The tragic spike in opioid-related deaths has brought the large and complex issue of drug use and misuse into sharp focus. As fentanyl-related overdoses grip 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, little data supports 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 crashes.
We recently published a study that shows that the number of British Columbians prescribed opioids long-term for non-cancer pain grew by 19 per cent between 2005 and 2012.
How big is the problem? By 2012, more than 110,000 B.C. residents — equivalent to the entire population of Kelowna — used opioids regularly. The number is likely higher today.
Each year, more people begin taking opioids than those who discontinue, producing an ever-growing population dependent on the drugs.
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 factors are interconnected. For example, mental illnesses such as depression are risk factors for developing opioid abuse, while depression can worsen chronic pain, and chronic pain can contribute to depression.
The key to tackling this problem lies in co-ordinated interventions across the health-care system.
We need to provide better support and therapy options for those who use opioids regularly. 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 overall prescription opioid consumption in B.C. has increased due to the use of stronger opioids and longer durations of opioid therapy. However, restricting access is insufficient and could be harmful if implemented in isolation.
Asking doctors to reduce their prescribing might decrease a patient’s prescription opioid intake on paper, but it doesn’t address the patient’s real need for pain relief or any addiction issues that might have developed.
For many, there are few alternatives for pain management, 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, might be unavailable or might involve long wait times.
Wait lists in the health-care system are also problematic. Patients might be left taking opioids for pain management while awaiting surgery or a consultation with a pain specialist. For individuals who have developed addictive behaviours, there is inadequate access to timely counselling, detox and addiction-treatment programs.
Too many patients have developed long-term dependency on prescription opioids. However, reducing opioid availability without providing alternatives might result in patients turning to the illicit market to support their need for the drugs.
There’s 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 in 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 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.
Kate Smolina is an expert adviser with EvidenceNetwork.ca. She was a postdoctoral fellow at the School of Population and Public Health, University of British Columbia, at the time the studies were conducted. She works as the director of the B.C. Observatory for Population and Public Health at the B.C. Centre for Disease Control. Kim Rutherford is a family physician at Spectrum Health, Vancouver, and a clinical instructor in the Department of Family Practice, University of British Columbia. She also works with Vancouver Coastal Health as an outreach physician in Vancouver’s Downtown Eastside.
