How to end Canada’s biggest public health emergency

TheGlobeandMail.com – Opinion/Editorials
May 22, 2017.   GLOBE EDITORIAL

In 2015, more Canadians were killed by opioid-related overdoses than lost their lives at the height of the HIV/AIDS epidemic. In 1995, at the peak of that earlier public-health disaster, 1,764 Canadians were killed by the blood-borne virus. The latest estimates are that opioids claimed the lives of more than 2,000 Canadians in 2015.

And all indications are that the death toll is rising, not falling.

Part of the problem may have to do with this: Doctors are not just prescribing opioids, but prescribing them widely and liberally. For example, the number of prescriptions for opioids and their derivatives increased five per cent in Ontario over the three years ending 2015-16. Last year, Ontario doctors wrote 9.1 million orders for opioid painkillers.

A recent article in Annals of Surgery, an American medical journal, summed up the situation tactfully, describing doctors, and surgeons in particular, as “unwittingly enablers of addiction, abuse and overdosage.” Addiction to illicit opioids often begins with licit prescriptions.

It’s why new medical guidelines for fentanyl, hydromorphone and other opioids were issued this month. They suggest using opioids as a treatment of last resort and call for smaller doses.

However, when it comes to opioids, many physicians find themselves ensnared in the appearance of conflicts-of-interest, extending even to the new guidelines. Last week, a Globe and Mail review of the 28 medical experts, academics and patient advocates who worked on them found that nine have received remuneration from drug companies, including Purdue Pharma, the pharmaceutical giant whose pain pill triggered Canada’s deadly opioid epidemic. Two of the nine voted on the guidelines and seven did not.

Meanwhile, frontline doctors find themselves in an unenviable position. These drugs are not prescribed without reason. A 2011 study published in the academic journal Pain Research and Management estimated that a staggering one in five Canadian adults suffers from some form of chronic pain.

A commentary in the same CMAJ issue that unveiled the new prescription guidelines identified another area that demands closer attention, “a less well-publicized problem of undertreated chronic pain.”

To that end, the authors outline the case for a national chronic pain strategy to improve the perennially poor access to specialized clinics and treatments. The idea is not without merit.

But no effort to confront or assuage the opioid epidemic can succeed without knowing who is prescribing what, to whom, and in what quantities.

Those previously mentioned figures on Ontario’s volume of prescriptions, from the province’s narcotics monitoring system, are eyebrow-raising. But the number of prescriptions filled doesn’t tell anything close to the whole story.

Was each dose appropriate? What proportion was diverted to friends, family or the street? How much free-floating pain medication sits unused in medicine cabinets across the country? How many prescriptions were issued but not filled?

Canada’s invisible painkiller epidemic is at least a couple of decades old and we don’t have good answers to those questions.

Given the scope and depth of the human catastrophe at hand, the lack of surveillance data is frankly shocking. The situation is all the more surprising when you consider the urgent and overwhelming response to recent public health emergencies involving infectious disease or food-borne illnesses – SARS, avian flu, listeriosis.

Where are the daily updates on opioid overdoses and deaths? Where is the all-out response?

Federal Health Minister Jane Philpott needs to do more. But Ottawa is catching up with a decade of ground lost under a Harper government that saw opioids as a law-enforcement problem, rather than a public-health issue.

It’s long past time to dispense with that unhelpful fiction. We need to get tough on addiction, not addicts. Nobody volunteered to have their lives ruined by addiction.

Eleven months ago, Ottawa announced $40 million to fund a national e-prescribing program. It aims to ensure that doctors are ordering the minimum quantity necessary, while reducing dosing errors, eliminating forgery concerns, and providing tighter control of medication that’s often diverted to the streets.

It’s a complicated, multijurisdictional effort, and though trial runs are slated for Alberta and Ontario this summer, it won’t be fully operational until mid-2018 at the earliest.

Opioid strategies and action plans, like the one adopted last winter by Ottawa and the provinces, are laudable and important.

But this big of an emergency demands big, course-changing action. Canadians, already among the world’s top per capita consumers of opioids, can no longer wait.

https://www.theglobeandmail.com/opinion/editorials/globe-editorial-how-to-end-canadas-biggest-public-health-emergency/article35066060/

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