Despite a national epidemic of opioid abuse and overdoses, prescriptions for painkillers – as well as therapies for treating dependency – have increased, new figures show.
Retail pharmacies across Canada dispensed 19 million prescriptions for opioids in 2016, up slightly from 18.9 million in 2015, according to estimates by health-data company QuintilesIMS. Prescriptions climbed six per cent over the past five years.
Overprescribing is behind the epidemic, which has worsened in recent years with the arrival of illicit fentanyl, leading to a sharp spike in overdose deaths. Canada ranks as the world's second-biggest consumer of pharmaceutical opioids.
A Globe and Mail investigation found that Ottawa and the provinces have failed to take adequate steps to stop the indiscriminate prescribing of opioids. As doctors continue to liberally prescribe opioids, a class of painkillers that includes oxycodone, hydromorphone and fentanyl, both the pharmaceutical-grade and illicit markets are thriving. Meldon Kahan, medical director of the substance-use service program at Women's College Hospital in Toronto, said the numbers show that efforts to educate doctors about the risks associated with opioids have had little impact on prescribing.
"If you create newly addicted patients through your intemperate opiate prescribing," Dr. Kahan said, "many of those patients will eventually go to the street, especially as prices are declining and the patient needs higher and higher doses."
The magnitude of the problem is reflected in the growing ranks of people treated for opioid abuse. The number of patients receiving the opioid therapies methadone and buprenorphine-naloxone soared 80 per cent in four provinces over the past five years, according to figures obtained by The Globe. Prescriptions for these therapies jumped 142 per cent, according to the figures tabulated for the first time.
British Columbia, Alberta, Saskatchewan and Nova Scotia each provided figures to The Globe for methadone and buprenorphine-naloxone paid for by provincial public drug plans and private insurers dating back to 2012. Manitoba and Ontario had figures for the past four years – the number of prescriptions for these therapies rose 71 per cent and 60 per cent, respectively.
In Alberta, the lion's share of treatment is covered by private insurers; in Manitoba, by contrast, the public plans pay for the majority of drugs. Provinces that track only opioids paid for by their public drug plans were excluded.While the prevalence of these therapies is "a testament to the scale of the opioid crisis nationally," said David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto, it's also encouraging that something is being done to address the problem.
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"One of the key things that needs to happen to save lives and help address the crisis is increasing access to drugs like methadone and buprenorphine," Dr. Juurlink said.
The national prescribing numbers from QuintilesIMS show that potentially highly addictive, long-acting painkillers were the drug of choice for many doctors. Hydromorphone, a controlled-release opioid, accounted for one out of every four prescriptions in 2016. Hydromorphone rivalled the popularity of lower-dose acetaminophen combined with caffeine and codeine. Acetaminophen is best known as the drug in Tylenol and is typically used for mild-to-moderate pain such as headaches.
Many doctors began shifting patients to hydromorphone in 2012, after the blockbuster drug OxyContin was no longer available in Canada. Prescriptions for hydromorphone have soared 57 per cent over the past five years.
"I think that's probably to a large degree because hydromorphone is similar to oxycodone," said Tara Gomes, an epidemiologist at Toronto's St. Michael's Hospital. Both are in tablet form, she said, and Hydromorph Contin, a brand-name version of hydromorphone, sounds a lot like OxyContin.
Purdue Pharma, the maker of OxyContin, launched sales campaigns two decades ago promoting the benefits of the drug and it quickly became the country's top-selling long-acting opioid. But it also became a lightning rod in the early 2000s, as reports of addiction and overdoses exploded. In 2012, Purdue pulled OxyContin from the market and alternative painkillers filled the void. Purdue also makes Hydromorph Contin.
The fact that Canada's opioid use shows no signs of waning points to the challenges doctors face in trying to change practices developed two decades ago, when they began prescribing the drugs to relieve moderate to severe pain as pharmaceutical companies marketed their use for everyday conditions such as chronic back pain.
"We need to reset the thinking on opioids," said Gordon Wallace, managing director of safe medical care at the Canadian Medical Protective Association, which provides advice to doctors when medical-legal difficulties arise. "In my time, the benefits of opioids for non-cancer pain were significantly over sold and the risks were under stated."
Since the beginning of January, 2016, Dr. Wallace said the association has fielded just under 300 calls about opioids from doctors. Many doctors are seeking advice in dealing with patients resisting any efforts to wean them off painkillers. The problem is particularly challenging for new doctors who have inherited patients on high-dose opioids from a colleague who has retired.
In an effort to curtail the use of prescription opioids, the U.S. Centers for Disease Control and Prevention published new guidelines last March, urging doctors to try non-drug approaches first to treat chronic pain and to prescribe opioids sparingly by starting patients with low doses and providing only a few days' supply. Physician regulatory colleges in some provinces, including Nova Scotia, have endorsed those standards.
Everyone in the profession, including the regulators, recognizes the challenges doctors face in managing patients who are on daily doses that exceed what's recommended in the U.S. guidelines, said Gus Grant, registrar of the College of Physicians and Surgeons of Nova Scotia. If doctors taper too quickly, patients risk going into withdrawal.
"We have to avoid the whiplash response of reducing everyone in short order," he said.
Dr. Grant was part of the panel that drafted updated national guidelines in Canada, which recommend much lower prescribing caps than the initial 2010 guidelines. The updated version also recommends that patients who are having difficulty with tapering be offered care from a multidisciplinary team, such as physiotherapists and mental-health workers, to help manage chronic pain on lower doses of opioids.
However, Dr. Grant said, the on-the-ground reality is that such multidisciplinary teams are not necessarily available everywhere.
"Clearly, as the regulator we are not going to hold anyone accountable for not delivering a service that's not available."
Guidelines for prescribing opioids across Canada
Ontario no longer pays for high-dose opioid medications under its public drug plans. The two Western provinces hardest hit by Canada's overdose crisis are introducing new rules for prescribing opioids. And Newfoundland and Labrador plan to have a prescription monitoring program fully implemented by year end.
These measures are aimed at curtailing the indiscriminate use of prescription painkillers and combatting an epidemic of opioid abuse. As of Jan. 31, Ontario delisted all opioids that exceed the equivalent of 200 milligrams of morphine a day from its drug formulary.
The impact was immediate: In the first week of January, the number of claims submitted to the Ontario Drug Benefit program for two of the high-dose drugs – 24- and 30-milligram capsules of hydromorphone – totalled 549, according to a Ministry of Health spokesman. By the week of March 12, the number of claims had shrunk to 30. The high-dose drugs are still available to palliative-care patients in Ontario through a separate program.
In Alberta, doctors will be required as of April 1 to check a patient's medication history in either the province's Pharmaceutical Information Network or an alternative, independent source before initiating or renewing a prescription for drugs such as opioids, benzodiazepines and sedatives.
There has been a four-fold increase in the number of prescriptions for methadone and buprenorphine-naloxone between 2012 and 2016 in Alberta, the biggest among the four provinces that provided five years of data to The Globe and Mail. But the province's public drug plan covered only 4 per cent of the drugs in 2015. This year's budget has earmarked $44-million to help people in Alberta get treatment, triple the amount spent on substance-use strategies in the past.
"We know the cost of medication and distance from our urban centres has made it difficult for Albertans living with substance use to get help," Associate Health Minister Brandy Payne said in an e-mail response.
In British Columbia, along with requiring doctors to check a patient's history in the province's PharmaNet database before prescribing drugs with potential for misuse or diversion, it is revamping clinical guidelines for treating opioid dependency. The guidelines, created by the recently formed B.C. Centre on Substance Use, emphasize providing a broad range of options tailored to individual needs. This includes exploring methods to help people who feel trapped on methadone transition off the treatment, said Evan Wood, director of the centre.