Efforts to promote safer opioid prescribing in Canada appear to be having an effect, as new research in CMAJ (Canadian Medical Association Journal) https://www.cmaj.ca/lookup/doi/10.1503/cmaj.250670 shows a decrease in opioid dispensing between 2018 and 2022.
In the early 2000s, use of prescription opioids to treat acute and chronic noncancer pain increased substantially in Canada, and with it came a rise in opioid-related harms. The availability of more opioid products, coupled with aggressive marketing of these drugs, contributed to these early increases in Canada and in other countries.
Many initiatives have been introduced with the goal of reducing these harms throughout the country, including policy changes, a focus on continuing medical education for evidence-based prescribing, and a national Canadian guideline for opioid prescribing published in 2017.
With these changes, a need has emerged for national information on prescription opioid use in Canada and how this varies in different parts of the population. Researchers aimed to help fill this gap with a study of opioid prescribing in 6 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Quebec) between 2018 and 2022. The number of people newly starting opioids declined 8% during the study period, and the total number of people accessing opioids declined 11%. In 2022, across Canada, approximately 1.8 million people started an opioid to manage pain for the first time. However, the rate of opioid prescribing varied among provinces, ranging from 55 new opioid starts per 1000 people in Ontario to 63 per 1000 people in Alberta.
"[T]he interprovincial variations in our findings may indicate differences in the implementation of prescribing guidelines, underscoring the need for coordinated national strategies and ongoing evaluation of their effects on patient outcomes," writes Dr. Tara Gomes, a researcher in the Ontario Drug Policy Research Network at St. Michael's Hospital, Unity Health Toronto, with coauthors.
Annual rates of new prescriptions were higher for females, older adults, and people living in lower-income neighbourhoods and rural regions. Codeine was most usually prescribed in most provinces, with the exception of Quebec, where people were more commonly dispensed morphine and hydromorphone. Oxycodone dispensing decreased over time, although in Ontario over one-quarter of opioids prescribed were still for oxycodone in 2022.
The authors caution that although lower rates of opioid prescribing may reflect doctors' efforts to ensure safe and appropriate prescribing, a balance is needed to ensure that people are not left without pain relief or cut off from medications without appropriate supports and coordination of care.
"Importantly, although these recommendations intended to promote safer opioid prescribing, improper implementation can lead to rapid dose tapering, abrupt opioid discontinuation, and reluctance to initiate patients on opioids when clinically indicated. In some cases, these changes have led to patients seeking access to opioids from the unregulated drug supply, which are inherently more harmful," write the authors.
The researchers suggest that clinicians engage in conversations with patients to ensure shared decision-making, and assess pain levels and ability to function.
"The truth is … that opioids are less effective and less safe than many care to admit," writes Dr. David Juurlink, an internist and researcher at Sunnybrook Research Institute and the University of Toronto, Toronto, Ontario, in a related commentary https://www.cmaj.ca/lookup/doi/10.1503/cmaj.251666 praising the continued decline in opioid prescribing.
Opioids can be effective when carefully prescribed, particularly for short periods. But, with long-term use, their effectiveness can wane and they can harm patients in ways that are hard to appreciate.
"Most clinicians have seen how well opioids can work when first given," writes Dr. Juurlink. "But they are at their pharmacologic best in the initial days of treatment. Continue them for weeks, months, or years and the calculus becomes progressively less favourable."
Juurlink urges thoughtful prescribing, which "begins with recognizing that all patients in pain fall into 1 of 3 mutually exclusive groups: those not yet on opioids, those taking opioids chronically (sometimes called 'legacy patients'), and those with established addiction. The latter 2 groups overlap and are easily harmed by rapid dose reduction, but they can also be harmed by dose escalation. For such patients, when pain intensifies, nonopioid strategies are preferred. The first group, by contrast, has the most to gain from thoughtful opioid stewardship."
