Proceed with caution when prescribing opioids, Ontario government agency urges doctors

An Ontario government agency is urging the province's doctors to be mindful of prescription strength and length when putting patients on a new course of opioids.

Health Quality Ontario has issued a report tracking the number of opioid prescriptions given to patients who had not been using the powerful painkillers for at least six months.

But the organization says both practices are still taking place and urges doctors to think carefully before including opioids as part of a treatment plan for such patients. 

Do benefits exceed potential harms?

The report says high doses and long prescription lengths are both risk factors for longer-term opioid addiction, a condition that has become even more dangerous in recent years due to the spread of fentanyl.

It says Canada has the world's second-highest opioid prescription rate behind the United States and doctors should be more open to considering alternative treatments whenever appropriate.

We know that most people that become addicted to opioids start out using prescription opioids.- Dr. Irfan Dhalla, Health Quality Ontario

"I think we should be taking a holistic approach to managing people's pain and thinking very carefully about whether the
potential benefits exceed the potential harms when we are newly starting somebody on prescription opioids," said Dr. Irfan Dhalla, vice-president of evidence development and standards at Health Quality Ontario.

Dhalla said managing opioid prescriptions is a difficult balancing act for all types of patients, adding various groups have
different needs depending on the length and nature of  their opioid use.

'You cannot have addiction without exposure'

Patients on long-term prescriptions to manage chronic pain, for instance, can't be taken off the medication too quickly for fear of either triggering withdrawal symptoms or driving people to seek alternatives through illegal channels.

Those illicit channels have become all the more dangerous in recent years as the highly potent opioid fentanyl proliferates through the drug supply, often being mixed with other street drugs and resulting in a nation-wide surge in overdose deaths.  

When dealing with patients without long-standing exposure to opioids, Dhalla said doctors must exercise a different kind of care. 

Family doctors, dentists, surgeons and other people with prescribing powers should consider whether opioids are necessary, whether they could be combined with other therapies, or whether alternatives are available for a patient's condition when devising a treatment plan, he said.

He said taking opioids at lower doses and for shorter periods both decrease a person's chances of becoming dependent on the drugs down the road, likening a more cautious prescribing approach to a parent delaying or discouraging the use of other addictive substances.

"You cannot have addiction without exposure," he said. "And we know that most people that become addicted to opioids start out using prescription opioids."

More measured approach gaining traction

The data from the report suggests that the more measured approach to new opioid prescriptions is beginning to gain traction.    

The report, assembled by looking at data from the Narcotics Monitoring Service, examined prescriptions issued by family doctors, surgeons and dentists for patients who had not taken opioids in the six previous months. It found roughly 1.3 million new-start prescriptions were issued in 2016, marginally lower than the number registered in 2013.

Of those prescriptions, the report found a slight decline in the number being issued for doses considered to put people at risk of addiction. About 3.4 per cent were for a very high dose of 90 morphine equivalents (MEQ) in 2016, up slightly from 3.3 per cent in 2013. The number issued for the lower but still risky dosage of 50 MEQ, however, dipped from 16.8 per cent in 2013 to 16 per cent in 2016.

The number of prescriptions issued for supplies lasting seven days or longer also dropped one per cent from 26.4 per cent in 2013 to 25.4 per cent in 2016. 

Proceeding with caution

Michael Gaucher, director of pharmaceuticals at the Canadian Institute for Health Information, said Health Quality Ontario's numbers are reminiscent of another recent study suggesting people are reevaluating their opioid prescription practices.  

A 2017 report from CIHI found that while the number of opioid prescriptions rose across the country, physicians were prescribing for lower quantities overall.

For Gaucher, the numbers suggested doctors were becoming more likely to proceed with caution and conduct regular follow-ups to see if patients still needed the drugs.

"We viewed it as a positive trend," Gaucher said, adding the Ontario numbers use different metrics but tell a similar story.

He said opioids "are well embedded in pain management, and it took many years really to get to where we are today, and it's going to take many years to really reverse this trend. 

"Even when we see relatively small decreases in the course of a year, I think it's positive to see."