More than 40,000 Ontarians were newly started on high doses of prescription opioids (over 90 mg of morphine per day, or the equivalent dose of a different opioid) in 2016. This is despite evidence that those who receive prescription opioids at higher than recommended doses are several times more likely to overdose compared to those on lower doses.
In addition, according to Starting on Opioids, a new report by Health Quality Ontario, the provincial advisor on health care quality, 1.3 million people overall were started on opioids in 2016 – at any dosage. This is a slight decrease of about 25,000 new starts, or 2 per cent, from 2013.
“At current rates of decrease, it would take Ontario more than a decade to reach the same prescribed opioid consumption rates as other economically similar countries such as Australia and the U.K.,” says Dr. Joshua Tepper, President and CEO of Health Quality Ontario. “We are hopeful the intervention of initiatives currently underway in Ontario to change opioid prescribing practices will bring the rate down much faster.”
The report also shows that of the 1.3 million Ontarians started on opioids at any dosage, nearly 325,000 were started with a prescription for more than seven days. Evidence tells us that initial prescriptions for more than seven days of opioids have been associated with a higher risk of long-term use.
Starts of opioids, as defined in the report, are prescriptions for people who have not filled an opioid prescription in at least six months.
“We encourage prescribers and patients to consider if there are non-opioid therapies that might be useful, before prescribing opioids,” says Dr. Tepper. “If opioids are the best option, the current standards and guidelines encourage the lowest possible dose and a short duration.”
For acute pain, a duration of three days or less is often recommended, according to expert opinion. And for starting on opioids for chronic pain, standards and guidelines say it’s preferable not to exceed a dose of 50 mg of morphine or equivalents per day, and to initiate opioids only after other therapies have been tried.
“It should be emphasized that chronic pain is very difficult to manage. For example, patients may not be able to afford non-opioid therapies, such as physiotherapy,” says Dr. Tepper. “And given the overdose crisis, which is increasingly related to non-prescription heroin and fentanyl, it is also very important for prescribers to not suddenly discontinue prescription opioids so patients don’t turn to street sources.”
To reduce the risk of addiction and opioid poisoning, there are some encouraging initiatives underway across the province to improve the prescribing of opioids.
In recognition of troubling trends in opioid prescribing and increasing opioid-related deaths, in 2016, the Ministry of Health and Long-Term Care launched a comprehensive strategy to address opioid-related harms, with a focus on modernizing opioid prescribing and monitoring, improving access to pain treatment, and enhancing addictions supports and harm reduction.
At the request of the Ministry of Health and Long-Term Care, Health Quality Ontario, in collaboration with patients, health care providers, caregivers, and organizations across the province, is in the final stages of developing three quality standards, that outline for clinicians and patients what high-quality care looks like. Two are about opioid prescribing for acute pain (short-term) and chronic pain (long-term), with a third outlining how to identify and treat people with opioid use disorder.
These standards of care will be put into action through coordinated efforts with a number of health care organizations who are providing customized data, tools and supports to physicians for appropriate prescribing.
Other initiatives are underway to prevent opioid addiction and overdose. To name a few, there are various hospitals designing programs to help with the post-discharge period for patients who have had major surgery to better manage their pain, and the Royal College of Dental Surgeons of Ontario produced a guideline for the province’s dentists and dental specialists. And, Ontario is expanding Rapid Access Clinics across the province to help people with hip, knee and lower back pain access the right treatment faster, including non-opioid treatments.
To provide a personal perspective of the issues raised by the data, the Health Quality Ontario report also features stories from patients and health care professionals.
- Canadians are the second-largest per-capita users of prescription opioids after the U.S. at over 34,000 daily doses per million in 2013-2015, according to the Report of the International Narcotics Control Board for 2016.
- About 44,000 health care professionals in Ontario prescribed opioids in 2016.
- Together, family doctors, surgeons, and dentists represented 86% of all new-start opioid prescriptions in 2016.
- In 2016, 865 people in Ontario died from opioid toxicity, up from 366 in 2003. Although many deaths involved opioids that were obtained from street sources, opioid-related deaths have also been shown to be concentrated among patients who are prescribed opioids more often, according to Public Health Ontario.
- Opioid related emergency department visits more than doubled to 4,427 in 2016 from 1,858 in 2003: Public Health Ontario.
To read the full report visit: www.hqontario.ca/StartingonOpioids
About Health Quality Ontario
Health Quality Ontario is the provincial advisor on the quality of health care. With the goal of excellent care for all Ontarians, Health Quality Ontario reports to the public on how the system is performing, develops standards for what quality care looks like, evaluates the effectiveness of health care technologies and services, and promotes quality improvement aimed at sustainable positive change. Visit www.hqontario.ca for more information.