No magic pill
Province one of two in Canada to see increasing rates of daily doses of opioids in 2016
Daily doses of opioid drugs are up in Saskatchewan, according to a new study by the Canadian Institute for Health Information (CIHI).
While the numbers are very small — the province saw in increase in half-a-per cent from 2015 to 2016 in daily doses per 1,000 people — Saskatchewan is one of only two jurisdictions that saw increases at all.
“When we look nationally, what we saw was a decrease in the total number of doses dispensed and an increase in the number of prescriptions,” said manager of pharmaceuticals information with CIHI Jordan Hunt. “We did see that trend towards smaller prescriptions in Saskatchewan as well, but what we didn’t see was the decrease in total quantity dispensed that we did see in some of the other provinces.”
That being said, Hunt noted that although there were significant drops in Ontario, British Columbia, and Nova Scotia, Saskatchewan was not an outlier in terms of the rest of Canada. Other provinces saw small drops in the same metric and Newfoundland saw a rise of less than one per cent.
Pharmacist manager of the prescription review program with the College of Physicians and Surgeons of Saskatchewan Julia Bareham said that while tracking this information about opioid prescriptions is useful, the data can be problematic.
“Sometimes these numbers may be slightly misleading when they don’t tell the whole story, but I think where there’s smoke there’s fire, and it at least demonstrates some trends and how we’re going up versus down,” she told the Times-Herald on Wednesday.
She pointed out that one of the sources for this particular information did not cover 40 per cent of Canadian pharmacies, but that another source was likely largely complete. Bareham also argued that the potency of opiates most often prescribed in the province may affect how doses are calculated.
“The reality of what happens with these drugs is that over a while, you develop a tolerance and we’ve got to slowly increase your dose to achieve the same results,” she said. “If we have an aging population, and we’re eventually transitioning over to those more potent opioids over time, that might explain why we see that increase.”
The most-used opioid in Saskatchewan is hydromorphone, which is five times stronger than morphine. It doesn’t tax a patient’s kidneys as much as other forms of opioids and, for this reason, is often used for older adults who may have reduced kidney function to begin with.
“I’m thrilled we’re not the highest, and also thrilled we’re not the lowest. In BC, we saw prescribers being afraid to prescribe and maybe patients not getting their appropriate treatment as a result,” Bareham said. “Finding that balance in the middle is a challenge, and even great physicians are going to be duped.”
While the study did not track illicit opioid use, Hunt noted that the prevalence of the drugs on the street is in some ways tied to prescriptions written by physicians. Canada is the second largest consumer of opioids after the United States, and the consequences of their preponderance have been a massive concern nationally.
“That’s not only to do with prescribed opioids, which is what we looked at — illicit opioids do play a role,” Hunt said.
“But we know prescribing opiates is part of the story there and is important for us to measure.”
For Bareham and the physicians she deals with, the question remains what the alternative is if opioids are becoming problematic. Often best practices indicate that non-drug treatments can be of use, like physiotherapy and massage, but in many cases, those services are not accessible in Saskatchewan. Furthermore, she said, for Indigenous patients who fall under a national health-care claims process, the cost of such treatments are not covered by the state.
“What happens when you have very complex pain, or complex chronic pain mixed in with a substance-use disorder?
“We really struggle to support these patients with the multidisciplinary approach that they need,” Bareham said.
The answer to that in other jurisdictions has been the creation of pain clinics, designed to work with the most complex cases.
Saskatchewan has none and the only option is in Alberta, which presents other challenges in terms of cost and travel.
“I certainly don’t want to deny that I think there’s room for improvement in the prescribing of opioids, but in defence of my prescribers, we don’t have a pain clinic in Saskatchewan,” Bareham said. “What do you do when you’re Dr. Smith and you have this super complex patient and over time, their pain has just crept up? Where do we send them?”
Still, following changes in the United States that were also adopted by some provinces, there are now Canadian guidelines in place for physicians prescribing opioids. Bareham said the college has also recently run a conference with top experts in the field in Saskatoon and that her job is to monitor the practice of prescribing and offer education on assessment and other options when she sees anomalies.
Since 2005, the province also has had in place a computer program for healthcare providers that tracks the medication patients are prescribed and dispensed. The idea is to identify possible abuse and to make sure each patient is being adequately treated.
“I’ll be curious to see what it looks like when we run these numbers again in a year,” she said.
“It’s so hard to talk about cause and effect.”
Hunt also noted that the changes to guidelines will likely result in a corresponding change for the next study, but that there are some positive trends to be seen in last year’s data.
“The number of prescriptions we see and the quantity we see, it is of concern. The one thing that’s encouraging is that we are seeing that trend towards shorter prescriptions,” he said. “Usually that means more interactions with the health-care system, with your prescriber, and more opportunities to assess how treatment is going, assess effectiveness, and consider whether it needs to be continued and to consider alternative treatments.”
Sometimes these numbers may be slightly misleading when they don’t tell the whole story, but I think where there’s smoke there’s fire, and it at least demonstrates some trends and how we’re going up versus down. Julia Bareham, Pharmacist Manager of the prescription review program, College of Physicians and Surgeons of Sasaktchewan
Defined daily doses per 1,000 population for top six opioids, 2016, and percentage change from 2015 to 2016, Canada from Pan-Canadian Trends in the Prescribing of Opioids, 2012 to 2016.