Keeping a pulse on Alberta’s opioid crisis
Physicians are prescribing opioids in lower doses and to fewer patients in response to evidence-based guidelines, better physician education, new prescribing rules and general awareness of opioid-related issues. Yet Albertans are still dying each year from illicit opioid use, accessed on the streets in our communities. As physicians, we must continue to keep a pulse on the crisis and work to be part of the solution. How did we get here, what are we doing and what’s next?
• General opinion that pain is under-treated.
• Opioid painkillers marketed as effective and safe.
• Opioids become the go-to drugs to treat acute and chronic pain. Physicians are unaware of their addictive properties.
• Research begins to show that long-term opioid patients are likely to develop dependence, making it difficult to reduce or discontinue use.
• Increased diversion of opioid prescriptions to the streets for illegal sale.
• Strong correlation between prescription opioid use and overdose deaths, particularly with high-dose prescriptions.
• Opioid crisis realized. Canada has the second-highest prescription opioid use per capita in the world, and Alberta has the highest per capita consumption among the provinces.
• First Canadian guideline for opioid prescribing recommends caution when exceeding 200 mg/day of morphine or equivalent (OME). The American guideline recommends a lower dose of 50 OME/day and to exercise caution when exceeding 90 OME/day.
• CPSA Council endorses the American guideline as best practice until a new Canadian guideline becomes available and supports a commitment to harm reduction, including naloxone and safe drug consumption sites.
• CPSA hosts Opioid Prescribing Forum and consults on a new draft standard for safe prescribing, requiring physicians to prescribe the lowest effective dose and check patient’s medication history before prescribing.
• CPSA launches its first MD Snapshot: Prescribing to physicians who prescribed an opioid or benzodiazepine between July-Sept. 2016. Majority of responding physicians find the report useful and plan to make changes to their prescribing practices.
• Canada’s per capita consumption of prescribed opioids drops slightly for the first time.
• CIHI releases first-ever annual report on trends in opioid prescribing for all provinces. Data shows Alberta is the highest per capita prescriber.
• CPSA Council removes regulatory barriers to prescribe buprenorphine/naloxone (Suboxone) to increase capacity for treating patients with opioid use disorder.
• CPSA endorses the newly published Canadian Guideline for Opioid for Chronic Non-Cancer Pain, which also cites 90 OME/day as the threshold for extra caution.
• CPSA issues final approved safe prescribing standard and advice document for drugs with potential for misuse or diversion, with specific safeguards for opioid prescribing. Physicians are to prescribe lowest effective dose and document justification when exceeding best practice recommendations; consult a database and independent source for medical histories; and discuss with the patient the risks, potential benefits and alternatives to the medication.
• CPSA releases first-ever data showing trends in per capita opioid prescribing on a standardized basis, for 2015 and 2016.
• Alberta’s prescribing of opioids drops by 25% in the past two years, measured on a standardized basis (OME per capita per day).
• CPSA continues to highlight opportunities for improved prescribing practices via customized quarterly MD Snapshot-Prescribing, and through group and individual practice mentorship programs.
• CPSA partners with educators, government and other healthcare professionals to improve training, collaborate on provincial and national strategies, develop harm-reduction guidance and identify gaps in resources for this area of practice.
• CPSA drafts new standard of practice to better support physicians in using current, evidence-based guidelines to treat opioid use disorder (OUD) and ensure safe patient care. The language used in the draft also reflects our evolving understanding of OUD and the need to reduce stigma, so more Albertans can access this care.
The opioid crisis as a public health issue continues to be a concern for the College. Continued de-escalation of the crisis will require a multi-pronged approach including prevention, treatment and harm reduction and most importantly, collaboration with government, healthcare partners and others.
Safe prescribing of opioids will continue to be a priority for the College in the years to come. While our work has moved the ball forward, there is still much more to do.