Evan Wood is the director of the B.C. Centre on Substance Use and a professor of medicine and Canada Research Chair at the University of British Columbia.
One of the confusing ironies of addressing the opioid crisis is that halting overdose deaths will require stopping prescribing for some, while actively prescribing opioids to others.
Having spent the past year being centrally involved in the response to British Columbia's overdose crisis, I'm always surprised when I hear people question the role of prescription opioids in the fatal overdose epidemic.
The shenanigans of the pharmaceutical industry in promoting opioid drugs as safe have been clearly exposed, and the deadly effects of over-prescription in areas where marketing strategies were most intense have also been well documented.
West Virginia, which the U.S. Centers for Disease Control and Prevention ranked as the U.S. state with the highest rate of opioid-overdose deaths, was blanketed with almost 800 million potent hydrocodone and oxycodone pills over a six-year period. A single pharmacy in Kermit, a town of a population of less than 400, was found to have received more than nine million hydrocodone pills over a two-year period.
Of course, careless dispensing of opioids from pharmacies requires careless prescribing by physicians who have clearly not understood the safety concerns with opioid drugs and the potential for abuses. Consider the case of a British Columbian patient documented to have received more than 23,000 oxycodone pills through more than 50 physicians and 100 pharmacies before authorities finally became aware.
In the face of such gross over-prescribing, it is also important to acknowledge the limited evidence on the possible benefits of opioid medications for chronic non-cancer pain. Here, the most prominent U.S. review has concluded: "Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms."
Collectively, the clear impact of opioid prescribing on addiction and overdose deaths requires an intensive strategy to reduce opioid prescribing. However, a single focus on reducing opioid prescribing will actually increase fatal overdoses.
This is because the demand for prescription opioids has ushered in a new era of street opioids, including illicitly manufactured fentanyl. Unlike the relatively bulky heroin, which is derived from the poppy plant and must be surreptitiously imported from places like Afghanistan, thousands of fentanyl doses can be ordered from China and shipped in a single envelope before being pressed into counterfeit OxyContin pills. When individuals have become opioid-addicted through physician prescriptions, there is an enormous risk of fatal overdose when drugs containing fentanyl are encountered.
For individuals who have become opioid-addicted, it is crucial to reduce exposure to fentanyl-laced drugs by providing treatment that has been proven effective. A recent meta-analysis published in the British Medical Journal demonstrated that overdose mortality rates among opioid-addicted people were almost five times higher when individuals were not on opioid agonist therapy, which involves prescribing a substitute opioid such as methadone or buprenorphine.
When one understands the harms of prescription opioids for patients who are not addicted, and the benefits of opioid agonist medications for individuals who have become addicted, the challenge for policy-makers is clear.
For individuals who have never been exposed to addictive and often toxic opioid medications, every effort must be made to prevent physicians prescribing them when they are not needed. Given that opioid prescribing is actually expanding in Canada, regulatory tools must be urgently expanded, including prescription monitoring programs that can identify and aggressively address unsafe prescribing of opioid medications.
On the other hand, a fully functioning addiction-treatment system is needed for people who have become opioid addicted. This system, which does not yet exist in any Canadian jurisdiction, must include the full range of opioid agonist therapies as well as recovery services for patients who are ready and able to come off opioids.
Since people with untreated addiction can initiate their peers into substance use, evidence suggests that treating opioid-addicted individuals can actually also reduce the number of newly addicted persons. As such, it is crucial that the addiction treatment system be developed alongside efforts to reduce the prescribing of opioid drugs for the treatment of chronic non-cancer pain. Otherwise, we will be faced with the all-too-common scenario in which pulling back the prescribing of pain medication pushes individuals towards fentanyl, with often deadly consequences.