Cindydidn’trespond.Shedidn’tevenlooktowardshim.

Nickcouldn’thelpbutfeelatingeofannoyance. Isavedyourlife,atleastyoucouldsaythanks,hethoughttohimself

Justthen,adoctorwalkedinwithanuneasylookonherface.BothCindyandNickturnedtowardsher.Thedoctorkeptglancingdownatherclipboard andbackatCindy.

“What’s thematter,Doc?”inquiredNick.

Thedoctorbitherlip.“It’sthebaby…” shesaid.“He’s…he’sshowingwithdrawalsymptoms.”

Nick’sheartdropped.ItdawnedonhimthatCindywasn’tworriedaboutherselfatall;shewasworriedaboutthepainkillersaffectingherbaby.HelookedbackatAuntCindy,whosefacehadfallintoherhandsasshesobbedviolently.

Whathadhedone?

So,nowthatyou’vereadthrough thecases,howwillyouapproach theOpioidCrisis?Informingyourownresearchproposal, trytodecideonanissuethatyoufeelmostpassionatelyabout first,thenaskyourselfasmanyquestionsasyoucanaboutwhereyoucangowithit.Ifnoneofthecasesparticularly intriguedyou,itishighlyencouragedtoexplorefurtherdetailsthroughyourownresearch!Remember, thecasesweredesignedpurelyforinspirationalpurposesanddonotcoverallaspectsoftheOpioidCrisis.Tosummarize,wehavecompliedsomeofthemainissuesseenthroughoutthecasesbelow.Furtherquestionstoconsiderarealsolistedintheadjacentcolumn.Toreiterate,youarenot limitedtotheseproblems;pleasefeelfreetoexploreyourownideas!

The Challenge

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Problemhighlighted Questions toconsider /explore

Opioids are being over-prescribed How does pain work? How do opioids work?Can an alternative painkiller be developed?

Opioid use often leads to addiction Is there a genetic basis for addictionsusceptibility? Is there a way doctor ’s canscreen patients before prescription?

Street drugs can be laced with unknownsubstances

Is there any way to test for opioid presence?Could the test be made commerciallyavailable?

Potent opioids can lead to overdose evenwhen consumed in small quantities

Why are opioids so dangerous? Can theharmful effects be reduced withoutaffecting the benefits?

Neonatal Abstinence Syndrome is a seriousissue that affects innocent newborns

Why and how do the babies get affected? Isthere any way to prevent this?

*Bonus*

Naloxone is the most commonly used drugto immediately treat overdose

How does it work? Does it have any sideeffects? Are there any ways to reduce /alleviate these side effects? Is there a betterway to treat overdose patients?

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ReferencesFirth,S.(2018,July17).GrowingArray ofStreetDrugsNow LacedwithFentanyl.Retrieved from

https://www.medpagetoday.com/primarycare/opioids/74071

Freepik. (2018).Abstractbluebackground. [online] Availableat:https://www.freepik.com/free-vector/abstract-blue-background_859016.htm#term=abstract background&page=1&position=8.

Freepik. (2018).Monochrome lowpolybackground. [online] Availableat:https://www.freepik.com/free-vector/monochrome-low-poly-background_2957011.htm#term=abstractbackground&page=3&position=1 [Accessed 1Nov.2018].

Informationsheet onopioidoverdose. (2018,August 21).Retrieved fromhttp://www.who.int/substance_abuse/information-sheet/en/

Mayo ClinicStaff.(2018,February 16).AmIvulnerable toopioidaddiction?Retrieved fromhttps://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372

Morphine. (n.d.).Retrieved fromhttps://livertox.nih.gov/Morphine.htm

Neonatal Abstinence Syndrome.(n.d.). Retrieved fromhttps://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387

Rzasa Lynn,R.,&Galinkin,J.L.(2018).Naloxonedosage foropioidreversal: currentevidence andclinicalimplications.Therapeutic advances indrugsafety, 9(1),63-88.

Schiller,E.Y.,&Mechanic,O.J.(2017).Opioid,Overdose.

Seth,P.,Rudd,R.A.,Noonan, R.K.,&Haegerich, T.M.(2018).Quantifying theepidemic ofprescriptionopioidoverdose deaths.

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Partnership :

Funding :

Sponsors

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