Dr. Roger Skinner
Regional Supervising Coroner, Office of the Chief Coroner for Ontario, Ontario Ministry of Community Safety and Correctional Services
Good morning, Mr. Chair, members of the committee, staff, and witnesses.
It is my privilege to assist you today, both as a physician and as a representative of the Office of the Chief Coroner for Ontario.
The issue of prescription drug misuse, especially in regard to opiates, is one of great significance to our office and to physicians as a whole. There is no doubt that this is a complex public safety concern of import and urgency. The Office of the Chief Coroner for Ontario investigates all non-natural deaths and some specified natural deaths in the province, totalling about 17,000 deaths a year.
The coroner's investigative mandate is threefold: to determine the identity of the decedent, the place and date of death, the medical cause of death, and the manner of death; to determine if an inquest is necessary; and to make recommendations to prevent deaths in similar circumstances, where appropriate. In Ontario, the coroner has powers of entry, inspection, and seizure that allow for a thorough examination of the circumstances of death, and for the compilation of detailed information about individual deaths and about broader population trends.
The Office of the Chief Coroner recognized the growing number of prescription opioid deaths a number of years ago. Opioid-related mortality in Ontario doubled between 1991 and 2004. This was in large part due to the misuse of sustained-released oxycodone. By 2008, the number of opioid deaths had grown to surpass the number of deaths of drivers in motor vehicle collisions. It has since continued to increase. The rate of death from opioids is more than twice that from HIV, and approaching that from sepsis. In Ontario, more than 500 people die from opioid toxicity each year. If deaths attributed to alcohol plus opioids are included, the number exceeds 700.
Accidental prescription drug deaths affect a broad range of age, from children to the elderly. Studies have shown that accidental drug deaths are more likely to be due to opioids, while suicides more often involve other prescription drugs. The source of drugs in declining order is: prescription, then a combination of prescription and illicit purchase, and then illicit purchase. The likelihood of the source of drugs being from a person's prescription increases with increasing age.
Our investigations and the studies of others indicated that a number of factors had contributed to the development of this crisis. These included: liberalization of the utilization of opioids for the treatment of non-cancer pain; lack of knowledge on the part of health care providers with respect to potential toxicity; lack of dosage guidelines; lack of effective means for monitoring who was prescribing and who was using opioids; aggressive marketing campaigns by manufacturers; and law enforcement restrictions due to health privacy legislation.
It was clear from our review that the problem cases were not coming from the cancer care sector. The problems were related to the treatment of chronic non-cancer pain, to illicit diversion of legally obtained opioids, and improperly prescribed opioids or improperly utilized opioids. The Office of the Chief Coroner identified the following issues in opioid-related deaths that required further investigation: the management of chronic non-cancer pain; the diversion or abuse of opioids, specifically oxycodone; access to prescribing information; and legislative hurdles to sharing of information.
The Office of the Chief Coroner for Ontario has endeavoured to share our information and experience with policy-makers, prescribers, and dispensers. We have participated in a number of efforts to address these issues, such as the College of Physicians and Surgeons of Ontario's report, “ Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis”; the National Opioid Use Guideline Group's “Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain”; the National Advisory Committee on Prescription Drug Misuse's report “First, Do No Harm: Responding to Canada's Prescription Drug Crisis”; the public health division of the Ministry of Health and Long-Term Care's “A Review of the Impacts of Opioid Use in Ontario, Interim Summary Report”; and the Institute for Safe Medication Practices Canada's report “Death Associated with Medication Incidents”.
I know you are aware of these reports, each of which sets out the problem and suggested solutions much better than I can in this brief presentation.
In addition to these collaborations, the Office of the Chief Coroner identified two related deaths that became the subject of an inquest focusing on the issue of prescription opioid misuse. The inquest was broad in its scope and examined addiction, access to drugs, prescribing and dispensing, enforcement, and legislative challenges. The jury made 48 recommendations that can be categorized and summarized as follows.
Regarding drugs, the jury recommended: the removal of sustained release products with more than 100 milligrams of morphine equivalent per dose, and the removal of products with more than 40 milligrams of oxycodone; the review of all approved opioids; the inclusion of dose recommendations in monographs; and a review of tamper-resistant formulations.
Regarding monitoring and data, the jury recommended the development of a database accessible to prescribers and dispensers in Ontario through eHealth and through the Narcotics Safety and Awareness Act.
In regard to treatment, the jury advocated for resources for comprehensive pain and addiction treatment programs and facilities.
In regard to education, the recommendation was for renewed public and professional education, including the development and maintenance of national guidelines and relevant research.
In regard to legislation and enforcement, the jury recommended the funding of provincial and municipal drug enforcement units, a clarification of privacy issues, and recommended mandatory sharing of information between health care providers and between police and health care providers.
These jury recommendations mirror the findings of the other reports referenced.
The problem of prescription drug misuse is complex. There is no simple solution. The answer lies in a nationally coordinated, multipronged approach. This is a difficult task that will become more difficult the longer we delay. The evidence is in, the analyses are done, and a pathway has been charted. What is needed now is a unified political and professional will to move forward and to keep the resolution of this public safety crisis as a priority. If we do so, I am confident that many premature deaths can be prevented.