Prepared for EvidenceNetwork.ca by Ann Silversides
“The misuse of opioids has grown exponentially with devastating consequences” — First Do No Harm: Responding to Canada’s Prescription Drug Crisis (Canadian Council on Substance Abuse, 2013).
Prescription opioids are powerful drugs frequently used to manage pain. However these drugs can lead to physical and psychological dependence and addiction, especially when used over a long term to address chronic pain. Beginning in the late 1990s, the number of opioid prescriptions increased very significantly in Canada, and this has been accompanied by rising rates of addiction and of opioid-related deaths, most of which are accidental.
High levels of prescribing opioid drugs have led to a widely acknowledged public health crisis.
Canada currently ranks second only to the U.S. in per capita consumption of prescription opioids, according to the International Narcotics Control Board. Both countries have declared public health crises, and notably, both countries are outliers in consumption by international comparison. The consumption of prescription opioids in the European Union and Australia/New Zealand is less than half that in North America.
Controversy: a balancing act, gaps in evidence and misuse
Prescription opioids can play a crucial role addressing certain kinds of pain, such as acute pain, cancer-related pain and the pain suffered by patients with terminal conditions. As a result, prescription opioids must continue to be available for physicians.
However, in order to reduce accidental deaths, addiction and other related harms, it is widely recognized that overall rate of opioid prescribing must be significantly lowered and that drugs be prescribed more appropriately. A key problem is the high rate of prescribing for chronic pain — a controversial practice supported by little evidence that benefits offset risks.
While the non-medical use of prescription opioids has been highlighted as a problem (prescription painkiller “abuse”), this phenomenon has been facilitated primarily by diversion: prescriptions written by physicians are by far the biggest source of prescription opioids in Canada. As well, a large proportion of patients who have been prescribed opioids for chronic pain run into problems that are not easily addressed. The increase in prescribing of opioids has disproportionately affected certain groups of people, including First Nations and low-income individuals. One reason for this is the lack of access to affordable alternatives to deal with chronic physical and psychological pain.
Scope of the problem: prescribing rates, deaths and addiction
The nation-wide scope of the problem can only be guessed at because there is no national tally on prescription-opioid related deaths and no standardized, coordinated system of monitoring and information gathering about opioid prescribing. This is unlike the United States, where the Centers for Disease Control has issued alerts based on relative prescribing rates among states. Some Canadian jurisdictions have prescription monitoring programs of varying types (electronic, paper-based, etc.), but they are not linked, nor is information about deaths investigated by coroners and medical examiners across Canada.
Most of the detailed documentation about the particulars of opioid dispensing and related harm in Canada is based on Ontario statistics. This is because of research by the Institute for Clinical Evaluative Sciences using information from the Ontario Public Drug Program, health administrative databases and the Office of the Chief Coroner of Ontario. This research shows, for example, that between 1991 and 2007, the number of prescriptions in Ontario for one type of prescription opioid — drugs with the active ingredient oxycodon — increased by almost 900% and oxycodone-associated deaths rose from less than 1 per 1-million people every year in 1991, to 12.93 per 1-million people in 2006.
According to the Ontario coroner’s office, prescription opioid-related mortality in Ontario doubled between 1991 and 2004, and more than tripled between 2004 and 2012, the year that deaths totaled 536. The demand for treatment for addiction also increased. The number of prescription-opioid-related admissions to publicly funded centres for substance use treatment in the province doubled between 2005/6 and 2011/12.
The British Columbia Coroner’s Service issued a report on the number of deaths from prescription opioids in the province from 2000 to 2010 and it recently issued a special warning about the increased number of accidental deaths from illicit use of the prescription painkiller fentanyl.
In Nova Scotia, alarms were raised about the harms related to prescription opioids addiction in the early 2000s. The Office of the Chief Medical Examiner in Nova Scotia identified 295 prescription drug-related deaths between 2007 and 2010. The prescription drug related deaths were 7.8 per 100,000 populations, compared to 1.76 deaths per 100,000 due to illicit drugs. By far the most common prescription drugs linked to deaths were opioids.
Across Canada: This 2013 bulletin from the Canadian Council on Substance Abuse provides a snapshot of problems with misuse prescription opioids (and illegal opioids) in selected cities across Canada.
Why the increase in prescribing opioids?
Many factors have contributed to the development of the prescription opioid crisis. The most important has been the liberalization of opioid prescribing for the treatment of chronic non-cancer pain, which is typically defined as pain that has persisted for more than six months and is associated with conditions such as low back pain and arthritis. Use of opioids to treat these kinds of conditions was considered controversial for many decades, then became common in the 1990s and 2000s, and is now becoming controversial again (see resources below).
Until the 1990s, because of concerns about the potential for patients to become addicted, physicians were generally reticent to prescribe opioids except to address the pain suffered by terminal patients, post-operative patients, and those with cancer-related pain. This reticence stemmed, in part, from the widespread therapeutic use of opium in the late 1800s and early 1900s, which led to serious problems with addiction. (Oxycodone is an analgesic medication that is synthesized from opium derivatives.)
The introduction of long acting oxycodone and controversial aggressive marketing campaigns (particularly for OxyContin) beginning in the late 1990s led to a change in attitude among physicians, particularly family physicians, especially when organizations such as the American Pain Society and others, many of them financially supported by opioid manufacturers, endorsed and promoted the use of opioids for chronic pain. The vast majority of opioids prescribed in Canada are prescribed by family physicians.
There was also a general sense that because the opioids received approval from regulatory agencies such as Health Canada and the U.S. Food and Drug Administration, that they are not as potentially addictive or harmful as illicit street drugs, such as cocaine.
Other factors that led to increased use of opioids included the lack of knowledge on the part of healthcare providers with respect to potential toxicity, lack of dosage guidelines and lack of effective means for monitoring who was prescribing and who was using opioids.
It is generally accepted that physicians are poorly trained in treating chronic pain and in identifying and treating addiction. According to several expert groups, physicians need more education about pain rehabilitation, including the role of other health professions, such as physiotherapy, occupational therapy, chiropractic, and cognitive behavioural therapy, in treating pain; opioids should not be considered the first line of defense. However, most non-pharmacological interventions to deal with pain are not covered under provincial healthcare plans and patients with chronic pain who seek access to public multi-disciplinary pain clinics, for example the comprehensive pain program at Toronto’s University Health Network, often face waits of many months or years.
The Royal College of Physicians and Surgeons of Canada recognized pain as a medical sub-speciality in 2010. The first program was established in 2013 at the University of Western Ontario faculty of medicine.
How the crisis is being addressed
The federal government assigned to the Canadian Centre for Substance Abuse (CCSA) the task of creating a strategy for reducing the harm from prescription drugs.
In 2013, the CCSA released First, Do No Harm: Responding to Canada’s Prescription Drug Crisis from the National Advisory Council on Prescription Drug Misuse. The Council developed a 10-year “roadmap” to reduce harm and made 58 recommendations and set up six implementation teams comprised of volunteers, most of whom are employees of related government and non-government agencies.
The National Advisory Council followed up a year later with a progress report on accomplishments to date.
In its 2014 budget, the federal government said it would spend $44.9 million over five years to address prescription drug abuse as part of the National Anti-Drug Strategy. The strategy, headed up by the Department of Justice, had previously dealt only with illegal drugs. As of summer 2014, no information was available on if or how this money was being allocated.
Prescription medication in Canada containing opioids
Health Canada has prepared a partial list of the pharmaceutical medications available in Canada that contain opioids.
Experts available for interview
Our commentaries on the opioid crisis
- Canada’s opioid ‘public health crisis’ // Les opioïdes responsables d’une «crise de santé publique» au Canada
- Key research documents on the use of prescription opioids for chronic pain are:
- Long term opioid treatment of chronic nonmalignant pain: Unproven efficacy neglected safety? 2013. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712997/
- Research gaps on the use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline, 2009. http://www.jpain.org/article/S1526-5900(08)00830-4/abstract
- Critical issues on opioids in chronic non cancer pain: An epidemiological study, 2006. http://www.sciencedirect.com/science/article/pii/S0304395906003162
- Canadian Drug Summary: Prescription Opioids (an introduction, from the Canadian Centre for Substance Abuse).
- One of the first comprehensive healthcare reports in Canada to acknowledge the extent of the prescription opioid problem, Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis, was published in 2010 by the College of Physicians and Surgeons of Ontario (CPSO). It made 31 recommendations.
- Also in 2010, the Federation of Medical Regulatory Authorities of Canada (of which CPSO is a member) published the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. The intent of the guideline was to give physicians guidance about prescribing opioids for chronic pain. The guideline is based primarily on expert consensus, not clinical trial evidence.
- In early 2012, drug manufacturer Purdue Pharma pulled OxyContin off the market. Coroners in Canada found oxycodone, the active ingredient in OxyContin, present in a large proportion of the prescription opioid related deaths. OxyContin was replaced by OxyNeo, a formulation designed to be more tamper resistant (i.e. more crush resistant and therefore less likely to be used non-medicinally). Later in 2012, Health Canada approved the introduction of generic OxyContin to the market, while the US Food and Drug Administration declined to approve it.
- 2013 saw the release of “First, Do No Harm: Responding to Canada’s Prescription Drug Crisis” from the National Advisory Committee on Prescription Drug Misuse. http://www.ccsa.ca/resource%20library/canada-strategy-prescription-drug-misuse-report-en.pdf
- Some observed decreases in oxycodone prescribing in Canada have been paralleled by increased prescribing of other strong opioids, in particular hydromorphone and fentanyl. The latest available figures show that Canada now leads the world in prescriptions for hydromorphone and is still second only to the United States in prescriptions for oxycodone.
- In April 2013, the Public Health division of Ontario’s Ministry of Health and Long-term Care released A Review of the Impacts of Opiate Use in Ontario: Interim Summary Report. The report set out to tracks the impact on patients of the 2012 discontinuation of OxyContin.
- Opioid Overdose Prevention and Response in Canada was released in June 2014 by the Canadian Drug Policy Coalition. It addresses prevention of overdose from both prescription and illegal drugs.
- Facing up to the prescription opioid crisis, 2011 (Canada)
- Non-medical prescription opioid use, prescription opioid-related harms and public health in Canada: An update 5 years later, 2014.