Thank you for giving me the opportunity to present to this committee. I commend you on the important work you're doing.
I am currently the medical director of the substance use service at Women’s College Hospital and an associate professor in the Department of Family and Community Medicine at U of T.
Before considering ways to deal with the opioid crisis, we first have to understand how we got here.
Back in the 1990s, the pharmaceutical company Purdue launched a massive advertising campaign for OxyContin. The campaign consisted of a few simple messages for doctors: controlled-release opioids such as OxyContin are less addicting than immediate-release opioids; addiction is extremely rare in patients with chronic pain; opioids are remarkably safe and effective; and there is no ceiling dose, that is, doctors can prescribe OxyContin in doses as high as necessary to relieve the pain.
This was the most successful pharmaceutical marketing campaign in history and it completely transformed physicians’ prescribing habits, yet these messages are simply not true. Opioids are of modest benefit, their long-term effectiveness is uncertain, and high doses increase the risk of addiction, overdose, and falls.
As a result, we are experiencing a unique iatrogenic—or physician-caused—public health crisis. In Ontario, there are 500 deaths per year from overdose. No other prescribed medication comes close to the suffering caused by opioids. Most of the people whose lives have been destroyed by opioids were not out seeking out opioids to get high. In fact, they were first exposed to opioids through a legitimate prescription for chronic pain.
Simply put, the root cause of the opioid epidemic is that physicians are prescribing opioids to too many patients at too high a dose. The good news is that since the crisis is caused by physicians, it can be solved by physicians, with the help of policy-makers and the public.
There are three areas that need attention: prevention of opioid addiction, prevention of overdose, and treatment. Provincial drug plans can play an important role in prevention by putting limits on reimbursement of high doses of opioids. The federal non-insured health benefits program has such limits, as does the Workplace Safety and Insurance Board in Ontario. The Ontario drug benefits plan is considering limits as well.
Medical regulators, that is, the provincial Colleges of Physicians and Surgeons, could reduce the harm of prescription opioids by establishing explicit prescribing standards. Physicians listen to their colleges. The basis for these standards is already laid out in the Canadian guideline on safe and effective prescribing of opioids for chronic non-cancer pain. This approach has been successful in other jurisdictions, such as Washington state.
Another critical need is to overhaul how product monographs are produced. A product monograph provides detailed information for physicians on how to prescribe the drug. The monograph is written by the company that makes the drug and is reviewed by Health Canada. Physicians view the product monograph as the definitive source of information on the drug. The OxyContin product monograph did not set those limits, and it did not properly warn physicians about the risks of high opioid doses. Current monographs for opioids and other drugs also have major inaccuracies.
This problem can be solved if Health Canada withholds approval until the monograph has been reviewed by independent objective experts. Internal staff at Health Canada simply do not have the expertise to do a meaningful review of the monographs for the hundreds of medications currently on the market. An objective expert review might have helped prevent or at least lessen the OxyContin tragedy.
Education is also of crucial importance. First of all, medical schools, residency programs, and organizations that accredit continuing education for practising physicians should ensure that medical education is free of company influence. Otherwise, we will see more crises like this in the future.
The three most important educational messages are these. First, do not prescribe opioids to patients at high risk for addiction unless absolutely necessary. Second, very few patients need high doses, and the chances of overdose, addiction, falls, and accidents increase substantially with the dose prescribed. Third, patients with both pain and addiction experience marked improvements in pain, mood, and function when their opioid dose is tapered or discontinued.
Turning to prevention of overdose, I believe the first task is a public awareness campaign. All patients must understand that giving or selling opioids to others is dangerous. The patient's opioid dose is safe because it is being slowly increased by the doctor, but if another person takes the same dose they could die of an overdose.
Also, patients need to keep their opioid medication in a safe and secure location, especially if they have adolescent children at home.
Provincial ministries of health can significantly reduce overdose deaths if they reimburse take-home prescriptions for naloxone. Naloxone programs in the U.S. have been shown to reduce opioid overdose deaths. Naloxone is inexpensive and very safe. Right now naloxone is distributed only through a few small needle exchange programs, so very few addicted patients have access to naloxone.
Take-home naloxone prescriptions should be accompanied by education. Simple messages such as “never use alone” can save lives.
Abstinence-based addiction treatment programs should also distribute naloxone to opioid-addicted patients on discharge because they have a very high relapse rate.
I'd like to turn now to treatment priorities. There are two main medical treatments for opioid dependence in Canada: methadone and buprenorphine. Methadone is very effective, but physicians must have special training before prescribing it, and many smaller communities do not have a physician with a methadone licence.
Buprenorphine or Suboxone is almost as effective as methadone, but is far safer. Buprenorphine can be safely prescribed by primary care physicians even if they are not trained in methadone prescribing.
Buprenorphine has transformed some remote communities that have been devastated by opioid addiction. For example, Sioux Lookout in northern Ontario has about 50,000 inhabitants scattered among some 50 first nation communities. Up to 50% of the adults in some of these communities are addicted to opioids, causing widespread crime, violence, family breakup, suicide, and overdose.
Methadone is not feasible in these communities, but over 400 patients are currently in buprenorphine treatment programs. This is truly a local community initiative. The treatment programs are organized and run by band leaders and by the physicians, nurses, and counsellors who live and work there. The health of these communities has improved dramatically.
The Sioux Lookout experience has been made possible because Ontario covers buprenorphine on its drug formulary and NIHB has followed suit. But outside of Ontario, NIHB and most provincial drug plans do not cover buprenorphine unless it is prescribed by a methadone physician. But since most communities do not have a methadone physician, this means that tens of thousands of patients have no access to either medication. In my view this denies the human rights of opioid-addicted patients to receive basic health care.
Both methadone and buprenorphine are on the WHO list of essential medications. The Canadian public would not tolerate this for any other medical condition.
I strongly urge provincial drug plans, NIHB, and provincial medical regulators to remove barriers to access to these life-saving medications.
Another priority is to create a more evidence-based integrated treatment system. Many treatment programs are abstinence-based. Patients often prefer abstinence-based treatment programs but they are not as effective as opioid substitution treatment with methadone or buprenorphine.
An integrated approach is needed and if the patient chooses abstinence-based treatment and then relapses, the program should immediately introduce opioid substitution therapy. The patient should not have to search for opioid substitution treatment elsewhere and should not have to endure long waiting lists and complicated assessment procedures.
I truly believe this crisis is solvable if patients, practitioners, and policy-makers work together to improve physicians' prescribing practices, introduce simple strategies to prevent overdose, and create a treatment system that is effective and accessible to all.
Thank you.