Our friends, neighbours and family members are dying of opioid overdose at a rate never seen before. Similarly, opioid addiction is causing tremendous harm to numerous individuals and their families. The problem is complex, and there is no simple solution.
The opioids causing this harm come from a few sources including illegal non-prescription opioids. However one important source of opioids in our homes and 'on the streets' are those prescribed by doctors, dentists and now in Ontario, nurse practitioners. The most recent report from Health Quality Ontario, 9 Million Opioid Prescriptions, helps offer some insight into the extent of opioid prescribing.
That report shows people in Ontario filled more than 9 million prescriptions for opioids in 2015/16, an increase from three years ago, with a trend towards prescribing stronger opioids like hydromorphone and away from weaker opioids like codeine. Nearly two million people in Ontario fill prescriptions for opioids every year - one in seven of us. Canada remains the second-largest consumer of prescription opioids in the world, after the US.
Why prescriptions are at such high levels and increasing is a complex question with no easy answers. The current situation stems from many factors such as access to other resources to treat pain (including affordability); physician education; inappropriate influence of pharmaceutical companies; and patient expectations. To a large degree, the rate of prescriptions documented in this Health Quality Ontario report can be seen as a symptom of a larger set of problems, and is not inherently the problem.
As governments, health care leaders, patient advocates, researchers, and front line health care providers begin to mobilize in the face of the individual stories and systematic data as outlined in reports like 9 Million, we need to be wary of some risks:
• We cannot demonize doctors who prescribe opioids or create a culture of fear where people don't address pain appropriately or acutely discontinue opioids. We do need to include physicians and their experiences and expertise in the design of solutions.
• We must not create an expectation of 'zero use' for opioids to treat pain. The desire and need to alleviate pain is a core tenant of a healing profession and evidence supports that opioids carefully used are part of the answer. For example, one critical area for the use of opioids is palliative care. As we meet our goal of delivering more palliative care at home, we will see community based opioid prescriptions increasing for these patients.
• We must not further stigmatize patients with pain and/or addiction - pushing them away from the health care system they need.
It will take a concerted effort by people in many parts of the health care system to address the issue of the inappropriate prescribing of opioids. There are many things that need to be done. Here are six actions that can contribute to better managing the issue:
1. Make a broad variety of evidence based tools readily available to front line providers regarding opioid prescription as well as the management of acute and chronic pain as well as addiction. The recently updated and published guidelines for prescribing opioids for chronic pain are one such example
2. Work to reduce the number of patients being prescribed high-doses of opioids. Patients taking high doses of opioids are more likely to become dependent on the drugs.
3. Introduce better systems to monitor opioid prescribing. As Tara Gomes, a Principal Investigator of the Ontario Drug Policy Research Network, said recently, "if prescribers knew the history when they saw a patient, it would avoid those prescriptions being written in the first place." Good data, provided in a timely way is a critical tool. Too often physicians and other prescribers don't have the information they need.
4. Where possible, carefully reduce doses of opioids in patients using them and provide appropriate treatment to those who have become dependent or addicted.
5. Improve access to non-opioid means of pain management. This includes non-opioid medications, and non-medication based approaches such as physical therapy. Accessibility includes geographic proximity, financial costs and timeliness. .
6. Better educate the public and patients about opioids - what they are, how they are used appropriately, the risks and what alternatives exist to their use. Conversations about opioids are among the hardest I have with patients. These conversations often test the patient-physician relationship and the understanding of how patient-centered care is achieved in the best interest of the patient.
Efforts by governments, public health officials, and the medical profession on these actions can make a difference. The bottom line is we must look at both our individual responsibilities as health care providers and the system issues and pursue multiple solutions at once.
All Ontario residents are committed to having a high quality health care system and part of that system involves improvement in the evidence-based management of patients living with pain and those living with addiction.
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