Writing Sample-Policy Analysis

PREVENTING OVERDOSE: A CRITICAL ANALYSIS OF STREAMS MODEL

Preventing Overdose:A Critical Analysis of Streams Model

Oksana KishchukFor: PAPM2000A

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Introduction

On January 14, 2016 Health Canada announced an amendment to review the prescription

classification of Naloxone an injectable anti-opiate drug, in an effort to combat the increased

number of overdose deaths by use of opioid drugs (Government of Canada, 2016). Presently,

Naloxone is available as a prescription only drug. If the amendment is successful Naloxone can

be distributed by pharmacists to the public without prescriptions in an to allow for easier access

and administration of the drug. This policy decision, like many others can be explained through a

policy model analyzing the factors of its implementation. The decision to propose this

amendment has been put forth due to a variety of factors of which can be described by John

Kingdon’s “streams model” presenting in his 1984 book, Agendas, Alternatives and Public

Policy. Kingdon’s theory provides a framework to describe policy decisions, explaining their

origins and timelines. Streams theory separates the discussion of a particular issue into three

streams, problems, policy and politics, operating simultaneously, and independently (Kingdon,

2011, p. 87). Streams theory states that action occurs when all three streams join together in

consensus for change, at a wedge event (Kingdon, 2011, p. 165).

This paper will argue that streams model accurately depicts the federal government’s

decision to propose an amendment to the drug schedule of Naloxone, an anti-opiate drug. This

decision was caused by the culmination of an increasingly visible problem of numerous overdose

deaths, a tangible policy solution presented by health organizations across Canada, and a public

outcry reacting to the increased visibility of an overdose problem. To begin a brief history of

streams model and Naloxone will be presented. Secondly, a discussion on opiate drug overdoses

in Canada will be presented followed by an analysis of the presence of a policy solution within

Canada. Thirdly, a discussion on the public mood regarding the prescription drug overdose crisis

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will be provided. Lastly, to provide a full application of streams model, the culmination of the

problem, policy, and public mood will be discussed, as well as the flaws of the model.

History

The Streams Model

The streams model was conceived by John W. Kingdon in his book, Agendas,

Alternatives and Public Policies, first published in 1984. Kingdon’s streams model of analysis is

an elaboration of the ‘garbage can model’ designed by Cohen, March and Olsen in 1972 which

argues that action within government occurs only when decisions and ideas discussion

independent of each other have a random interaction. (Baumgartner & Jones, 2015, p. 32).

Kingdon elaborates upon this concept suggesting that rather than the interactions being random,

they are the result of complex and intricate processes operating in three separate streams,

problems, policies and politics that when joined together with a wedge event create action

(Schuh, 2000, p. 34) (Kingdon, 2011, p. 87). The problems stream operates by using problem

definition, an integral feature of a policy model for Kingdon. It is necessary that indicators, such

as statistical data, are used to define a problem as they signal changes in continuous issues and

allow experts to assess the problem’s degree of significance (Kingdon, 2011, p. 91). Indicators

are provided through feedback channels in the form of reports or daily operational feedback

(Kingdon, 2011, p. 101). Integral to the problems stream success is the wedge event, a glorified

indicator.

The second stream in Kingdon’s model is the policy stream consisting of policy

communities, governmental and non-governmental, creating a multitude of policies, floating in

“primeval soup” (Kingdon, 2011, p. 117). Through natural selection, Kingdon (2011) says,

policies will rise to the focus of the community with the assistance of policy entrepreneurs,

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advocates for a specific issue (p. 122). The policy is then put through a variety of criteria to test

success including “technical feasibility” (Kingdon, 2011, p. 131), its compatibility with the

values of major actors, and its sustainability into the future (Kingdon, 2011, pp. 132–137). Once

the policy has successfully completed these criteria it needs to diffuse into the public aided by

the bandwagon effect a phenomenon where major players begin to agree on an issue until its

eventual unanimous adoption as a policy decision and a change in the public mood (Kingdon,

2011, p. 141).

The final stream of the streams model is politics. It is comprised of “national mood…

organized forces… [and] governmental phenomena” (Kingdon, 2011, p. 146). The national

mood is “the common perspective of a large number of people in the country” (Schuh, 2000, p.

35), determined by a variety of factors such as polls (Kingdon, 2011, p. 149). Kingdon (2011)

states, that while organized political forces, also known as interest groups are not a large part of

decision making, risks of opposing interest groups are taken into consideration when decisions

are made (p. 151). Lastly, government actors respond in accordance with the interests of the

public and interest groups to create policy that is favorable to both groups (Kingdon, 2011, p.

158). The three streams join together to create change at a wedge event, known as the policy

window. This window acts as an “opportunity for advocates of proposals to push attention to

their special problems” (Kingdon, 2011, p. 165) and occurs when a problem is coupled with a

solution and is present on the decision agenda of the government (Kingdon, 2011, p. 166).

Naloxone in Canada

Naloxone is an anti-opiate drug that suppresses the effects of opiate drugs such as heroin

(Simon, Hedrich, McDonald, & Strang, 2016, p. 1). Naloxone is injected into an arm or thigh

muscle, immediately acting as an antidote to opioids and reversing their effects for 30 to 90

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minutes (HealthLink BC, 2015, p. 1). There have been no discovered addictive qualities of

Naloxone and in 2014 the World Health Organization recommended that Naloxone be available

to “anyone likely to witness an overdose”, listing it as an essential medicine (Simon et al., 2016,

p.2).

Within Canada, Naloxone was approved for use within hospitals over 40 years ago with

Health Canada currently listing 10 drug products containing naloxone as approved for

use(Government of Canada, 2015). Four of these products are classified under the Canadian

Drug Safety Act Schedule 1 as Narcotics, while the other six products are classified as

prescription drugs (Government of Canada, 2012). All of these drug products cannot be used

unless administration or prescription by a physician is provided to a specific individual

(Government of Canada, 2012). Currently, there are many Naloxone distribution programs

across Canada run by health regions, cities, or street distribution clinics. Once obtaining a

prescription for a client, these programs train clients, family and friends on the proper

administration procedure of Naloxone and distribute the medication (Eggertson, 2014).

In July 2015 the Government of Canada announced it was reviewing the status of the

drug Naloxone, to remove the drug from the prescription only drug list due to an increasing

threat to public safety of overdose deaths (Government of Canada, 2015). The process,

anticipated to take approximately 18 months, began with a consultation process with provinces

and territories to provide information on existing naloxone distribution programs in their cities,

towns and health regions. If consultation results were proven to be positive, an online public

consultation process would proceed. The proposal is currently at this stage and if it is not met

with any opposition the drug schedule of naloxone will change as soon as possible (Government

of Canada, 2016).

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Overdose Crisis: Problem

The problem streams, as the name suggests, focuses on identifying and verifying a clear

problem in society, either a crisis or long term problem (Kingdon, 2011, p. 90). Actors bring

indicators of a problem to the attention of officials via indicators and when events are large

enough guide the government to push for a policy change. In the case of the proposed

amendment of Naloxone, it was caused in part by this process as there was an increasingly

visible opioid problem at the time of the proposed amendment. The first call for action on

prescription drug abuse in Canada was in a 1979 study and it has only become more pressing

since (Haydon, Rehm, Fischer, Monga, & Adlaf, 2005, p. 459). In 2014, Canada has the second

highest per capita consumption of narcotic drugs in the world (Narcotics Control Board, 2014, p.

20) Of particular concern is benzodiazepine, an opioid, of which Canada uses an amount 15

times greater than then United States (Haydon et al., 2005, p. 459).

As the streams model states, actors, both governmental and non-governmental are

responsible for bringing a problem to light (Kingdon, 1984, p. 117). As the Government of

Canada does not collect nation-wide data on prescription drug overdose deaths across Canada,

the major governmental actors are provincial governments. Additionally, other major non

governmental actors are community clinics providing information about overdoses by their

clients.

The problems stream gains momentum by guiding events, containing indicators of a

current problem and the possibility of a future crisis. The first indicators of a prescription drug

overdose problem began in the the 2000s. In Ontario, between 1991 and 2004, deaths related to

opioid use increased by 41%, and according to a coroner report, death was unintentional in

52.4% of the cases examined (Dhalla et al., 2009, p. 891). Specifically in Ontario prescriptions

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of oxycodone, an opioid drug, increased by 850% between 1991 and 2007 (Dhalla et al., 2009, p.

892). Even more troubling was that until 2010 there was no recommended maximum dose

threshold for many opioid prescription drugs, allowing large prescriptions to be filled (Gomes et

al., 2011, p. 18). This information, coupled with Canada’s staggeringly large nationwide

consumption was an indicator to the problem stream that there was the potential for a crisis to

unfold. The problems stream, according to Kingdon is also concerned with the budgetary

constraints of a problem (Kingdon, 2011, p. 98). Aside from social implications substance abuse

is a budgetary concern, costing Canada 39.8 billion in 2009 (Grant, 2009, p. 655).

As mentioned earlier, one of the key aspects of the problems stream is the wedge event,

or a glorified indicator. For the Naloxone decision, this became clear as overdose deaths began to

increase at an alarming rate. Between 2006 and 2011 there was a 23% increase in high dose

opioid prescriptions in Canada (Gomes, Mamdani, Paterson, Dhalla, & Juurlink, 2014, p. 13). In

BC, between 2014 and 2015 there was a 27% increase in drug overdose deaths (Woo, 2015).

Furthermore, in Alberta in 2015, over 200 people died of an overdose from just one type of

opiate drug (Woo, 2015).

Community Solution: Policy

As it became clear that there was an overwhelming problem at hand, the policy

community was building support and providing a solution which allowed for a policy decision to

be made. In Kingdon’s model this is described as the policy stream where policy entrepreneurs

pushing ideas through criteria to create change (Kingdon, 2011, p. 117). Provincial government

and community clinics across Canada acted as entrepreneurs developing a policy to reduce the

number of overdose deaths.

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Research across Canada found that 85% of overdoses occurred when an individual is not

alone (HealthLink BC, 2015, p. 2), and thus if provided with a tool, friends family and strangers

may be able to prevent more overdose deaths. To address the growing overdose crisis,

organizations across Canada began to formulate policy, acting as policy entrepreneurs, to combat

the crisis by implementing Take Home Naloxone (THN) programs, providing Naloxone to opiate

prescription drug users and abusers with prescriptions.

A major aspect of policy’s success according to Kingdon is its technical feasibility

(Kingdon, 131), and whether or not the policy will succeed when implemented. The feasibility of

THN kits was already proven as the drug had been administered via prescription to those using

opiate drugs through many clinics, and with great success. The first THN program started in

Edmonton, Alberta in 2005 (Eggertson, 2014). The program was started by Streetworks, a needle

exchange program, whose staff would identify potential participants, train individuals on

Naloxone use, and, when a prescription was issued, provide a THN kit (Canadian AIDS

Treatment Information Exchange (CATIE), 2015). All current programs in Canada follow a

similar method of implementation: identify clientele that would benefit from a naloxone kit,

obtain a prescription for the individual, and train the individual and family and friends how to

administer the naloxone should it be necessary. The organizations began to see real change, with

a Naloxone distribution program in BC reversing 85 overdoses in its first twenty months of

operation (Tzemis, Al-Qutub, Amlani, Kesselring, & Buxton, 2014, p. 3). THN were proven to

be feasible as protocol for administration had already been created through existing programs

and data showed that Naloxone was saving lives.

The second qualifier of success for a policy in streams model is its acceptability amongst

the specialists in the policy community(Kingdon, 2011, p. 133). THN programs have been

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accepted across Canada by experts as a valuable method of preventing overdose deaths. Since

the inception of the THN program in Edmonton, several other programs have started across

Canada signalling its acceptance among professionals in the field of prescription drug abusers.

Among the many programs implemented are the Preventing Overdose in Toronto (POINT)

program which began in 2011, the Peer Overdose Prevention Program in Ottawa, beginning in

August, 2012, and the British Columbia Take Home Naloxone (BCTHN) program which

commenced in 2014 (Eggertson, 2014, p. 8). The overwhelming support of naloxone programs in

the professional communities is still strong as earlier this year seventy three physicians signed a

petition to allow ease of access to Naloxone products (Clancy, 2016).

Lastly, a consideration within the policy stream is the “anticipation of future constraints”

(Kingdon, 2011, p. 141). To be proven successful a policy solution must adequately provide

solutions for budgetary concerns and “public acquiescence”(Kingdon, 2011, p. 141). The

distribution of naloxone kits provided little budgetary concerns as an average kit which can be

used for one overdose episode costs just $20-$30CDN (Canadian AIDS Treatment Information

Exchange (CATIE), 2015). Regarding public support, current programs have had overwhelming

support from clients and their families. In a study conducted to review the BCTHN program,

both client and provider feedback was positive. Clients and family and friends stated they felt

confident in using the kits, and a sense of security knowing they were able to save a loved one’s

life with the use of a kit (Tzemis et al., 2014, p. 157). Support amongst providers was also

positive as the programs allowed an avenue of contact between provider and client to relay

important overdose information, and discuss health issues (Tzemis et al., 2014, p. 158).

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Public Support: Politics

The last stream in Kingdon’s (2011) streams model is comprised of three characteristics;

national mood, organized political forces, and consensus building (p. 146), of which were all

active in the decision to change the drug schedule of Naloxone. To reiterate, the streams model

describes the national mood as the opinion of a majority of the population in regards to a

particular topic (Kingdon, 2011, p. 146). With support from the national mood for the increased

access to Naloxone, according to Kingdon, the policy has the public basis to move forward

(Kingdon, 2011, p. 147). In the West in particular, a skyrocketing number of deaths due to

prescription drugs have drawn the public’s attention towards to issue as well as the solution of

Naloxone. Many of those that have died of opiate drug overdoses are young, recreational users

and thus their families have began to advocate strongly for a policy solution (Woo, 2016).

In streams model Kingdon notes the importance of interest groups in mitigating change,

an aspect of streams model that is especially pertinent in the case of Naloxone in Canada. The

two major interest groups in this field are the Canadian Centre on Substance Abuse, and the

Canadian Drug Policy Coalition. Kingdon says while decisions are not made just to please

interest groups, their reactions to certain policy decisions do play a role in policy change

(Kingdon, 2011, p. 150). With the interest groups taking notice in the increase of overdose

deaths, both have advocated at the national level for ease of access to Naloxone, working on

collaborations with the Federal Government such as the “First Do No Harm” report, which as

allowed these groups to advocate their position directly towards the government (Bishop, 2013).

The last component of the streams model is the government in particular elected officials,

which takes into consideration the interests of both the national mood and the interest groups.

True to the streams model, in response to the increased public support and rallying for increased

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access to Naloxone, the Government of Canada began a consultation process in July 2015, to

consider amending the drug schedule of Naloxone. In this process the government consulted with

the governments of the provinces and territories, and their respective interest groups and the

public mood (Government of Canada, 2016), following the outline of streams model.

The Window of Opportunity

In Kingdon’s model, there are two final steps to a policy decision. Once the streams have

aligned with the help of a wedge event and the problem has been coupled with a solution agreed

upon by all streams, the issue enters onto the government agenda (Kingdon, 2011, p. 166). This

moment occurred in July of 2015 when the government issued a consultation process to change

the drug schedule of Naloxone. The problem of drug overdoses was on a steady up rise, current

THN programs had proven successful, and the public was in support of policy that would

decrease the number of deaths.

The second final step is the advancement to the decision agenda, operating within the

government agenda (Kingdon, 2011, p. 166). The decision to amend the drug schedule of

Naloxone was placed on the decision agenda on January 14th, 2016 when Health Canada

announced the amendment to the drug schedule of Naloxone, to allow the drug to be provided

over the counter in emergency situations (Government of Canada, 2016). Kingdon (2011) says if

the policy is successful here, the policy decision is formed (p. 166).

Flaws of the Streams Model

While the streams model does effectively explain Health Canada’s decision to amend the

drug schedule of Naloxone, it is important to note that is does not account for all components of

this policy decision. Streams model does not take into consideration the international influence

of this decision, in particular in the policy stream, as many THN programs were operating

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worldwide prior to their introduction to Canada (Strang, McDonald, Hedrich, & Simon, 2016, p.

89). It could be argued these programs have provided international influence to clinics that had

been administering the programs and thus providing a viable solution for the policy stream, an

aspect that is absent from Kingdon’s model. Additionally, as the streams model was conceived in

1984 it does not account for the influence of social media. The public mood in this decision is

largely facilitated by advocating families who use social media campaigns to draw attention to

their cause and grow the public mood for a policy change (Clancy, 2016). This is a factor that the

original streams model does not accurately account for.

Conclusion

The streams model, generated by John Kingdon, accurately describes the policy decision

of Canada to propose an amendment to the drug schedule of Naloxone as the structure of

implementing this change follows the outline of streams model. First this is evidenced by the

increased problem of opiate drug consumption and subsequent overdose deaths across Canada,

indicating that there is a problem at hand. Secondly, the policy dialogue had a tangible solution

to mitigate the crisis in the form of already proven successful THN programs across the country.

Thirdly, the national mood and interest groups supported government policy that had the

potential to decrease the number of overdose deaths. Finally, the culmination of an overdose

death crisis, probable policy solution presented by provincial governments and the public

demand for a solution prompted Health Canada’s decision to propose an amendment to the drug

schedule of Naloxone.

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References

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Writing Sample-Policy Analysis

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