Crime Victims’ Experience with Chronic Pain in Canada

Office of the Federal Ombudsman for Victims of Crime

June 2020

The Federal Ombudsman for Victims of Crime is mandated to promote awareness of the needs and concerns of victims and survivors of crime among policy makers, and to identify systemic issues that affect victims negatively so that they can be addressed.

Introduction

In 2018, the Government of Canada formed the Canadian Pain Task Force (CPTF), giving it a three-year mandate to investigate how to develop an improved approach to the prevention and management of chronic pain. The CPTF produced its initial report^[1] on assessing how chronic pain is managed in Canada in 2019 and is currently working on its second report.

With the growing knowledge about the role chronic pain plays in the lives of so many, comes the understanding that its effects are costing Canadians dearly. Two commonly cited statistics are:

One in five Canadians suffers from chronic pain; and,
Pain accounts for 10-16% of emergency department visits.

This submission addresses the significant linkage between the chronic pain some Canadians suffer as a result of their experience with violence, abuse and trauma. The Task Force Co-chairs should seek out and include victims, victim advocates and academics specializing in victimology in their stakeholder group, so that their concerns and views are included in the strategies and tactics that are developed to address chronic pain. By doing this, the CPTF can ensure that the chronic pain issues of victims and survivors of crime are addressed along with those of other Canadians.

While the initial report of the CPTF identifies certain groups as being at higher risk for chronic pain, such as older adults, women, Indigenous peoples, veterans and people affected by social inequities and discrimination, it fails to mention one group which is also disadvantaged, and that is, victims and survivors of violent crime, including victims of impaired drivers.

We believe there is intersectionality between the identified groups above and victims of crime. The CPTF initial report is striking in that its language describing the experiences and feelings of chronic pain patients is virtually identical to the language used by victims and survivors of crime to describe their experiences and feelings. Disbelief, stigma, lack of services, isolation and lack of support are all conditions victims regularly encounter.

The incidence of violent crimes in Canada leaves behind a legacy of many victims who suffer disabling injuries. The disability is sometimes permanent. Either way, victims of violence suffer pain, which is sometimes chronic, and related psychological and social effects. Their voices need to be heard and their needs addressed. The lack of structures to address chronic pain is a systemic issue that negatively affects victims and survivors of crime.

Violence, abuse and trauma can cause chronic pain

Gender-based violence—a case in point

The CPTF initial report highlights women as a group that suffers disproportionately from chronic pain, but does not delve into why women are so afflicted. A possible explanation, at least in part, is that women are by far the most likely to be victims of gender-based violence (GBV), and to suffer injury due to this violence.

GBV takes many forms: intimate partner violence (IPV), sexual assaults, hate crimes committed against non-gender conforming persons, including assaults, and sexual predation on children. Many of the OFOVC’s clients are victims of one or another form of GBV.

GBV is recognized as a growing problem in Canada; so much so, that the Department of Women and Gender Equality (WAGE) is developing a national strategy to address it.^[2] Below are statistics collected by WAGE which provide an overview of what GBV looks like in Canada:

“Some populations are more likely to experience violence and may face unique barriers and challenges that put them at particular risk. For example:

Women are at a 20% higher risk of violent victimization than men when all other risk factors are taken into account;^[3]
Of all sexual assault incidents, nearly half (47%) were committed against women aged 15 to 24;^[4]
Indigenous women (10%) were more than three times as likely to report being a victim of spousal violence as non-Indigenous women (3%).^[5] Indigenous identity is a key risk factor for victimization among women, even when controlling for the presence of other risk factors;^[6]
Women with a disability were nearly twice as likely as women without a disability to have been sexually assaulted in the past 12 months;^[7]
Lesbian and bisexual women are 3.5 times more likely than heterosexual women to report spousal violence;^[8]
Six in ten (58%) senior victims of family violence were female, with a rate 19% higher than that of male seniors;^[9] and
Women living in the territories are victimized at a rate eight times higher than those living in the provinces. Women living in the territories have a risk of violent victimization about 45% higher than men’s (when controlling for other risk factors).^[10] Remote and isolated communities face particular challenges related to access and availability of support.”^[11]

Men and boys can also be victims of gender-based violence, whether it be as a result of gender non-conformity, domestic violence or as child victims of sexual predators.

Intimate partner violence

Chronic pain in abused women stems in part from a complex biopsychosocial stress response to abuse-related physical or psychosocial trauma in childhood and adulthood. Trauma is defined as extreme stress associated with such events as physical and sexual assault.

Chronic pain may result from neuropathic changes associated with abuse-related injuries and endocrine and immune system changes associated with psychological responses to trauma, such as Post-traumatic stress disorder (PTSD). PTSD has been identified as a mediator of the relationship between trauma and physical health outcomes. In a recent review of studies of immune function in PTSD, an excess of inflammatory immune activity similar to that associated with chronic pain was identified. Intensity, distress, and disability are greater in persons with chronic pain who also have PTSD.^[12]

Some studies have found that there is evidence to support that psychological abuse can result in chronic physical pain.^[13] IPV, also known as domestic violence or abuse, exists in all societies across the globe. The World Health Organization states the physical damage resulting from IPV can include: bruises and welts; lacerations and abrasions; abdominal or thoracic injuries; fractures and broken bones or teeth; sight and hearing damage; head injury; attempted strangulation; and back and neck injury.^[14] However, in addition to injury, and possibly far more common, are ailments that often have no identifiable medical cause, or are difficult to diagnose. These are sometimes referred to as ‘functional disorders’ or ‘stress-related conditions’, and include irritable bowel syndrome/ gastrointestinal symptoms, fibromyalgia, various chronic pain syndromes and exacerbation of asthma.^[15] Research from 2012 from the Department of Justice Canada examining the Health Impacts of Violent Victimization on Women and their Children notes: Physical health problems associated with IPV exposure include chronic pain, disability, fibromyalgia, gastrointestinal disorders, irritable bowel syndrome, sleep disorders and general reductions in physical functioning/health-related life quality. Recent analyses indicate that IPV may be associated with cardiac disease.^[16]

According to the Department of Justice Canada, there is growing evidence of the strong links between violence against women and children and significant physical and mental health impairment, and risky health behaviours. These are prevalent among children, youth and adults victimized during childhood and/or adulthood. Certain groups, for example Canada’s Aboriginal women, are at increased risk of more, and more severe, violence, and potentially more significant health impacts. While physical injuries and death form an important sub-set of the health impacts of violence, the more prevalent consequences are longer-term mental health problems, which in turn contribute to health risks as well as increasing the likelihood of being a violent offender or being re-victimized at a later point in time. As well, newer research points to the longer term chronic diseases associated with violent victimization.^[17]

Female victims of sexual assaults

Sexual violence (SV) is an urgent public health issue that is common and has lifelong effects on health. Women, particularly young women, are also by far the most frequent victims of sexual assaults. As noted above, in 2014 nearly half (47%) of sexual assaults were committed against women aged 15 to 24. While not all women who are sexually assaulted suffer serious physical injury, this preponderance of female victims of sex-related crimes could also be a contributing factor to the high numbers of women experiencing chronic pain. If nothing else, the stress associated with being the victim of sexual violence can be very harmful to emotional and mental health.

According to Statistics Canada’s Police-reported crime statistics in Canada, 2014 (UCR 2014), there are three categories of sexual assault committed against adults. The 2014 UCR reported 105 sexual assaults at level III, 319 at level II, and 20,735 at level I. The UCR also reported 4,452 sexual violations against children.^[18]

By comparison, the 2014 General Social Survey (GSS) conducted by Statistics Canada recorded that 633,000 Canadians over 15 years of age were sexually assaulted.^[19]

Thus, the GSS demonstrates that sexual assault is the least-reported violent crime, at between 5-10 percent. The chart below documents results from four successive GSS conducted at five-year intervals from 1999-2014.^[20] Results from the 2019 GSS are expected to be published in late 2020.

violent victimazation incidents reported to police

The criminal justice system can impose additional harms upon survivors who report sexual violence. Police response is a factor, as well as the criminal trial process. Victims and survivors’ experiences of the criminal justice process have frequently been negative and traumatic, to the point where going through the justice system is often referred to as the “second rape”.

In the only nationally representative female sample to examine health conditions associated with any lifetime experience of rape, US researchers examined injury and health outcomes (e.g., fear, injury) resulting from any violence by a perpetrator of rape. About two in five rape victims (39.1%) reported injury (e.g., bruises, vaginal tears), and 12.3% reported a sexually transmitted disease as a result of the rape victimization. Approximately 71.3% of rape victims (an estimated 16.4 million women) experienced some form of impact as a result of violence by a rape perpetrator. Among U.S. women, the adjusted odds of experiencing asthma, irritable bowel syndrome, frequent headaches, chronic pain, difficulty sleeping, activity limitations, poor physical or mental health, and use of special equipment (e.g., wheelchair) were significantly higher for lifetime rape victims compared with non-victims.^[21] We should make efforts to gather injury and health outcomes for Canadian women impacted by sexual assault.

Medication use among survivors of intimate partner violence

A critical area of research focus is the linkage between medication use to ease the chronic pain experienced by victims of violence. There a few studies that explore the pattern of medication use in women who have experienced IPV and they show how that their experience differs from that in the general population. Individuals with a history of interpersonal trauma, including intimate partner violence, sexual assault, and adverse childhood experiences, are disproportionately affected by the current opioid epidemic.^[22]

The complex associations found among health problems, employment, diagnoses, and medication use highlight the need to consider treatment patterns within the context of the impact of lifetime abuse, economic survival, and parenting demands. Medication use must be understood as only one of a range of health interventions available to assist abused women to promote their health.^[23]

A recent research study on the relationship between sexual assault and opioid misuse noted that the relationship was confounded by exposure to other types of interpersonal trauma. Intimate partner violence was associated with opioid misuse among men. Adverse childhood experiences were associated with misuse among women. The interaction between intimate partner violence and sexual assault increased odds of opioid use among women.^[24]

Studies show how critical it is to address interpersonal trauma co-occurrence and examine gender differences in clinical practice and research related to opioid use/misuse. Such approaches are important for understanding the relationship between interpersonal trauma and opioid use/misuse by more accurately representing the complexity of the lives of survivors.

Adverse childhood experiences and chronic pain

The CPTF initial report highlights chronic pain in children, but again does not delve into what might be causing children to experience this pain. One factor that may help to explain some chronic pain in children is exposure to what is called adverse childhood experience (ACE).

ACE is described as physical, mental, or sexual abuse, emotional or physical neglect, a violent home environment, household substance abuse, exposure to parent mental illness, parental separation or divorce, and parental incarceration.^[25]

One source of ACE can be early childhood trauma resulting from IPV in the home. Even if a child in the home does not suffer direct physical or sexual abuse, merely witnessing violence between adults in the family can do serious damage to children that can have lifelong consequences.

While researchers are hesitant to state that there is a direct causal relationship between ACE and a variety of health issues experienced in adulthood, they do infer that the presence of 6 or more ACEs is associated with increased risk for a variety of negative health outcomes, including chronic pain, during childhood and beyond.^[26] Researchers also highlight a relationship between chronic pain and psychological distress in children and adults.

Victims of impaired drivers and chronic pain

While police-reported impaired driving cases have declined sharply over the past thirty years^[27], according to Justice Canada, “Impaired driving is the leading criminal cause of death and injury in Canada.”^[28] Victims can be pedestrians, cyclists or other motorists and their injuries can range from minor to severe and life-threatening. We know from the work of agencies like MADD Canada that injured survivors of impaired driving crashes often exhibit severe injuries such as burns, brain injuries, spinal cord injuries and physical disabilities. Many survivors live with chronic pain as a result of these violent, criminal offences.

Individuals who are involved in impaired driving crashes often incur bruises, broken bones, and head injuries. Those with burn injuries wear the scars of their trauma for the world to see. Burns can be physically and psychologically devastating. Fortunately, survival and mortality rates have improved substantially as a direct result of medical advancements. These advancements include painful and sometimes lifelong medical procedures.^[29] Survivors with spinal cord injuries face permanent and lifelong changes, often resulting in paralysis and/or loss of sensation below the site of the injury. Spinal cord injuries can also be physically and psychologically devastating.^[30]

Many victims/survivors of impaired driving crashes also experience silent, unseen and sometimes undiagnosed injuries to the brain. In fact, impaired driving crashes are a leading cause of traumatic brain injury. Survivors do not always suffer a coma, skull fracture, lacerations and broken bones, but later on, the consequences of the head injury begin to interfere significantly with the person’s life, and neither the injured individual nor the family relates the problems back to the crash. Even an injury that has been labeled a mild traumatic brain injury can be a significant injury that impacts family, personal relationships, employment and general well-being.^[31]

In 2018 police reported almost 70,400 impaired driving incidents, with a rate of 190 incidents per 100,000 population. Almost all (93%) police-reported impaired driving incidents continued to involve alcohol in 2018, while a small proportion (6%) involved drugs. The rate for all drug-impaired driving violations increased 25% from 2017. There were 4,423 drug-impaired driving offences in 2018, 929 more than the previous year.^[32]

Gun violence and chronic pain

Every year, a number of Canadians are wounded by gun violence but survive. Wendy Cukier’s research has found that gun deaths and injuries in Canada are a serious public health problem, claiming more than 1200 lives each year and resulting in over 1000 hospitalizations.^[33] In 2017, firearm related violence in Canada reached a 25 year-high: 266 people were killed with guns, and over 7,660 incidents of violent crime involving a firearm were recorded. ^[34]

In 2019, in Toronto alone, more than 760 people were shot.^[35] The consequences of gun violence are severe, but not always lethal, with survivors having to often undergo multiple surgeries as a result and life-changing effects. We know that survivors of gun violence carry wounds, both physical and emotional, for the rest of their lives.

Boston University's School of Public Health took part in a multi-decade study of firearm injuries.^[36] It found that the severity of gun wounds has increased significantly in recent years, which correlates with the growing lethality of modern weapons. "For those who live, the bullet has still gone through the body and caused injury to the intestine, to the liver or the spleen or to any number of blood vessels, and that is an extraordinary amount of damage to the human body," said Sandro Galea, dean at the BU School of Public Health, who co-authored the study.

According to Galea, the data show that 30% of shooting victims die; about 30% are treated in an ER and released; and roughly 40% require complicated treatments and prolonged hospitalization. Also, "Firearm injury is an extremely traumatic event," said Galea. "We know that people who suffer traumatic events have a high likelihood of having mental illness after that event, including post-traumatic stress disorder (PTSD)."

The Robert Woods Johnson Foundation reported a small research project examining chronic pain post recovery for gunshot wounds. Investigators interviewed 40 gunshot victims and found that just over half the victims retained, for various medical reasons, the bullet in their bodies. Researchers reported that those who retained the bullet in their bodies live with chronic or debilitating pain, and often suffered from anxiety and stress. What wasn’t reported was whether any of the victims also suffered from post-traumatic stress disorder (PTSD) in consequence of the violence.^[37]

The health-related cost of violent victimization

In 2016, the Department of Justice Canada published a study using data from the GSS and the Revised Uniform Crime Reporting Survey (UCR2) conducted in 2009 to illustrate the estimated medical and other costs associated with violent victimization. “The purpose of this report is to estimate the total costs associated with victimization of five violent crimes (assault, criminal harassment (stalking), homicide, robbery, and sexual assault and other sexual offences) involving adult victims (18 and up) where there was no spousal relationship between the victim and the offender in Canada in 2009.”^[38] These figures thus do not include medical costs associated with victims of IPV or victims of impaired drivers.

The self-reported GSS estimates the following incident (or victim) numbers for Canada in 2009:

Crime	Female	Male	Total
Assault	541,202	877,592	1,418,794
Criminal harassment	493,296	174,792	668,088
Robbery	62,575	80,846	143,421
Sexual offences	382,066	179,741	561,807

The police-reported UCR2 reports the following incident numbers for Canada in 2009:

Crime	Female	Male	Total
Assault	67,083	92,944 (58%)	160,027
Criminal harassment	37,001	32,741	69,742
Homicide	83	370 (82%)	453
Robbery	6,723	13,344	20,067
Sexual offences	8,054 (92%)	723	8,777

The estimated medical costs were found to be:

Crime	Total medical costs
Assault	$104,721,940.00
Criminal harassment	72,881,451.00
Homicide	3,806,629.00
Robbery	30,607,516.00
Sexual offences	113,121,308.00
Total	$325,138,844.00

The report highlights that the medical costs are likely to be under-estimated, due to a lack of data. In fact, there is no way of knowing how many of these victims and what proportion of the costs are associated with chronic pain. However, the sheer magnitude of the number of victims of violent crimes, and the associated medical costs, make it a factor which must be included in the discussion.

Canadian Pain Task Force Themes

The relationship between violent victimization and chronic pain established, it is time to outline how to address the chronic pain of victims in the context of the CPTF themes: Pain research and related infrastructure; Access to timely and appropriate pain care; Awareness, education, and specialized training; and Population health surveillance and health system quality improvement.

Pain research and related infrastructure

While the UCR is conducted annually, it is known to capture only a fraction of the data regarding violent victimization, as up to 70 percent of crime goes unreported. Virtually the only tool available in Canada to measure violent victimization is the GSS, which is conducted only every five years. Data regarding the seriousness of injuries sustained by victims and their short- and long-term care needs are not reported by either of these instruments.

Both health care services and victim services are provided at the provincial/territorial level, and extracting comparable data from these sources is challenging. These factors limit our knowledge base generally regarding violent victimization in Canada and, in particular, regarding the number of crime victims who may suffer chronic pain as a result of their injuries.

At the same time, several provinces are reducing services and funding for victims. It is vitally important to increase and improve the knowledge base about violent victimization and its consequences, so that policy makers will understand the need to increase services and funding for victims, rather than reduce them.

Moving forward, developing a single, common approach to collecting and reporting data about violent victimization and its consequences for victims could be of enormous assistance to researchers and policy makers alike. Also, it is critical that pain research address how many victims suffer from chronic pain due to violence or how many become disabled because there is little research currently available on this subject.

Moving towards acquiring knowledge regarding the relationship between violent victimization and chronic pain

In the United States, since 1979, violence has been identified as a public health issue. The Centers for Disease Control and Prevention, the key US public health agency, conduct an annual survey, The National Intimate Partner and Sexual Violence Survey^[39] to track IPV, sexual violence (SV), and stalking over time. While the ultimate aim of their research is prevention, the data collected provide important indicators for analysts, policy makers and administrators.

There is currently no corresponding research instrument operating in Canada.

Quantitative data

Hard data are essential to health care professionals, and other service providers, to policy makers and to administrators. The increasing use of electronic systems to collect and store patient data brings with it opportunities including:

For health care providers, to have patient information at their fingertips;
For researchers and policy analysts, to analyze the data to obtain an accurate picture of the state of the health of Canadians, and whether the health care system is truly serving their needs, in order to formulate recommendations and policies; and,
For administrators, to determine whether resources are adequate and appropriately deployed.

As an example of how hard data could help in making policy decisions, in 2019 a survey conducted in Alberta found that 45 percent of Albertans had experienced some form of sexual assault in their lifetimes. As is common with sexual assault survivors, few reported the crime to authorities. During that same year, 2,693 survivors of sexual violence were helped by a single victim service agency. Now, the province of Alberta is moving towards reducing the funding available to such agencies—a policy decision.^[40]

Forty-five percent of any population is a significant proportion. It is so significant that it is likely to encompass a cross-section of all races, religions, sexual and gender orientations, income levels and ages. That such a diverse group could have the one commonality of victimization by sexual assault is a sobering thought.

Access to timely and appropriate pain care

At the heart of the CPTF initial report is the acknowledgement that, despite all of the research that has been done in recent years, the standard of care for chronic pain patients has not appreciably improved. Part of the reason behind this lack of improvement may be attributable to the standard model of health care.

Everywhere in Canada there are long waits to receive any kind of medical care. In some regions of our country there is virtually no service and patients need to travel long distances to receive essential services and care.

The CPTF initial report refers to multidisciplinary pain clinics as the gold standard—while at the same time indicating that these clinics are few and far between. The few that do exist are concentrated in large urban areas, which makes them inaccessible to a majority of Canadians.

Awareness, education, and specialized training

These elements are particularly important in the context of treating patients who are victims of violent crimes. Health care professionals should be aware that, in addition to whatever injuries they may have sustained, patients who are crime victims have special needs.

Crime victims can be socially disadvantaged in a variety of ways. They may be:

Racialized;
Language minorities – they may not speak English or French as a first language;
Physically and/or mentally handicapped;
A victim of long-term abuse; and,
Suffering heightened emotional and/or mental distress due to their disadvantage, and may exhibit fear and/or trust issues.

The needs of these patients can be addressed in a variety of ways.

Trauma-informed approach

Every health care professional coming into contact with victims of violent crimes should be taught the trauma-informed approach.

Trauma and violence-informed approaches are policies and practices that recognize the connections between violence, trauma, negative health outcomes and behaviours. These approaches increase safety, control and resilience for people who are seeking services in relation to experiences of violence and/or have a history of experiencing violence.

Trauma and violence-informed approaches require fundamental changes in how systems are designed, organizations function and practitioners engage with people based on the following key policy and practice principles:

Understand trauma and violence, and their impacts on peoples' lives and behaviours
Create emotionally and physically safe environments
Foster opportunities for choice, collaboration, and connection
Provide a strengths-based and capacity-building approach to support client coping and resilience

Service providers and organizations who do not understand the complex and lasting impacts of violence and trauma may unintentionally re-traumatize. The goal of trauma and violence-informed approaches is to minimize harm to the people you serve—whether or not you know their experiences of violence.

Embedding trauma and violence-informed approaches into all aspects of policy and practice can create universal trauma precautions, which provide positive supports for all people. They also provide a common platform that helps to integrate services within and across systems and offer a basis for consistent ways of responding to people with such experiences.^[41]

Delivering services in a culturally appropriate manner

Cultural competence is a requirement for health care workers given that Canada is a country that is increasingly diverse. Health care professionals should reflect the communities they serve, and they need to develop an understanding of and respect for the various cultural identities of the people they serve. This would also help to improve access to service for those people whose first language is neither English nor French and to those with varying cultural practices.

Population health surveillance and health system quality improvement

As noted above, reliable, accurate measurement and recording—statistics—on key indicators of public health—including on victimization—are an essential tool for health care professionals, policy makers and administrators. This tool can be used to describe the state of public health, draw inferences on current needs and how to allocate resources, and make predictions regarding future needs and allocation of resources. Directing resources to where they are most needed optimizes service to the public while at the same time avoiding waste. This translates into savings for governments.

Health statistics are not tracking visits of crime victims to ERs

The Justice Canada study on health care costs related to victimization cited above demonstrates that crime victims are significant users of health care services. Many patients visit ERs due to trauma, but the cause of the trauma is not recorded. Indeed, as an example, the Canadian Institute for Health Research (CIHI) report on ER statistics in 2015^[42] indicates that the top reasons for visits to ERs were as follows:

Acute upper respiratory infection
Ear infection
Fever
Abdominal/pelvic pain
Acute upper respiratory infection
Throat infection
Pain in throat/chest
Dorsalgia (back pain)
Urinary system disorders

The reasons vary across age groups.

These data are deceptive. There is no mention of ER visits for injuries. In addition, they obviously do not include visits to the ER by persons transported by ambulance, many of whom will have sustained some form of injury, some of which will have been attributable to a crime committed against them.

The Public Health Agency of Canada - Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) is also not tracking crime victims.

The lack of data on visits to ERs by victims of violent crimes renders them virtually invisible.

Impaired driving statistics are inadequate

There does not appear to be one single source of consistent, reliable data on injury due to impaired driving. Sources measure and report on different variables. The only area where all sources seem to be in agreement is on the decline in the incidence of impaired driving since 1986.

In its 2015 report The Alcohol and Drug Crash Problem in Canada, the Canadian Council of Motor Transport Administrators (CCMTA) states that, “the extent to which alcohol is involved in serious injury crashes is not well documented and, consequently, poorly understood for two primary reasons. First, drivers involved in such crashes are seldom tested for the presence of alcohol. Second, investigating police officers do not always report the presence of alcohol in these crashes.”^[43] To determine the number of impaired drivers CCMTA used a surrogate or indirect measure of the alcohol-related serious injury crash problem. A driver is identified as having been involved in an alcohol-related serious injury crash if the crash in which someone was seriously injured involved a single vehicle at night, from 9:00 pm to 6:00 am (SVN), or if, in the case of a non-SVN serious injury crash, the police reported alcohol involvement – i.e., at least one drinking driver in the crash. While CCMTA maintains that this is a reliable method of estimating, it cannot be classified as hard data.

Some examples of data published about impaired driving for the year 2015:

Transport Canada (TC) does not specifically report on motor vehicle collisions resulting from impaired driving, but rather on the total number of collisions.^[44] Thus, TC found 1,669 fatal collisions; 116,735 personal injuries; 1,858 fatalities; 10,280 serious injuries; and 161,902 total injuries.
Statistics Canada reported 72,039 impaired driving incidents, 122 were cases causing death and 596 were cases causing bodily harm.
The CCMTA infers that 490 persons died in alcohol-related crashes within 30 days of the collision. This figure would include the impaired drivers.

These data are confusing because, although they must be related somehow, no-one has done the necessary work to put the data together. Without synthesis and analysis, it is not useful data on which to base policy decisions.

Appropriate pain care

The CPTF initial report highlights the fact that every patient experiences their pain differently, so that no two pain relief plans will be the same. This applies equally to crime victims, some of whom will experience different types and intensities of physical pain over time; each necessitating a different approach. For example, some may require medication to control pain in the short term and others may require it over a longer period. However, it is important to standardize the approach to all patients, both for quality control and for data collection purposes, beginning with the taking of the patient history and the triage process.

As with physical pain, the mental and emotional aspects of pain will vary across patients. It is likely that many victims of violence will feel heightened mental distress associated with their victimization. This may mean that they require other types of therapies, such as acupuncture, massage, physiotherapy and occupational therapy, in addition to primary health care.

Medications

In the run-up to the last federal election in fall 2019, there was much discussion of the need for universal pharmacare for Canadians. While there is no universal agreement on this issue, in the context of chronic pain patients, especially those who are victims of violence, there are strong arguments in favour of such a program:

Many, if not all, chronic pain patients require some form of medication for pain relief;
The cost of medication is higher than average in Canada; and,
Many patients, especially victims of crime, do not have access to social assistance or private insurance.

At the same time, there is a need for more and better training for physicians on pain, on pharmaceuticals and on alternative therapies. More research on pharmaceuticals also needs to be done. For example, cannabis was and is being prescribed for pain; however, adequate research to support its use has not yet been done. “…current clinical evidence to support the use of cannabis for pain is limited.”^[45]

Appropriate pain care includes affordability

A related issue is the significant out-of-pocket expenses incurred by crime victims for complementary therapies that are not covered by social assistance or provincial/territorial health care plans, and for which they may not have private insurance coverage. These therapies, such as acupuncture, massage, physiotherapy and occupational therapy can be essential to the healing process, yet remain out of reach for many. Other key therapies, such as dental care and vision care, carry high price tags and our Office hears from many victims about how their pain costs them a lot of money.

Persons who are victimized by violence and crime should not have to pay out of pocket for healthcare expenses or to access the therapies they need to restore their health.

Prevention—the best cure

There is a strong relationship between health and other social issues, such as racial discrimination, poverty and disability—and victimization. While research, technology and more and better holistic medical care will help to alleviate, and possibly even cure, the chronic pain of many patients, for victims and survivors of violence there is no cure, save prevention. As a society, we owe it to ourselves to do everything we can to protect and support our most vulnerable citizens.

From the perspective of the OFOVC, we are most concerned with the human costs associated with violent crime. However, we are deeply conscious of the enormous financial burden that violent crime imposes on society: emergency and long-term health care, policing, court processes, and incarceration and supervision of offenders. These costs are borne by law-abiding citizens, which seems somehow unjust.

In a post-COVID-19 world, our governments will be seeking ways to reduce costs to help defray the expenses incurred during the pandemic. There are many ways to reduce healthcare costs associated with crime victims.

Some examples would be to:

Adopt a more rigorous approach to prevention and prosecution of all forms of violence, in particular GBV;
Those who provide clinical care for women with chronic pain in all areas of healthcare delivery should assess for a history of child abuse and IPV. Research highlights the relevance of routinely assessing for abuse-related injury and PTSD and depressive symptom severity when working with women who report chronic pain.
Work to eliminate to the extent possible childhood trauma and to alleviate its effects;
Intensify efforts to reduce impaired driving, with a focus on rural areas, where the incidence is higher.

In the short-term, it may be necessary to increase social service spending to accomplish some of these goals. In the long-term, however, reducing these forms of trauma will also result in reduced social services expenditures, as the need for such services will decline over time. It will also assist in reducing health care costs and expenditures related to criminal offences.

^[1] https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019.html

^[2] Department of Women and Gender Equality: https://cfc-swc.gc.ca/violence/strategy-strategie/index-en.html

^[3] Perreault, Samuel, 2015. Statistics Canada. Criminal victimization in Canada, 2014.

^[4] Conroy, Shana and Adam Cotter, 2017. Statistics Canada. Self-reported sexual assault in Canada, 2014.

^[5] Boyce, Jill, 2016. Statistics Canada. Victimization of Aboriginal people in Canada, 2014.

^[6] Perreault. Op cit.

^[7] Cotter, Adam, 2018. Statistics Canada. Violent victimization of women with disabilities, 2014.

^[8] Burczycka, Marta, 2016. Statistics Canada, Family Violence in Canada – A Statistical Profile 2014. "Section 1: Trends in self-reported spousal violence in Canada, 2014".

^[9] Conroy, Shana, 2018. Statistics Canada, Family Violence in Canada – A Statistical Profile 2016. "Section 5: Police-reported family violence against seniors".

^[10] Allen, Mary and Samuel Perrault (May 2015) "Police-reported crime in Canada’s Provincial North and Territories, 2013." Juristat. Statistics Canada Catalogue no. 85-002-X.

^[11] Perrault, Samuel and Laura Simpson (April 2016) "Criminal victimization in the territories, 2014". Juristat. Statistics Canada Catalogue no. 85-002-X.

^[12] Wuest, J. et al: “Pathways of Chronic Pain in Survivors of Intimate Partner Violence.” Journal of Women's Health. September, 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120089/

^[13]Ibid.

^[14] World Health Organization: https://apps.who.int/iris/bitstream/handle/10665/77432/WHO_RHR_12.36_eng.pdf

^[15] Ibid.

^[16] Wathen, N. Health Impacts of Violent Victimization on Women and their Children. Research and Statistics Division Department of Justice Canada, 2012 - https://www.justice.gc.ca/eng/rp-pr/cj-jp/fv-vf/rr12_12/rr12_12.pdf

^[17] Ibid.

^[18] Statistics Canada: https://www150.statcan.gc.ca/n1/pub/85-002-x/2015001/article/14211/tbl/tbl05-eng.htm

^[19] Statistics Canada: https://www150.statcan.gc.ca/n1/pub/85-002-x/2015001/article/14241/tbl/tbl01-eng.htm

^[20] Statistics Canada: https://www150.statcan.gc.ca/n1/pub/85-002-x/2015001/article/14241-eng.htm#a10

^[21] Basile, K. et al. Chronic Diseases, Health Conditions, and Other Impacts Associated with Rape Victimization of U.S. Women. Journal of Interpersonal Violence. 2020 Jan 23.

^[22] Williams, J.R., Cole, V., Girdler, S., and Cromeens, M.G. Exploring stress, cognitive, and affective mechanisms of the relationship between interpersonal trauma and opioid misuse. PLoS One. 2020;15(5):e0233185. DOI:10.1371/journal.pone.0233185

^[23] Wuest, J., Merritt-Gray, M., Lent B., Varcoe C., Connors A.J., and Ford-Gilboe, M. Patterns of medication use among women survivors of intimate partner violence. Canadian Journal of Public Health. 2007;98 (6):460-464. DOI:10.1007/BF03405439

^[24] Williams, J.R., Girdler, S., Williams, W., and Cromeens, M.G.. The Effects of Co-Occurring Interpersonal Trauma and Gender on Opioid Use and Misuse [published online ahead of print, 2020 Feb 13]. Journal of Interpersonal Violence. 2020. DOI:10.1177/0886260519900309

^[25]Nelson, S. et al. A conceptual framework for understanding the role of adverse childhood experiences in pediatric chronic pain. Clinical Journal of Pain. 2017 March 33(3):264–270. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5143226/

^[26] Wuest, J. et al, ibid; Nelson, S.M., et al: ibid.

^[27] Statistics Canada: https://sencanada.ca/content/sen/committee/421/LCJC/Briefs/2018-LCJC_StatCan_e.pdf, slide 6.

^[28] Justice Canada: https://www.justice.gc.ca/eng/cj-jp/sidl-rlcfa/

^[29] Living with burn injuries, MADD Canada - http://www.madd.ca/media/docs/victim-survivor-living-with-burn-injury.pdf

^[30] Living with spinal cord injuries, MADD Canada - http://www.madd.ca/media/docs/victim-survivor-living-with-spinal-cord.pdf

^[31] Living with brain injuries, MADD Canada - http://www.madd.ca/media/docs/victim-survivor-living-with-brain-injury.pdf

^[32] Statistics Canada: https://www150.statcan.gc.ca/n1/daily-quotidien/190722/dq190722a-eng.htm

^[33] Cukier, W. (1998). "Firearms Regulation: Canada in the International Context." Chronic Diseases in Canada, 19(1): 25-34.

^[34] https://www150.statcan.gc.ca/n1/en/pub/89-28-0001/2018001/article/00004-eng.pdf?st=TK9nBac

^[35] NPR - https://www.npr.org/2020/01/03/793257323/in-canada-gun-violence-is-a-growing-problem-for-toronto

^[36] https://d279m997dpfwgl.cloudfront.net/wp/2019/07/Kalesan_A-multi-decade-decade-joinpoint-analysis-of-firearm-injury-severity_2018.pdf

^[37] http://nationalpainreport.com/living-with-pain-chronic-pain-and-gun-violence-8818230.html