Canadian opioid epidemic:
how did we get here?

A highly respected, if unorthodox, physician in his mid-30s injures his leg while playing golf. When the pain continues, doctors discover severe muscle tissue damage due to compromised circulation. The physician undergoes multiple surgical treatments with a difficult recovery and is prescribed the opioid narcotic pain killer Vicodin (acetaminophen and hydrocodone), but the pain never really goes away. Over time, he needs more and more of the drugs in order to cope with his chronic pain as well as the stress of a demanding life. Does this sound familiar? The popular television character, Dr. Gregory House, reveals a common journey to opioid addiction, beginning with a legitimate medical need for pain management which grew into tolerance, dependency, and addiction.

The current opioid epidemic is well-publicized in both mainstream and medical literature in terms of size and scope. What are the unique circumstances that led to the dramatic rise in opioid prescriptions over the last few decades? The following is a brief overview of the resultant morbidity and mortality for the insured population. 

An opiate is a drug containing opium or its derivatives used in medicine for inducing sleep and relieving pain. It is considered a narcotic, which is a class of drugs that dulls the senses, relieves pain, causes drowsiness, and, in moderate doses, even profound stupor or coma. Opiates are originally derived from the poppy plant and have been around for thousands of years. 

Starting in the early 20th century, the Canadian government has taken steps to restrict the general distribution of opiates. The Controlled Drugs and Substances Act (CDSS) of 1996 classified eight schedules of drugs as well as penalties for the possession, trafficking, exportation, and production of controlled substances in an effort to curtail drug use, addiction, and illegal sales. 

Prior to the mid-1990s, physicians typically only treated pain when it was severe, such as from cancer, surgery, or trauma, and in acute-care settings like hospitals. In the middle of the decade, attitudes towards pain and pain relief began to change. It was believed that clinicians generally failed to assess pain and provide adequate relief since pain is both subjective and multidimensional. One medical group even launched a campaign encouraging pain to be considered the fifth vital sign (along with pulse, blood pressure, respiration, and temperature).

While focus on alleviating all types of pain grew, new time-release opioid formulas began to appear on the market claiming to be nearly addiction-proof and that their steady 12-hour coverage would avoid withdrawal. This combination sparked a rapid rise in the amount of prescription opioids dispensed in both Canada and the U.S. In Canada alone, the overall number of prescriptions for opioids increased by almost seven per cent between 2012 and 2016, and 21.5 million prescriptions were dispensed in 2016 compared to 20.2 million prescriptions in 2012.¹

Narcotics were no longer recommended only in the case of extreme pain but routinely prescribed by general physicians for all types of pain, including low back pain, migraines, muscle aches, etc. Physicians were now actively managing pain and it seemed the failure of the medical community to assess pain and provide pain relief was subsiding. 

Strong medications to alleviate chronic pain became more commonplace but were being used in private, less supervised settings. As a result, the increase in opioid prescriptions have been associated with serious risks, including opioid use disorder, diversion, addiction, and overdose deaths.

Results from the 2017 Survey on Opioid Awareness confirmed that in terms of use, 29% of Canadians aged 18 years and older reported using some form of opioids in the past five years. Twelve per cent of Canadians agreed that they would share their opioids to relieve the pain of a family member or friend.²

A statement made by the Public Health Agency of Canada (PHAC) in March 2018, reported that 2,923 people are believed to have died from opioid-related overdoses between January and September 2017; a 45% increase over the same period in the previous year and just 23 lives fewer than all apparent opioid-related overdose deaths in 2016.³ Based on the latest available data, public health officials estimate that there were more than 4,000 opioid-related fatalities in Canada in 2017.⁴

The PHAC also reported that the majority of apparent opioid-related deaths were accidental or unintentional in both 2016 (88%) and January to September 2017 (92%). 

In December 2016, the Government of Canada replaced the National Anti-Drug Strategy, which relied heavily on enforcement action, with the Canadian Drugs and Substances Strategy (CDSS) which takes a public health approach to problematic substance use and emphasizes compassion and collaboration between sectors. This new approach recognizes the powerful social factors that require health and social service responses alongside the reduction of illegal drugs to combat the opioid epidemic. 

To further support national measures associated with the CDSS and to respond to the opioid crisis, the Government announced an investment of $100 million over five years and $22.7 million ongoing in 2017.

Provincial and territorial governments have also been actively responding. Almost all jurisdictions have their own strategies in place or in development, and have organized committees to manage the situation. Municipalities and local public health officials are also working on solutions that work best for their communities.

To assist primary care physicians, an updated version of the national guidelines for opioid prescription was published in March 2018 in the Canadian Medical Association Journal.⁷ These guidelines include ten recommendations which cover the following critical areas:

• When physicians should begin or continue to prescribe opioids for chronic pain
• Which drugs should be used, along with dosage, duration, follow-up, and plans for discontinuation
• How to assess the risks and harms of opioid use

As of 2016, fewer doses are already being dispensed per prescription at 10.5 daily doses per a prescript down from 11.8 daily doses in 2012.¹ 

The effectiveness of increased awareness, better prescribing patterns, comprehensive multi-modal treatments, and alternative pain treatments will hopefully result in fewer opioid prescriptions. 

In the meantime, as insurers we need to be aware that the opioid epidemic is not limited to a single socioeconomic group or geographic region. As described in the House example, opioid addiction can affect even those who are prime insurance candidates. 

The PHAC report showed three-quarters of opioid-related deaths occurred among males, with the highest proportion (28%) clustered among Canadians aged 30 to 39.⁸ Even individuals receiving long-term opioid therapy in a primary care setting struggle with addiction. Once addicted, it can be very hard to stop using.

There are several risk factors for prescription opioid abuse and overdose to be aware of when evaluating insurance applicants. The most notable include:^9,10

• Overlapping prescriptions from multiple prescribing doctors and pharmacies
• High daily dosages
• Mental illness or a history of alcohol or other substance abuse

Pain remains a common subjective complaint for many individuals seen in primary care settings. Especially in the case of chronic pain, physicians and patients need to work together to achieve a good quality of life. This may not mean a complete absence of pain, but rather the right balance between reducing pain while also reducing the risk for adverse consequences such as opioid overuse, narcotics addiction, and death. Achieving this goal is more complex than prescribing medications alone.

Life, critical illness, and disability insurers need to be aware that opioid use disorder is one of the most challenging forms of addiction facing the Canadian health care system, and a major contributor to the marked rises in opioid-related morbidity and death that Canada has been seeing in recent years. The evolving landscape of non-medical opioid use has become increasingly dominated by prescription opioids diverted from the medical system and, more recently, by highly potent, illicitly manufactured synthetic opioids (e.g. fentanyl and its analogues, including carfentanil).¹¹

While some progress appears to have been made, the current opioid epidemic is not likely to disappear overnight. Insurers need to be aware that opioid addiction is not limited to particular socioeconomic groups or geographic locations and understand the potential morbidity and mortality consequences of opioid addiction related to those applying for coverage in order to underwrite them appropriately.

References
1. https://www.cihi.ca/sites/default/files/document/pan-canadian-trends-opioid-prescribing-2017-en-web.pdf
2. http://www.statcan.gc.ca/daily-quotidien/180109/dq180109a-eng.htm
3. https://www.canada.ca/en/public-health/services/publications/healthy-living/national-report-apparent-opioid-related-deaths-released-march-2018.html
4. https://www.canada.ca/en/public-health/news/2018/03/statement-from-the-co-chairs-of-thespecial-advisory-committee-on-the-epidemic-of-opioid-o.html
5. https://www.cihi.ca/en/opioid-crisis-having-significant-impact-on-canadas-health-care-system
6. https://secure.cihi.ca/free_products/Opioid%20Poisoning%20Report%20%20EN.pdf
7. http://www.cmaj.ca/content/190/9/E247#ref-1
8. https://www.canada.ca/en/public-health/services/publications/healthy-living/national-report-apparent-opioid-related-deaths-released-march-2018.html
9. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA 2008;300(22):2613-20.
10. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315-1321.
11. Fairbairn N, Coffin PO, Walley AY. Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: challenges and innovations responding to a dynamic epidemic. Int J Drug Policy 2017;46:172–9.