Action needed for opioid epidemic

After the U.S., Canada is the world's number twoconsumer of opioid prescriptions.Rising rates of addiction and opioid-related deaths have led to calls for a national strategy.Two articles just published in the Canadian Medical Association Journal (CMAJ) today, suggest a way forward.

In the first article (apologies for the paywall), researchers from Toronto and Vancouver say Canada should adopt a comprehensive plan to stop rampant prescribing of opioids and to prevent or reduce the resulting harms.The plan, they say,should include strict guidelines for doctors that make prescribed opioids the exception and not the rule. And they say opioidsshould be prescribed in small doses and for the shortest possible time. It should include an electronic system that tracks opioids dispensed by pharmacies in real time, that doctors must check to find out if the patient is getting prescriptions from other doctors.It should also include a national surveillance system that tracks ER visits, deaths and other harms linked to opioids.

What prompted this call for action is the failure of other measures that have been tried by authorities -none of which has stemmed the crisis. In 2010, a group of experts wrote national guidelines for doctors on opioid prescribing. Full disclosure: I was a member of that group. The authors of the article in CMAJ say the guidelines were soft on specifics such as which patients should never get opioids.

In 2012, several provinces removed OxyContin from provincial formularies after reports of disproportionateharms and deaths. But that led to a shift in prescribing to drugs still on the formulary, such asfentanyl and hydromorphone. Some provinces have electronic prescription monitoring systems that don't work in real time. Draft federal regulations in 2015 called for tamper-proof opioids, but these were also limited to OxyContin.

A second article(also behind a paywall) by doctors in BC notes that the prevalence of opioid addiction and related health problems have increased - making it the third leading cause of substance abuse after tobacco and alcohol.Reducing doctor prescriptions will prevent addiction, but won't help those already addicted. Therefore, theauthors call for more treatment facilities, and greater access to drugs that reduce cravings, suca asSuboxone, as a public health priority. Access is restricted in parts of Canada despite studies showing the drug works.The article says provincial restrictions should be lifted and access standardized across the country.The U.S. and France provide increased access to Suboxone through family doctors - which seems to help.

True, the provinces have primary responsibility for health care. Still, there's plenty the federal government can do that doesn't conflict with provincial jurisdiction over health. It can speed up the approval of addiction drugs like Suboxone, and can also provide additional funding to the provinces for addiction treatment.The federal government can also take the advice of doctors at the Centre for Addiction and Mental Health in Toronto, and withdraw approval for high-dose opioids that have contributed to excess harm.

Health Canada also has the mandate to gather detailed statistics on opioid abuse-related ER visits, hospital admissions for addiction and, of course, deaths.The data can be presented nationally and with regional breakdowns to locate and deal with opioid hot spots. The U.S. government has been gathering that sort of data for years. That helped the authorities in that country recognize much earlier than Canada the connection between prescribing and dispensing of high doses of opioids and the risk of harm.

There is always a risk that curbing the opioid epidemic will have an adverse impact on people with chronic pain.
Keep in mind that the goal is safe prescribing - not no prescribing. Putting dosage limits on opioid prescriptions will increase the safety of people with pain. In April, the U.S. Centers for Disease Control published opioid treatment guidelines that recommend non-drug treatments be tried first, followed by non-opioid pain relievers.

It's clear that with the advent of opioid therapy,the provinces moved away from providing non-drug treatments that are more expensive. If these new strategies move chronic pain patients into non-drug treatments, that would be a good thing.