Kate Smolina was a postdoctoral fellow at UBC's School of Population and Public Health. She currently works as the Director of the BC Observatory for Population & Public Health at the BC Centre for Disease Control. Kim Rutherford is a family physician and also works with Vancouver Coastal Health in the city's Downtown Eastside.
Across Canada, the tragic spike in opioid-related deaths has brought to national attention the large and complex issue of drug use and misuse. As fentanyl-related overdoses are gripping the country, there is a connected, but separate, crisis of doctor-prescribed opioids being increasingly used on a regular, long-term basis.
While prescription opioids are effective for short-term pain relief, there is little data supporting the effectiveness of long-term use – but there is evidence of potential harm. Longer opioid therapy can also lead to individuals requiring higher doses to obtain the same degree of pain relief. Higher doses may further increase associated harms such as overdose, falls and motor-vehicle accidents.
We recently published a study that shows the population of individuals in British Columbia prescribed opioids long-term for non-cancer pain grew by 19 per cent between 2005 and 2012.
How big is the problem? We found that by 2012, more than 110,000 B.C. residents used opioids on a regular basis – a size similar to the entire population of Kelowna. The number is likely higher today.
The rising rate of long-term prescription opioid use is occurring because each year, more people begin taking opioids than those who discontinue. This cumulative effect is producing an ever-growing population dependent on opioids.
At the heart of the issue is the ongoing demand for these drugs. This demand is fuelled by many factors, including physical pain, psychological pain, psychiatric conditions and/or socioeconomic factors, such as housing, food and job insecurity, and lack of social belonging. Many of these factors are interconnected. For example, mental illnesses such as depression are a risk factor for developing opioid abuse, while depression can worsen chronic pain and chronic pain can contribute to depression.
So, how should we tackle this problem? The key lies in co-ordinated interventions across the health-care system.
First, we need to provide better support and therapy options for those who are already using opioids on a regular basis. The current approach largely revolves around limiting supply by restricting opioid prescribing, including a push for lower doses and shorter courses of treatment.
Such an approach is warranted, given that the overall prescription opioid consumption in British Columbia has increased because of both the use of stronger opioids and longer durations of opioid therapy. However, restricting access is insufficient and could be harmful if implemented in isolation.
Why? Asking doctors to reduce their prescribing may decrease a patient's prescription opioid intake on paper, but it does not address the patient's real need for pain relief nor any addiction issues that may have developed.
For many patients, there are few alternatives for pain management available, due in part to a lack of publicly funded programs and inadequate public and private health-insurance coverage. For instance, access to physiotherapy is often limited for those without extended health benefits, while many alternative medications for pain are costly. Other interventions, such as steroid injections, may be unavailable in some places or have long wait times.
Wait lists in our health-care system are also problematic. Patients may be left taking opioids for pain management while awaiting surgery or a consult with a pain specialist. For individuals who have developed addictive behaviours, there is inadequate access to timely counselling, detox and addiction treatment programs.
We have come to a point at which too many patients have developed long-term dependency on prescription opioids. However, reducing opioid availability without providing alternatives may result in some patients turning to the illicit market to support their need for the drugs.
There is an urgent need for co-ordinated, accessible, timely and affordable therapy options for the treatment of chronic pain, addiction and mental illnesses.
We must also work to prevent the emergence of new chronic opioid users by ensuring there are a variety of funded options to treat acute pain to decrease the likelihood of it progressing to chronic pain. These options could include topical agents, neuropathic medications, steroid injections, nerve blocks, physiotherapy and active rehabilitation services.
Finally, a public education campaign about the effectiveness and risks of using opioids is necessary.
Further upstream, investment into public-health programs and services that aim to encourage healthy diets, weight control, regular exercise, good sleep habits and stress management could help prevent many pain conditions.
We must broaden our response to the current crisis to address the aspects of our health-care system that contribute to the increasing demand for, and continued reliance on, opioids. We can't afford to wait.