The overall amount of opioids Canadians are getting in their prescriptions is dropping, while the number of prescriptions for the drugs is rising amid the ongoing and deadly opioid crisis, new data from the Canadian Institute for Health Information (CIHI) shows.
The total number of defined daily doses for opioids declined slightly less than 5% from 2012 to 2016 across Canadian provinces, while the overall number of prescriptions increased almost 7%.
Opioids — which include well-known types such as codeine, oxycodone, morphine and fentanyl — are used as a painkiller and can be highly addictive.
“While these are very broad indicators, the fact that the overall quantity of opioids prescribed is going down and the number of prescriptions is going up is what we want to see,” says Dr. Robert Strang, chief medical officer for Nova Scotia.
“Opioid prescriptions for acute pain should be for a short time period only, with ongoing reassessment for repeat prescriptions.”
These trends are consistent across most of Canada, and the rate of decline has accelerated with heightened awareness of the opioid crisis. CIHI’s recent report Opioid-Related Harms in Canada highlights the potential dangers of these drugs, demonstrated by the rise in hospitalization and emergency department numbers across the country related to opioid poisonings.
A recent report by the Public Health Agency of Canada shows that there were more than 2,800 opioid-related deaths across the country in 2016.
“Overdose death data is key for us to study, but it’s only one piece of the puzzle,” says Strang. “We also need to look at the data CIHI is providing related to opioids to understand how all of this is connected.
“Between the prescribing, hospitalization and emergency room data, there are some alarm bells that we need to pay attention to.”
Here are some of the key findings of CIHI’s report on opioid prescribing in Canada:
Between 2012 and 2016, the total number of defined daily doses of opioids dispensed in Canada declined from 238 million to 226 million. When adjusted for population growth, the rate per 1,000 people decreased by 8.9% during this period.
“The good news is that the overall quantity of opioids dispensed in Canada is declining, but the fact that such a large number of people are still being prescribed opioids continues to be a concern,” says Michael Gaucher, director of Pharmaceuticals and Health Workforce Information Services at CIHI.
In 2016, 21.5 million prescriptions for opioids were dispensed in Canada — up from 20.2 million in 2012.
“That’s a very high number of prescriptions for opioids — and it’s been too high for years,” says Gaucher.
“Opioids are very effective drugs and they’re an important part of pain management for many Canadians, but the benefits and risks need to be considered when being prescribed.”
This increase is just over 2% when adjusted for population growth.
During this period, an increasing proportion of all opioid prescriptions in Canada were for strong opioids, up from 52.2% in 2012 to 57.3% in 2016.
6 opioids accounted for more than 96% of all opioid prescriptions: hydromorphone, morphine, fentanyl, oxycodone, codeine and tramadol. The first 4 of these 6 are considered strong opioids and are usually prescribed for moderate to severe pain.
“Ideally, we’d like to see the prescribing of all of those strong opioids going down,” says Strang.
“We have to acknowledge that this is a balancing act. While we’re trying to reduce the prescribing of opioids overall, we have to recognize that there are people who, for a very significant period of time, have been dependent on strong opioids. We’re not going to change that overnight.”
Although a great deal of attention has focused on fentanyl and the harms attributed to its use and misuse, it is much less frequently prescribed than other strong opioids. Since 2012, the number of prescriptions for strong opioid prescriptions other than fentanyl has increased more than 19%, while the number of fentanyl prescriptions has decreased by almost 7%.
“This is a very interesting number and I think it’s the opposite of what the public thinks about fentanyl,” says Gaucher.
“I think this shows that the fentanyl reportedly being used by Canadians is more likely coming from illicit sources rather than from prescriptions.”
Seniors had the highest rates of opioid prescriptions in Canada between 2012 and 2016, with more than 200 in 1,000 seniors receiving at least one in 2015–2016. The data also shows that 1 in 8 seniors prescribed an opioid were prescribed a strong opioid on a chronic basis.
“There are a lot of negative outcomes from prescribing opioids to seniors that go beyond death,” says Strang. “There are substantive negative impacts on people’s lives.”
Seniors are at greater risk for opioid-related harms due to several factors, including age-related changes in drug absorption and metabolism, and cognitive changes that may increase the risk of accidental drug poisoning.
British Columbia and Quebec had the lowest number of defined daily doses per 1,000 people, at 5,496 and 3,601, respectively, while Alberta and Newfoundland and Labrador had the highest, at 7,955 and 7,878, respectively. The overall Canadian average was 6,110 defined daily doses per 1,000 people.
“This new report rightly points out that we need to look at Quebec in much more detail and try to figure out why it’s so different from the rest of the country with regard to opioid prescribing,” says Strang.
Both B.C. and Nova Scotia adopted new opioid prescribing guidelines in 2015, and they both also experienced the most substantial decreases in opioid dispensing between 2015 and 2016, with defined daily doses per 1,000 population declining by 11.7% in B.C. and by 6% in Nova Scotia.
“When you look at the overall decreases across the country, particularly in B.C. and Nova Scotia, over the past year, changes in policy and increased awareness of the potential dangers of opioids seem to be making an impact,” says Gaucher.