One in seven uses opioids: new report
Growing potency, strength of drugs among troubling trends
A new report on how doctors prescribe opiates in Ontario cites troubling trends.
The report is titled 9 Million Prescriptions: What we know about the growing use of prescription opioids in Ontario. It was prepared by a multidisciplinary team of Health Quality Ontario, the provincial advisory body on health care.
It shows one in seven Ontarians, or about 14 per cent, filled an opioid prescription in 2015-2016, the fiscal year studied by the report’s authors. In early 2016, about a quarter of opioid prescriptions were for a one-time, immediate-release drug and for less than two weeks.
“Not only are we seeing more prescriptions going out, not only do we see more people getting them, we also see the potency, the strength, of the opioids going up,” Dr. Joshua Tepper, the family doctor who is president and chief executive officer of the agency, said from Toronto.
Prescribing of codeine declined by seven per cent between 2013-2014 and 2015-2016. Fentanyl patch prescriptions dropped by 18 per cent. Prescribing of morphine rose by four per cent, tramadol by 12, and hydromorphone by 29 per cent.
“The shift away from codeine toward much more potent opioids such as hydromorphone is very concerning,” the report reads. “We do not know why this is happening, especially given increasing awareness of the harms associated with prescription opioids.”
Despite the discussion about the availability of opioids on the street, Tepper said, “the power of the pen” wielded by doctors and dentists, for example, is “a significant source of opioids in society.”
“It was surprising that we continue to see the trend in these directions,” Tepper said.
About 44,000 health professionals prescribed opioids in 2015-2016, the fiscal year studied for the report. Most were in family or general medical practices or in dentistry.
In that year, nearly two million in Ontario filled a total of more than nine million prescriptions, about 450,000 more prescriptions than in 2013-2014.
“There are no studies that show the long-term benefit of opioids and the studies that do show some benefit typically lasted three months or less,” Dr. Pamela Leece, a Toronto researcher and family doctor practising in addiction medicine, writes in the report .“There’ s clinical experience that shows some patients benefit from daily opioids, but for many patients we know that the harm outweighs the benefit for opioid use.”
Drug safety researcher Dr. David Juurlink, a Toronto clinical pharmacologist and toxicologist, agreed.
“In general, the higher the dose, the more likely it is that a patient is being harmed more than helped by therapy,” he writes. “This is a good reason to consider a gradual taper to lower doses.”
Tepper said the report was not, however, created to place blame.
“We want to avoid jumping to criticism... One risk we have is placing all the responsibility on one individual or one group of individuals. “It won’t lead to success.” Instead, he said, the document shows the complexity of the opioid crisis and raises important questions about the factors behind the trends and how best to reverse them while providing pain relief.
“Pills aren’t always the answer,” said Tepper.
“There is a range of other options available.
“How do we create the right range of non-opioid medication and nonprescription approaches to pain?
“Each patient’s going to require a different set of approaches.”
Tepper said addressing the crisis will require a “wide range of investments” to address patients’ pain and drug dependence while educating health professionals and patients alike. “It can be done.” The doctor said governments, providers and patients all have responsibilities.
“Everybody has to lead in their own respective areas,” he said, and who or which organization co-ordinates an initiative will depend on who’s most appropriate to do so.
Patients need more information about their options and the risks, he said, and providers need “more data on an ongoing basis.”
“They do need access to any prescriptions their patients are getting,” he said. But doctors and other providers also need more information about their own opioid-prescribing trends.
Researcher Leece reported some people who die of an overdose have complex conditions which may include past trauma, addiction, stress and mental health symptoms. That, she explained, makes it difficult to get all the care they need.
“If we reduced the stigma, improved access to care, and integrated health and social services in a really compassionate way for people, we’d be able to improve outcomes for patients,” wrote Leece.
In examining the number of people filling opioid prescriptions, Health Quality Ontario found the highest rate, 18 of 100 people, in the Erie St. Clair Local Health Integration Network (LHIN) of southwestern Ontario. The Ontario average was 14. The North East LHIN was second with 17.
Five LHINs had a rate of 15: the South East, Central West, North Simcoe Muskoka, North West and Hamilton Niagara Haldimand Brant. The Toronto Central LHIN was lowest at 11.
In terms of the total number of prescriptions filled per capita, the North East LHIN, meanwhile, had 110 prescriptions per 100 people. That’s almost triple the lowest rate, that of Toronto’s area’s Central LHIN, which had 38. The Ontario average was 66.
“The findings are remarkable,” Tepper said. He added it’s not known why prescribing varies by region.
“I suspect it’s complicated,” he said, explaining it may be due to the prevalence of disease or problems with access to other forms of pain management or addiction support. The report also suggests differences in population, prescribing practices, age and gender may also play roles.
Only those with truly low - not simply lower - rates should take comfort in the statistics, said Tepper.
Even if a LHIN does not have the highest rate, he said, “You’re still part of a very concerning picture.”
The report notes Ontario has taken several steps to reduce addiction and overdoses but recommends further monitoring without calling directly for specific action, only “continued scrutiny and a comprehensive approach” to reduce harm.