Canada is in the midst of a “man-made epidemic” of opioid addiction – this spring, BC even declared a state of emergency after a surge in drug-related deaths. Provinces across the country are working on the issue, as spiking addiction rates and deaths raise alarms.
Sherry Stephenson is one of the people who got caught up in opioid addiction. “I struggled my whole life with addictions, but nothing got the better of me than these opioids,” she says. She was first prescribed them after a car accident in the summer of 2003 – just months after she’d graduated from college. She’d been a single mom since 16 and had overcome an abusive relationship, using cocaine and alcohol, and the death of her father from a heroin overdose. Her family doctor prescribed OxyContin and Percocet to deal with the pain from that car accident, and she was on them for the next six years, slowly increasing the doses. “They numbed every ounce of pain I had in my body and my life – emotional too. It just made everything okay, until it wore off, and I needed to fix that pain again,” she explains.
The drugs, which she chewed and snorted near the end of those years, would lead to kidney damage and make her so dependent that she had to take a pill before she got out of bed in the morning. She explains that her doctor didn’t seem to notice any of the signs that she was addicted or ask too many questions at her monthly appointments to refill her prescriptions. “This guy was basically the best drug dealer I ever had,” she says.
The problem of overprescribing opioids in Canada began in the mid-90s, when they shifted from being used primarily in palliative care and for cancer pain – which they’re still recommended for – to much greater use in chronic pain. By the early 2000s, the opioid crisis had become obvious, with opioid addiction and overdose doubling between 1991 and 2004 in Ontario. And while the drugs being prescribed have changed – shifting from OxyContin, one of the first long-lasting opioids, to OxyNEO, a similar drug that’s harder to abuse, as well as fentanyl and Hydromorph Contin – the overall amount of opioids prescribed has is still rising. In 2012, Canadians filled 18 million opioid prescriptions. Last year, there were 22 million. That makes us the second-largest consumers of opioids in the world, after the U.S.
Not all opioids are coming from physicians’ prescription pads – many of those addictions start from recreational drug use. But there is also no debate that many people became addicted after using these drugs as prescribed, then abusing their prescription drugs by crushing, snorting or injecting them, or turning to drugs like heroin or made-in-China fentanyl bought on the streets. “There is a huge push by the media to think of this as a fentanyl disaster, and certainly the spike in deaths is related to fentanyl. But the underlying issue [of opioid addiction] is not new,” says Mark Tyndall, executive medical director of the BC Centre for Disease Control and professor at the UBC School of Population and Public Health.
For this article, however, we’re leaving aside the issue of street drugs to focus on the many issues around the prescription of opioids for chronic, non-cancer pain. Here are five ideas on how the health care system can better manage the opioid crisis.
1. Change our guidelines around prescribing opioids
There was a strong push towards prescribing opioids in the late ’90s and early 2000s, when “the companies that make these drugs spent hundreds of millions educating doctors on the use of opioids for chronic pain, telling us that these drugs worked well over the long term, and that the risk of addiction was less than 1%. But in hindsight when you look at the literature they used to support those claims, it’s incredible that we bought that message,” says David Juurlink, a physician at Sunnybrook Health Sciences Centre and Head of the Division of Clinical Pharmacology and Toxicology at the University of Toronto.
That oft-repeated 1% stat had minimal scientific backup, and the real rates of addiction are much higher. A 2015 systematic review found addiction rates may be as high as 8% to 12%. And Purdue Pharma, makers of OxyContin, was recently found guilty in the US of misleading doctors about the addictiveness of the drugs during that time – they even used fake scientific charts.
Now, “we need to reset the practising habits of physicians,” says Gordon Wallace, managing director of safe medical care with the Canadian Medical Protective Association. One way to do that is for Canada to revise its opioid prescribing guidelines, which haven’t been updated since 2010. A new version of the Canadian guidelines is set to be released next summer.
Meanwhile, the provinces are working on their own guidelines. Health Quality Ontario is creating a quality standard for opioid prescribing for pain. In Alberta, the College of Physicians and Surgeons is circulating a draft proposal around prescribing guidelines that would require doctors to prescribe the lowest effective dose, to track the drug use history of their patients, and to discuss potential side-effects with them.
And the College of Physicians and Surgeons of B.C. recently endorsed the stricter American guidelines from the Centres for Disease Control and Prevention, which were updated in 2016. They are significantly more conservative than Canada’s current guidelines, with recommendations that physicians should consider non-drug therapies (like cognitive behavioural therapy and exercise) before opioids. If they do prescribe opioids, they should be reassessed within a month, and at least every three months after that. Indeed, it’s not clear if opioids are effective for long-term pain. Most studies on opioids’ effectiveness are short-term (less than eight weeks long), with no placebo-controlled randomized clinical trials looking at the effect on pain of using opioids for over a year.
2. Rein in high-dose prescribing
After taking opioids for some time, people usually become tolerant and need more to achieve the same pain-management effects. But this can be dangerous, because it increases the risks of side effects like sedation, death and addiction. People who are on low doses of opioids are three times more likely to be dependent on or addicted to opioids; those who are on high doses are 122 times more likely. There’s even a phenomenon where taking opioids can increase people’s pain.
“The majority of people who are on long-term opioid therapy, particularly at higher doses, are actually being harmed more than helped by it,” says Juurlink. “Especially for people who are on high doses, it’s incumbent upon their doctors to have the difficult conversation with them, to say I know you think these drugs are helping you, but a slow taper will often leave people feeling better, more alert, more able to function.”
The new CDC guidelines address this issue directly, stating that doctors should reassess after increasing doses above 50 morphine milligram equivalents (MME) a day, and avoid increasing or “carefully justify” increasing doses to above 90 MME a day.
In a similar move, Ontario recently announced that it would stop covering high-dose opioids (higher than 200 MME a day) on its public drug plan (the dose above which physicians should carefully reassess the patient’s needs, according to the current Canadian guidelines). Above that level, “there is little evidence to demonstrate improved pain management, while [it’s] strongly associated with adverse events, addiction and opioid-related mortality,” reads a Q&A about the change.
3. Introduce better monitoring systems
Another crucial component is to create prescription monitoring systems that both physicians and pharmacists can access. The current Narcotic Monitoring System in Ontario issues an alert to pharmacists if abuse is suspected, but doctors don’t have a way of seeing if their patient has seen a different prescriber the day before, for example. “To me one of the big shortfalls of this system is that it’s down to the pharmacist to be the gatekeeper,” says Tara Gomes, a Principal Investigator of the Ontario Drug Policy Research Network. “If prescribers knew the history when they saw a patient, it would avoid those prescriptions being written in the first place.”
That’s already happening in BC, where the PharmaNet systems allows physicians and nurse practitioners access to the drug records of their patients online.
She’d also like to see systems to help the regulatory colleges across the country identify outlier prescribers, and help them refine their prescribing habits. One example of that is Alberta’s Triplicate Prescription Program, which gathers dispensing data in the province for select drugs. As a result, it allows the College of Physicians and Surgeons of Alberta (CPSA) to identify doctors who may be over-prescribing opioids and offer them education, as well as having doctors who are experts in chronic pain management or addiction work directly with them to provide advice on how to manage their patients. This system has been shown to be effective in the short term, says Trevor Theman, registrar for the College of Physicians and Surgeons of Alberta, but they’re just starting to collect data on whether it effects long-term prescribing habits.
“People aren’t very good at looking at themselves,” says Theman. “This is true in chronic disease management too – physicians say I’m sure I manage my diabetes patients well, [but if you look at the data], some things are getting missed.”
The program offers insights into the extent of the issue in Alberta. Theman estimates that a quarter of the province’s 10,000 doctors have one or more patients exceeding the college’s standards in terms of dose or duration. About 15* doctors have patients on over 4,000 MME a day. “It’s an enormous problem,” he says.
4. Taper existing opioid users and help those who have developed addictions
Some patients who are dependent on opioids will respond well to a slow taper, gradually lowering their physical need for the drug. But for others who have become addicted, they may need a set of more intense interventions, like access to better mental health services, abstinence programs, and methadone or Suboxone to stabilize their cravings.
That’s important because cutting off high-dose prescribing can force regular users to the streets, to avoid the excruciating effects of withdrawal. “People who are already addicted, to say that we have tighter rules, and in the next month we’re going to have to wean you off, many of those people will be going to the streets,” says Tyndall, which has happened in some places in the U.S. after tighter restrictions.
“People who are currently on opioids need better access to proper chronic pain management, addiction treatment and detoxification,” says Theman. “For that group, it’s not just a matter of turning off the tap.”
5. Focus on alternative ways of managing pain
Experts agree that it’s time to place more importance on methods of treating pain that don’t include opioids.
Fiona Campbell, a physician and the president elect of the Canadian Pain Society, says that we should be using what she calls the 3 ‘P’s approach to managing pain: looking at combinations of not only pharmacological, but also physical and psychological strategies. She also says that better prevention and treatment of acute pain can also make chronic pain less likely to develop. “However, if conservative strategies fail for the treatment of chronic pain, we should consider using opioids safely and effectively.”
Cognitive behavioural therapy, exercise, mindfulness and physiotherapy are all proven ways to reduce pain without medication, and acetaminophen and NSAIDs like aspirin and ibuprofen are also effective for most pain. For more complex pain, neuropathic medications can be another good option, says Campbell.
Publicly funding physiotherapy and psychotherapy for the treatment of chronic pain is also necessary, she says. “I think a real barrier here is that expert professional help like physiotherapy isn’t publicly funded,” she says. “So the easiest intervention is for primary care providers to provide prescriptions.”
*This article has been updated from the original version to correct an inaccuracy in the number of Alberta doctors prescribing over 4000 MME.