Are prescriptions contributing to the crisis?
Canada needs a new approach to address opioids and this national epidemic
Each day in Canada, 17 Canadians are hospitalized due to opioid poisoning and 11 lives are lost. The opioid crisis is a force that is devastating entire communities across the country.
Much of the focus is based on emergency services. For example, health leaders and harm-reduction workers came out last week, urging Ontario to declare a state of emergency to address the deteriorating opioid crisis and reconvene its opioid emergency task force. Meanwhile, provinces are signing the federal government’s Emergency Treatment Fund, which provides one-time funding to provinces and territories for evidencebased treatment services.
Treatment is a critical function in tackling this crisis. But there is another lens through which we can view this health epidemic – Canada needs a new approach to address the scourge that is continuing to kill and their contribution to the crisis.
An expert report (by drug policy researchers and clinicians) has analyzed the data of over six million prescription drug claims from 2013 to 2017. The goal is to determine the impact of prescription opioids on the health and safety of Canadians, as well as provide governments, payers and healthcare professionals insights on the use of prescription opioids in Canada.
The report, entitled Opioid Prescribing in Canada and its Potential Contribution to the Opioid Crisis is available online for all Canadians to read. It analyzes how Canadians are being prescribed opioids, the dosing of opioids compared to Canadian expert guidelines, and the use of opioids with other therapies.
Here are some of the realities. Onein-five public plan claimants and one-in-six private plan claimants in Canada are being prescribed an opioid each year. Of this, chronic opioid users account for 21 per cent of all users, and 64 per cent of all opioid prescriptions.
People aged 25 to 44, followed by those aged 45 to 64 use the highest doses of opioids – both age groups use above the maximum dose recommended in the 2017 Canadian Guidelines for Opioids for Chronic NonCancer Pain (the guidelines suggest a maximum 90 mg dose daily).
Every year, people on lower doses continue to increase their dose. Approximately 10 per cent of patients each year are increasing above the 50 mg threshold and four per cent are increasing above the 90 mg threshold.
The 2017 Canadian Guidelines strongly discourage the use of opioids and benzodiazepines together. Benzodiazepines are a type of sedative commonly prescribed for anxiety or insomnia. These drugs are linked to a higher risk of opioid-related harm when taken with opioids. Nevertheless, one-in-six (16 per cent) public plan claimants and one in 10 (10 per cent) private plan claimants taking chronic opioid therapy were also taking chronic benzodiazepine therapy.
As the length of opioid therapy increases, so does the dose of opioids. This could be due to opioid-tolerance and potentially something called hyperalgesia (a condition where increases in opioid dose lead to an increase in perceived pain).
Report contributor Dr. David Juurlink, head of the clinical pharmacology and toxicology division at Sunnybrook Health Sciences Centre, says that prescribing high-dose opioids (such as oxycodone, hydromorphone and fentanyl) for chronic pain is a dangerous practice that can harm patients, even when it seems to be helping, but that the new prescribing guidelines aim to help by promoting more judicious prescribing.
There were some encouraging signs with dose reduction among payers in the report. There was a decrease in the dose in the top 25 per cent of prescriptions from 2013 to 2017. However, a significant number of chronic opioid claimants are taking higher than the guideline-recommended 90 mg dose daily.
By having clearly set goals at the start of therapy, healthcare professionals can consider tapering and stopping patients using opioids if The bottom line is that the opioid epidemic charts a path of destruction that is both widespread and intimate and doesn’t discriminate. People from all walks of life are affected.
they are not reaching their goals rather than continually increasing opioid doses.
One recent positive approach happened last week. WorkSafeNB announced it has tightened up its policy regarding opioid prescriptions for injured workers in New Brunswick, asking doctors to give careful consideration before prescribing opioids and only covering a two-week prescription of less than 50 mg of morphine equivalent per day.
The bottom line here is that the national opioid epidemic charts a path of destruction that is both widespread and intimate and doesn’t discriminate. People from all walks of life, age groups and socio-economic backgrounds are affected.
There is not a one-size-fits-all solution for patients. Albert Einstein was prescient when he proposed the idea “we cannot solve our problems with the same level of thinking that created them.” Canada’s health stakeholders must come together to craft new approaches to address this scourge.
Helen Stevenson is the CEO/founder of Reformulary Group, a healthcare technology company focused on helping Canadians make smart drug choices. She is formerly assistant deputy minister of Health in Ontario and executive officer of Ontario Public Drug Programs. Mike Boivin is a clinical pharmacist consultant and a continuing education developer. He is founder of CommPharm Consulting. Mike is a contributor to the opioid analysis.