Opioid Prescribing Falls in Canada, But Are Patients Better Off?

By Pat Anson

The number of patients prescribed opioids for pain in Canada has fallen over 11% in recent years, according to a new study published in the Canadian Medical Association Journal (CMAJ). The decline reflects trends in the U.S. and other Western nations, which adopted stronger guidelines to discourage opioid prescribing nearly a decade ago.

Like most studies of its kind, the new research only looked at the number of opioid prescriptions that were dispensed, and did not evaluate the health of Canadian patients after access to opioids was reduced or whether their pain improved using non-opioid pain therapies.

In 2022, about 1.8 million Canadians began taking an opioid to manage pain for the first time, 8% less than when the study period began in 2018.

“Our study provides valuable information on the progressive decline of prescription opioid dispensing for pain and high-dose initiations among new users, as well as the types of opioids prescribed and important geographic differences in these trends across Canada,” wrote lead author Nevena Rebić, PhD, a clinical researcher at Unity Health Toronto.

“Our findings suggest that national efforts to promote opioid stewardship and safer opioid prescribing for acute and chronic noncancer pain over the past decade have had an impact.”

“High-dose initiations” were defined as dosages that are above Canada’s recommended daily dose of 50 morphine milligram equivalents (MME) or lower. Less than 20% of new prescriptions in Canada exceeded 50 MME. Over half of the opioid prescriptions were for codeine.

Patients most likely to be prescribed an opioid were females, older adults, rural residents, and those living in lower-income areas.

Manitoba consistently had the highest rate of opioid prescribing, while British Columbia had the lowest among the six provinces that were studied. The lower rate in BC is somewhat of surprise, given the province’s reputation as the being the epicenter of the “opioid crisis” in Canada.

Monthly Rate of Opioid Prescribing in 6 Canadian Provinces

SOURCE: CMAJ

Rebić and her colleagues cautioned that “ongoing monitoring is needed” to ensure that pain patients are not left suffering from inadequate pain management, rapid opioid tapering or discontinuation, or that they turn to street drugs for relief. The authors acknowledge that has occurred “in some cases,” without exploring the severity of the problem.

“If the (opioid) pain prescribing is better, then why do we still get letters from patients in extreme pain telling us they were cut off, tapered or refused medical care?” asks Marvin Ross of the Chronic Pain Association of Canada (CPAC), which has long criticized Health Canada and the authors of Canada’s medical guidelines for discouraging the use of opioids.

Ross said the new analysis of opioid prescriptions was “a waste of time, money and effort,” and called the researchers “inane pill counters” who lack clinical experience with patients.

“The purpose of prescribing a pill is to help the patient get better or to ameliorate their symptoms, so saying we prescribed 10% fewer pills tells you nothing about that. To focus on the number says nothing about achieving prescribing goals unless you begin from the bias that prescribing any of it is bad,” Ross told PNN in an email. 

In a commentary on the study also published in CMAJ, an anti-opioid activist claimed that addiction and other potential harms of opioids are being overlooked by Canadian doctors who still prescribe them too freely.

“Most clinicians have seen first-hand how well opioids can work when first given. But they are at their pharmacologic best in the initial days of treatment. Continue them for weeks, months, or years and the calculus becomes progressively less favourable,” wrote David Juurlink, MD, a clinical internist at Sunnybrook Research Institute, and a member of Physicians for Responsible Opioid Prescribing (PROP).

“In this way, opioids transition from effective analgesics to drugs required primarily to stave off a withdrawal syndrome they themselves created.”

According to a recent analysis by Health Canada, only 18% of fatal opioid overdoses in Canada in early 2025 involved a pharmaceutical opioid. The vast majority of deaths were linked to illicit fentanyl, fentanyl analogues, and other illicit opioids such as heroin.

Canada Facing Nationwide Shortages of Opioid Pain Medication

By Pat Anson

Pain patients in the United States have been dealing with persistent shortages of opioid pain medication for years. Now their counterparts in Canada face a similar issue.

Health Canada has issued a warning about nationwide shortages of oxycodone and acetaminophen combinations, along with medications that combine codeine with acetaminophen. Acetaminophen and oxycodone are sold under the brand names Percocet and Endocet, while acetaminophen-codeine combinations are often sold as Tylenol #3.

While the opioid shortages in the U.S. appear to be largely driven by a national opioid settlement that rations pain medication at the pharmacy level, the Canadian shortages are being blamed on manufacturing disruptions and increased demand.

“We recognize the importance of having acetaminophen with codeine or oxycodone products available for patients. Addressing this shortage is a top priority,” Health Canada said in a statement.

“We're communicating with health care providers, provincial and territorial governments, and distributors to coordinate the sharing of information about this shortage. We're also working with manufacturers and stakeholders to monitor the supply of acetaminophen with codeine or oxycodone and looking at options for increasing access to these products.”

The Canadian Pharmacists Association (CPA) expects the shortages to last a few more weeks, when a “significant resupply” is expected.

“The shortage is the result of manufacturing issues affecting one major supplier, which has increased pressure on other manufacturers. While the supply situation is expected to improve by mid-August, supply constraints are expected to continue until the end of September,” the CPA said in a statement.

A patient advocate says the opioid shortages don’t appear to be causing many problems for patients, at least not yet.

“As far as the shortages go, at least for those I was able to speak with, they are coping with it,” Barry Ulmer of the Chronic Pain Association of Canada told PNN.

“The real problem is the lack of actual doctors who will prescribe (opioids) and in doses needed. Even though Health Canada and the provincial regulators say opioids are O.K. to use, they still warn doctors about overprescribing and tapering is still a very real reality. Almost every doctor that I have known over the years have now retired or just plain quit because of this ongoing problem.”

Smaller Doses and Tapering Recommended

Until the shortages ease, the CPA is advising pharmacists to suggest non-opioid pain relievers for patients suffering from acute short-term pain, such as headaches and muscle strains.

For long-term pain patients already using oxycodone and codeine combinations, the CPA recommends limiting doses to 90 morphine milligram equivalents (MME) a day. Switching to another opioid and/or tapering is another alternative.

“If the current dose is high, give 50% or less of the new opioid converted to morphine equivalents. Otherwise, start with 60–75% of the previous dose converted to morphine equivalents,” the CPA said.

In the United States, either scenario would be considered a rapid taper, which can raise the risk of an overdose or mental health crisis. The CDC recommends more cautious tapering of patients, with a dose reduction of just 10% a month.

The American Society of Health-System Pharmacists (ASHP) first reported U.S. shortages of oxycodone-acetaminophen combinations in the summer of 2023. Not much has changed in the last two years.

In its June report, the ASHP said several drug manufacturers have oxycodone-acetaminophen combinations on back order, with no estimated resupply date. Only one drug maker, Major Pharmaceuticals, anticipates having new supplies in early August.

Some companies are phasing out the production of opioid medication. Endo Pharmaceutical stopped making Percocet in 2024, while Teva Pharmaceuticals discontinued production of immediate release oxycodone in 2023 and Transmucosal Immediate-Release Fentanyl Medicine (TIRF) in 2024. Opioid litigation has been very costly to Teva and other drug makers. In 2022, Teva paid $4.25 billion to settle thousands of opioid liability lawsuits.

American Doctors Are Moving to Canada to Escape Trump Administration

By Brett Kelman, KFF Health News

Earlier this year, as President Donald Trump was beginning to reshape the American government, Michael, an emergency room doctor who was born, raised, and trained in the United States, packed up his family and got out.

Michael now works in a small-town hospital in Canada. KFF Health News and NPR granted him anonymity because of fears he might face reprisal from the Trump administration if he returns to the U.S. He said he feels some guilt that he did not stay to resist the Trump agenda but is assured in his decision to leave. Too much of America has simply grown too comfortable with violence and cruelty, he said.

“Part of being a physician is being kind to people who are in their weakest place,” Michael said. “And I feel like our country is devolving to really step on people who are weak and vulnerable.”

Michael is among a new wave of doctors who are leaving the United States to escape the Trump administration. In the months since Trump was reelected and returned to the White House, American doctors have shown skyrocketing interest in becoming licensed in Canada, where dozens more than normal have already been cleared to practice, according to Canadian licensing officials and recruiting businesses.

The Medical Council of Canada said in an email statement that the number of American doctors creating accounts on physiciansapply.ca, which is “typically the first step” to being licensed in Canada, has increased more than 750% over the past seven months compared with the same time period last year — from 71 applicants to 615. Separately, medical licensing organizations in Canada’s most populous provinces reported a rise in Americans either applying for or receiving Canadian licenses, with at least some doctors disclosing they were moving specifically because of Trump.

“The doctors that we are talking to are embarrassed to say they’re Americans,” said John Philpott, CEO of CanAm Physician Recruiting, which recruits doctors into Canada. “They state that right out of the gate: ‘I have to leave this country. It is not what it used to be.’”

Canada, which has universal publicly funded health care, has long been an option for U.S.-trained doctors seeking an alternative to the American health care system. While it was once more difficult for American doctors to practice in Canada due to discrepancies in medical education standards, Canadian provinces have relaxed some licensing regulations in recent years, and some are expediting licensing for U.S.-trained physicians.

In mere months, the Trump administration has jeopardized the economy with tariffs, ignored court orders and due process, and threatened the sovereignty of U.S. allies, including Canada. The administration has also taken steps that may unnerve doctors specifically, including appointing Robert F. Kennedy Jr. to lead federal health agencies, shifting money away from pandemic preparedness, discouraging gender-affirming care, demonizing fluoride, and supporting deep cuts to Medicaid.

The Trump administration did not provide any comment for this article. When asked to respond to doctors’ leaving the U.S. for Canada, White House spokesperson Kush Desai asked whether KFF Health News knew the precise number of doctors and their “citizenship status,” then provided no further comment. KFF Health News did not have or provide this information.

Philpott, who founded CanAm Physician Recruiting in the 1990s, said the cross-border movement of American and Canadian doctors has for decades ebbed and flowed in reaction to political and economic fluctuations, but that the pull toward Canada has never been as strong as now.

Philpott said CanAm had seen a 65% increase in American doctors looking for Canadian jobs from January to April, and that the company has been contacted by as many as 15 American doctors a day.

Rohini Patel, a CanAm recruiter and doctor, said some consider pay cuts to move quickly.

“They’re ready to move to Canada tomorrow,” she said. “They are not concerned about what their income is.”

The College of Physicians and Surgeons of Ontario, which handles licensing in Canada’s most populous province, said in a statement that it registered 116 U.S.-trained doctors in the first quarter of 2025 — an increase of at least 50% over the prior two quarters. Ontario also received license applications from about 260 U.S.-trained doctors in the first quarter of this year, the organization said.

British Columbia, another populous province, saw a surge of licensure applications from U.S.-trained doctors after Election Day, according to an email statement from the College of Physicians and Surgeons of British Columbia. The statement also said the organization licensed 28 such doctors in the fiscal year that ended in February — triple the total of the prior year.

Quebec’s College of Physicians said applications from U.S.-trained doctors have increased, along with the number of Canadian doctors returning from America to practice within the province, but it did not provide specifics. In a statement, the organization said some applicants were trying to get permitted to practice in Canada “specifically because of the actual presidential administration.”

Michael, the physician who moved to Canada this year, said he had long been wary of what he described as escalating right-ring political rhetoric and unchecked gun violence in the United States, the latter of which he witnessed firsthand during a decade working in American emergency rooms.

Michael said he began considering the move as Trump was running for reelection in 2020. His breaking point came on Jan. 6, 2021, when a violent mob of Trump supporters besieged the U.S. Capitol in an attempt to stop the certification of the election of Joe Biden as president.

“Civil discourse was falling apart,” he said. “I had a conversation with my family about how Biden was going to be a one-term president and we were still headed in a direction of being increasingly radicalized toward the right and an acceptance of vigilantism.”

It then took about a year for Michael to become licensed in Canada, then longer for him to finalize his job and move, he said. While the licensing process was “not difficult,” he said, it did require him to obtain certified documents from his medical school and residency program.

“The process wasn’t any harder than getting your first license in the United States, which is also very bureaucratic,” Michael said. “The difference is, I think most people practicing in the U.S. have got so much administrative fatigue that they don’t want to go through that process again.”

Michael said he now receives near-daily emails or texts from American doctors who are seeking advice about moving to Canada.

‘You Left Just in Time’

This desire to leave has also been striking to Hippocratic Adventures, a small business that helps American doctors practice medicine in other countries.

The company was co-founded by Ashwini Bapat, a Yale-educated doctor who moved to Portugal in 2020 in part because she was “terrified that Trump would win again.” For years, Hippocratic Adventures catered to physicians with wanderlust, guiding them through the bureaucracy of getting licensed in foreign nations or conducting telemedicine from afar, Bapat said.

But after Trump was reelected, customers were no longer seeking grand travels across the globe, Bapat said. Now they were searching for the nearest emergency exit, she said.

“Previously it had been about adventure,” Bapat said. “But the biggest spike that we saw, for sure, hands down, was when Trump won reelection in November. And then Inauguration Day. And basically every single day since then.”

At least one Canadian province is actively marketing itself to American doctors.

Doctors Manitoba, which represents physicians in the rural province that struggles with one of Canada’s worst doctor shortages, launched a recruiting campaign after the election to capitalize on Trump and the rise of far-right politics in the U.S.

The campaign focuses on Florida and North and South Dakota and advertises “zero political interference in physician patient relationship” as a selling point.

Alison Carleton, a family medicine doctor who moved from Iowa to Manitoba in 2017, said she left to escape the daily grind of America’s for-profit health care system and because she was appalled that Trump was elected the first time.

Carleton said she now runs a small-town clinic with low stress, less paperwork, and no fear of burying her patients in medical debt.

She dropped her American citizenship last year.

“People I know have said, ‘You left just in time,’” Carleton said. “I tell people, ‘I know. When are you going to move?’”

KFF Health News is a national newsroom that produces in-depth journalism about health issues.

Safer Opioid Supply Helps Reduce Overdoses

By Pat Anson

Should people at high risk of an overdose be prescribed opioids like hydromorphone or should they get methadone to help them cope with opioid addiction?

It’s a controversial question in Canada, where harm reduction programs are being used to give high-risk drug users a “safer supply” of legal pain medications as an alternative to increasingly more toxic and deadly street drugs. Critics say safer opioid supply (SOS) programs don’t reduce overdoses and are a risky alternative to more traditional addiction treatment drugs like methadone.

A new study, however, found that SOS programs are just as effective as methadone and may even be safer in the long run. Researchers in Ontario followed the health outcomes of over 900 people newly enrolled in SOS programs, comparing them with a similar number of drug users who started methadone treatment.  

Their findings, published in The Lancet Public Health, show that people in both the SOS and methadone groups had significant declines in overdoses, emergency department (ED) visits, hospitalizations, severe infections, and health care costs in the year after they started treatment. In both groups, deaths related to opioids or any other cause were uncommon.

ED Visits Fell After High-Risk Drug Users Enrolled in SOS or Methadone Programs

THE LANCET PUBLIC HEALTH

"This is the first population-based study to compare SOS programs with opioid agonist treatment, and to explore how people's outcomes change in the year after initiation," said lead author Tara Gomes, PhD, an epidemiologist and Principal Investigator at the Ontario Drug Policy Research Network (ODPRN).

Gomes and her colleagues found that people on methadone had a slightly lower risk of an overdose or being admitted to hospital, but they were also more likely to discontinue treatment and be at risk of a relapse. The higher dropout rate outweighed most of the benefits of methadone over SOS.

"Neither methadone nor safer supply programs are a one-size-fits-all solution, but our findings show that both are effective at reducing overdose and improving health outcomes," said Gomes. "They are complementary to each other, and for many people who haven't found success with traditional treatments like methadone, safer supply programs offer a lifeline. Our findings show that when safer supply programs are implemented, we see fewer hospital visits, fewer infections, and fewer overdoses."

SOS programs were launched in Ontario and British Columbia to combat a rising tide of overdoses linked to illicit fentanyl. A decade ago, Vancouver was the first major North American city to be hit by a wave of fentanyl overdoses, which led Vancouver to become a laboratory for harm reduction and safe injection sites that provided heroin or prescription opioids to drug users.  

The results have been somewhat mixed. An investigation by the National Post found that hydromorphone pills given to drug users in Vancouver were being sold on the black market, with the sellers then using the money to buy street drugs. Complaints about people selling their safe supply drugs led to British Columbia’s Health Minister recently changing the rules so that the SOS drugs are consumed while under the supervision of a pharmacists or healthcare provider.

A 2024 study in JAMA Internal Medicine found that opioid-related hospitalizations rose sharply in British Columbia after harm reduction programs were launched there, although there was no significant change in overdose deaths. The spike in hospitalizations may have been due to more toxic street drugs and counterfeit pills on the black market.

What Do Tariffs and the War On Pain Patients Have in Common? Fentanyl-Phobia

By Crystal Lindell

Did you know that there’s a drug that kills 480,000 people in the United States annually? Based on years of headlines, you might assume that the drug in question is fentanyl, but you’d be wrong. It’s actually tobacco.

There’s another drug that kills 178,000 people in the United States annually. It's called alcohol. 

Meanwhile, illicit fentanyl, the street drug everyone loves to be scared of, was involved in the deaths of 73,654 people in 2022.

Any death is too many, but those statistics highlight how disproportionately we focus on fentanyl as the deadly drug we should fear most. 

For years now, overdoses involving fentanyl have been used to justify denying pain patients access to much safer prescription opioids, such as hydrocodone. Now it’s also being used as an excuse for new tariffs against Canada, Mexico and China, which went into effect this week. 

During his speech Tuesday night, President Donald Trump justified the tariffs by saying: “They’ve allowed fentanyl to come into our country at levels never seen before, killing hundreds of thousands of our citizens and many very young, beautiful people, destroying families. Nobody has ever seen anything like it.”

The situation shows how many aspects of our daily lives are impacted by the War on Drugs, whether it’s a doctor’s visit or economic policy. It also highlights just how much the war is used to justify whatever economic, healthcare, and law enforcement policies our government wants at any given time. 

Because, of course, if any of this was actually about saving lives, then we would be focusing on the drugs that kill more people than fentanyl: alcohol and tobacco. Those are both still sold over the counter though. 

Instead, our leaders lean on whipping up a moral panic about fentanyl. The end result is the same, whether that moral panic is used against patients or neighboring countries: it causes unnecessary pain and suffering. 

The headline on an NBC News article calls out the fact that the tariffs probably won’t reduce fentanyl deaths: “Trump says tariffs were enacted to curb fentanyl, but U.S. overdose deaths are already declining.”

The article also points out that nearly all confiscated fentanyl is seized at the US-Mexican border. In the current fiscal year, just 10 pounds of fentanyl have been recovered at the Canadian border, compared to 5,400 pounds at the Mexican border.

Canadian Prime Minister Justin Trudeau is under no illusion that fentanyl deaths are the real reason for the tariffs. MarketWatch reported that Trudeau called Trump’s rationale for using tariffs to stop the miniscule amount of fentanyl coming from Canada "completely bogus." 

"We have to fall back on the one thing he has said repeatedly – that what he wants is to see a total collapse of the Canadian economy, because that will make it easier to annex us," Trudeau said. "We are, of course, open to starting negotiations, (but) let us not fool ourselves about what he seems to be wanting."

Stepping back a bit, it’s important to note that the fentanyl bogeyman is just the latest facet of the War on Drugs, which the United States has been fighting and losing since 1971. The tariffs highlight how little the so-called war has ever been based on actually helping anyone. 

It would be wise to be skeptical anytime the War on Drugs is used as a justification for government policy. Just because a government claims something is the reason for a law or policy, that does not mean that that is the actual reason. That applies to tariffs, as well as limiting opioid pain medication. 

Skepticism should be applied to all drug-related policy in the United States. 

Canada Seeks Feedback on Proposed Opioid and Cannabis Guidelines

By Pat Anson, PNN ditor

Health officials and pain management experts in Canada are seeking public feedback on proposed changes to Canada’s 2017 opioid prescribing guideline. They’re doing it through an online survey, with responses accepted not only from Canadians, but from providers, patients, caregivers and policymakers in the United States and other countries.

“We are very happy to receive feedback from both Canadians and Americans,” says Jason Busse, DC, a clinical epidemiologist and professor of anesthesia at McMaster University. “We are still in the process of drafting the guidelines, as the feedback we receive will affect these documents.”

Busse is leading a panel at McMaster’s Michael G. DeGroote National Pain Centre that has developed 11 draft recommendations for a revised opioid guideline. Survey respondents are being asked whether they agree or disagree with the recommendations, which focus on whether opioids should be a first line treatment for people with chronic non-cancer pain.

Consistent with the current guideline, the panel believes there are several non-opioid treatments that are just as effective as opioids and have less risk of adverse events. It also strongly recommends that opioids not be given to people with a history of opioid overdose, substance abuse, or mental health problems. For pain sufferers without such a history, the panel recommends “discussing a trial” of opioids if nonopioid treatments haven’t lessened their pain.

If opioids are prescribed, the panel suggests avoiding daily doses higher than 80 morphine milligram equivalents (MME), and strongly recommends against doses higher than 150 MME.  The estimated risk of a fatal overdose at 80 MME is relatively low at 0.23% (2.3 overdoses for every 1,000 people) and at 150mg MME is 0.5% (5 in 1,000).

The 80/150 MME recommendations are a substantial change from Canada’s current guideline, which suggest that initial doses of opioids be less than 50 MME and that they not exceed 90 MME.

For people in pain who are stable on long-term opioid therapy, the panel recommends that clinicians “initiate a discussion” of tapering to a lower dose, potentially including discontinuation. If the patient refuses, the panel recommends that another “discussion” be repeated every 6 to 12 months. Forced or involuntary tapering is not recommended.

“The Guideline Panel has formulated their recommendations based on current evidence and the values and preferences of people living with chronic pain. We are seeking public feedback on the current wording of the recommendations and associated remarks. We will review all feedback received in order to further optimize the wording and clarity of the recommendations and remarks,” Busse said in an email to PNN.

To take the opioid survey, click here.

Medical Cannabis Survey

A second survey is also being conducted by the National Pain Centre to help formulate a Canadian guideline for treating chronic pain with medical cannabis. As with the first survey, this one is open to everyone, regardless of where they live.

There are currently four draft recommendations for cannabis. The panel recommends a “trial of cannabis” for chronic pain only if a patient has tried other therapies that haven’t worked. The panel says there is evidence of small improvements in pain, physical function and sleep when cannabis was used.

Smoking cannabis is not recommended. The panel suggests that patients start with low doses of cannabis taken orally in oils and soft gels or inhaled through a vaporizer. Doses can be increased, depending how a patient responds.

Another recommendation is that cannabis be used by patients as a substitute for opioids or to help taper them to lower doses. The panel says “there is little to no difference” in effectiveness between cannabis and opioids, but that cannabis has far less risk of adverse events.

To take the cannabis survey, click here.  

Both surveys will take about 20 minutes to complete and will remain open until 12pm ET, February 29, 2024.

Study Finds Low Risk of Overdose From Prescription Opioids

By Pat Anson, PNN Editor

A large new study that identifies the top risk factors for an overdose involving prescription opioids has inadvertently shown just how low the risk is in the first place.

In a systematic review published in the Canadian Medical Association Journal, researchers at McMaster University looked at 28 studies involving nearly 24 million patients in the United States, Canada and the United Kingdom who were prescribed opioids for chronic pain.

They found 10 “predictors” associated with a higher risk of a fatal or nonfatal overdose, such as a patient taking high doses, having a substance abuse problem, and having multiple prescribers or pharmacies.

Many of these risk predictors are already well-known. What’s different about this study is that the researchers calculated the odds of an overdose happening in different situations and doses. That’s where things get interesting:

“High-certainty evidence from 14 studies involving 1,315,173 patients showed a linear dose–response relationship with opioid overdose. The association was small at a 50-mg morphine equivalent dose/day (OR 1.69, 95% CI 1.50–1.90) and large at 90 mg (OR 2.57, 95% CI 2.08–3.18), with an absolute risk 2.6 per 1000 for fatal overdose and 5.1 per 1000 for nonfatal overdose at a 90-mg morphine equivalent dose/day.”

In plain English, the risk of a fatal overdose at 90 morphine milligram equivalents (MME) is not “large.” It’s only 0.26% at 90 MME, which is considered a fairly high dose. The risk of a fatal overdose is even lower at 50 MME – just 0.16% -- a level that researchers say is “small-to-trivial.”

I’m not a statistician, but 0.26% and 0.16% seem like pretty small odds – similar to the lifetime risk of dying in a car accident, fire or drowning. Unlike opioids, there is no talk of a ban on swimming pools, motor vehicles or matches.

“I think that most people living with chronic pain would agree with your interpretation,” says co-author Jason Busse, DC, a clinical epidemiologist and professor of anesthesia at McMaster University. “I do think, however, that a minority of patients will place greater value on the possibility of overdose and death even though the absolute risk is small.”

Busse’s involvement in the study is notable, because he was the lead investigator in Canada’s 2017 opioid guideline, which suggest that initial doses of opioids be kept under 50 MME and strongly recommend that they never exceed 90 MME. The CDC opioid guideline in the United States makes similar recommendations.

Given the small risk of an overdose actually happening at 50 or 90 MME, the new study would seem to debunk both guidelines. Busse sees it a bit differently, telling me by email that the overdose calculations will help patients understand the risks associated with prescription opioids.

“Our work in this area has suggested that most people living with chronic pain, who have not found sufficient relief with non-opioid therapy, would be interested in a trial of opioids. Specifically, when provided with the evidence for benefits and harms, including the risk of overdose, that most patients in whom non-opioid therapy has proven insufficient would elect to pursue a trial of opioid therapy,” Busse said.

“By presenting the evidence to patients, and helping them to understand the anticipated benefits and harms, we can help ensure that the decisions they make are the right ones for themselves.”

Unfortunately, pain patients in the U.S. and Canada don’t get to make decisions for themselves. Decisions are made for them by doctors, pharmacists, regulators, and law enforcement. Patients increasingly have trouble finding a provider willing to treat them or getting a prescription filled at a pharmacy.

And because the “voluntary” opioid guidelines are usually treated as mandatory,  patients who are prescribed opioids are often kept at ineffective low doses that are well below 90 or even 50 MME.

‘Opiods Kill and Opioids Are Bad’

Experts say the low risk of overdose from prescription opioids was established in previous studies, but people got caught up in opioid hysteria and ignored the evidence. The new study, they say, is no different.

“This paper examines well plowed ground and provides no new insight. Quite the contrary, it obfuscates through oversimplification of the problem,” says Stephen Nadeau, MD, a Professor of Neurology at the University of Florida College of Medicine. “The essential message is that opioids kill and opioids are bad.”

Nadeau says Busse and his co-authors ignored factors like genetic differences in opioid metabolism and put too much emphasis on the risk of a patient having multiple prescribers or pharmacies. The latter could simply be a sign that they were abandoned by a doctor or turned away by a pharmacy, not doctor shopping. Statistics mined from databases don’t tell you that.

“This paper takes a rigorous statistical approach to explain what is happening in a highly heterogeneous population in which there is a high probability of misconstruing the sources of variance. I think it would have been OK if published in 2015, but we have learned a thing or two since then and now the paper serves only to obfuscate and mislead,” said Nadeau.

Two findings in the study worth highlighting are that researchers found little risk of an overdose when a patient is co-prescribed opioids with benzodiazepines, sedatives or muscle relaxants – the so-called “Holy Trinity.” The overdose risk is also “small-to-trivial” when a patient is given long-acting opioids instead of short-acting ones. Those findings contradict the recommendations made in the U.S. and Canadian guidelines.

“The opioid crisis has generated interest in identifying patients at higher risk of addiction or overdose and has led to the development of several screening tools; however, these instruments have either not been validated or shown poor psychometric properties,” wrote lead author Li Wang, PhD, a researcher at McMaster University. “Our findings suggest that awareness of, and attention to, several patient and prescription characteristics, may help reduce the risk of opioid overdose among people living with chronic pain.”

One of the co-authors of the study is David Juurlink, MD, a member of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group. Like several other PROP members, Juurlink disclosed that he has been a paid expert witness in legal cases involving opioids.

Previous studies have also found that the risk of overdose is small — 0.3% — in Medicaid and Medicare patients prescribed opioids for the first time. Another study of Medicare patients found that over 90% had little to no risk of overdosing. Low risk patients had only 0.006% chance of an overdose.

Waiting and Wanting to Die in Canada

By Ann Marie Gaudon, PNN Columnist

RIP Margaret Bristow October 23, 1959 – August 10, 2022

No, that’s not a typo. My friend Maggie will be dying in a few days, on August 10 to be exact.

Confused? I am trying to make sense of this, too.

One night a few months ago, I was hurting. Oh, my goodness was I hurting! I was lying in bed and decided to do a quick body scan.

I began with my head. I had a throbbing headache, which I suspect was a result of fairly severe TMJ. It felt like my jaw was locked solid, which is terrifically painful, and my tongue was burning as well.

I also was suffering with tinnitus that night, which is typically accompanied by severe ear pain. I also felt gastroesophageal reflux burning a fiery hole in my gut.

Next up was a severe back injury from 2017, which was irritated and oh boy did that ever hurt! Down I went to my bladder, which was burning from an interstitial cystitis flare. Pudendal neuralgia had nerve pain radiating from my sacrum down both legs and into both hips. Osteoarthritis had my hips, knees, legs and ankles throbbing.

Finally, both feet felt like I had knives stabbing into them over and over, as I now have plantar fasciitis to add to my list of pain conditions. What a state I was in. Neuropathic pain, visceral pain, and musculoskeletal pain -- all in a rage.

Nine different pains in total that night, which is not at all typical for me. I had nowhere to put this earthly body for more comfort. Sitting or lying on my back increased the pudendal neuralgia; lying on my side increased my ear and hip pain; lying on my stomach was painful for my neck; and standing increased the plantar fasciitis.

I had nowhere to go, so I lay there quite still. In case you are wondering, yes, I have medications and I took them all. I also took everything OTC that I had in the house. It didn’t seem to make any difference; the pain was surging and the medications were no match for it.

I thought to myself that if this were to become permanent, I would surely not survive it. My problem-solving brain told me the only way out would be the release of death. If nothing could tame all of these pains, what choice would I have? I couldn’t work like this and I couldn’t engage in relationships like this.  I could barely string together two sentences in my head.

I could not function in any capacity, so I lay there quite still, trying my best to be with the pain, but not overtaken by it. In that one horrible night, I understood why my sweet friend had chosen to die on August 10, 2022.

‘I Would Rather Have My Medication Back’

Maggie Bristow has been in chronic pain for over 25 years from fibromyalgia, degenerative disc disease, spinal stenosis and arthritis. Her pain became so severe that she was given opiate medication, which she took for many years. By 2016, the Ottawa woman felt the medication was not working very well, because her pain was increasing.

Already feeling pressured to reduce his prescribing, her pain physician took her off opiates and tried many other types of treatment, but nothing worked. He told her there was nothing else left to try.

To this day I do not fully understand this part of Maggie’s story. Was she properly titrated on opiate medications? Were they combined with something else? What about novel approaches like opiates placed in the spinal fluid? I will never know. I do know that Maggie felt she was out of options.

“My body constantly feels like a blow torch has been taken to it. I’ve not been able to sleep in a horizontal position for 20 years and I am housebound due to the intense pain,” Maggie told me.

“Simple tasks like opening the mail, preparing food and maintaining good hygiene are agonizing, monumental tasks. I would rather have my medication back or be allowed to die peacefully.”

With her pain increasing, Maggie just wanted it to stop. That year she applied for assisted death under Canada’s Medical Assistance in Dying law (MAID), and was flatly denied because she did not meet the criterion that a natural death be “reasonably foreseeable."

MAGGIE AND HER LATE PARTNER, BRIAN

Maggie persevered and once again in 2019 applied for MAID. For the second time, she received a phone call telling her that her request had been denied. She felt very deflated, upset and confused.

Quality of life continued to worsen for Maggie and she waited patiently for new legislation to pass last year amending the MAID law, which removed the criterion that “death was foreseeable.”

When she applied for a third time, the MAID physician requested a new MRI, a second opinion from another neurologist, and someone to give her opiate pain medication. Maggie was dumbfounded at this third request, because she was searching for five years for opiates to no avail. She chose to ignore that, and responded to the other two requests which showed results that her spine was “totally inoperable.”

Weeks and months dragged on for Maggie. Finally, a call came from her general practitioner who told her that the MAID physician advised that she tried to contact Maggie with no success. Maggie said that was nonsense because she is housebound and never heard from her. The truth was that the MAID physician was not comfortable signing off on her case.

Part of the policy for MAID is that if a doctor is unwilling to help you, they must refer you to another doctor who will provide service for you. This however did not happen. Maggie was left hanging and extremely put out for all the time wasted when she could have been researching other avenues. She was now desperate.

A phone call took place to provincial MAID, with Maggie telling them that the Ottawa MAID declined her request. What were her options? They told her they would just refer her back to Ottawa. Really? Maggie was now quite angry and she called her GP, who reached someone else in the organization and found a MAID physician in Toronto who would help her to die.

This is where I go off the rails. A doctor will not help you get opiate medication, but will help you die? This was not the Canada that I was born into.

The MAID physician in Toronto reached Maggie via video conference and after her assessment said she would sign off immediately on her request. Maggie felt good about this but also knew that it takes two doctors to sign off for your peaceful death to happen.

Time dragged on again. The GP called her contact to ask what was happening and soon another video conference with a second MAID physician took place. This physician did not give Maggie any indication of what the decision was. Weeks later, Maggie received a call from the first doctor, who told her that her application was approved.

They would indeed help her to die as per her wishes, on August 10, 2022 at approximately 2:00 pm. They will have a long drive to get there, but Maggie’s sister will be with her. Afterwards, her organs will be harvested for donation and her body will be shipped back to Ottawa for cremation.   

Maggie blames Health Canada for the many problems she and other Canadian patients in severe pain have getting opiate medication.

“People like me, and there are many of us, continue to suffer. Suicide is our only option. This is a level of cruelty that is very difficult to fathom and really has to stop,” she said.

The world will be losing a gem on August 10. Maggie is a warrior woman for all that she has endured. She is a survivor through and through. I have seen grace, generosity of spirit, love, and even a sense of humor through all of this.

Is Maggie beyond treatment without a doubt? I will wonder about that for the rest of my life as I remember my sweet friend and all that she embodied.

Maggie’s partner Brian, the love of her life, passed in 2008. She will be survived by two children and five grandchildren.

Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for over 30 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website. 

If you are in crisis and live in Canada, help is available by calling the Canada Suicide Prevention Service at 833-456-4566. If you live in the US, help is available by calling the 988 Suicide & Crisis Lifeline (formerly know as the National Suicide Prevention Lifeline) at 988 or 1-800-273-8255 (TALK). You can also call 911 for immediate help.

More Canadians Using Cannabis for Pain Relief

By Pat Anson, PNN Editor

Chronic pain sufferers in the United States and Canada are increasingly turning to cannabis for pain relief. The latest evidence of that is a large survey of people in pain in Quebec, Canada.

Of the 1,344 participants who answered questions about their cannabis use, nearly a third (30.1%) said they used cannabis for pain management, far more than those who used it for other health conditions (9.1%) or for recreational purposes (12.7%).

The online survey was conducted in 2019, a few months after recreational cannabis was legalized in Canada in October, 2018.  Prior to full legalization, cannabis use by Canadians living with chronic pain was estimated at 10% or less.

“Based on studies conducted before the legalization of recreational cannabis, the prevalence of cannabis use estimated in the present study indicates a threefold increase in reported usage,” researchers reported. “Because people living with CP (chronic pain) have reported using even more cannabis during the first wave of the COVID-19 pandemic, it seems reasonable to expect the prevalence to be even higher today. Our results suggest that cannabis is a common treatment reported by people living with CP and underscore the importance of rapidly generating more evidence on the safety and efficacy of cannabis.”

The survey findings, recently published in the Canadian Journal of Pain, show that pain sufferers under the age of 26 were most likely to use cannabis (36.5%), while those aged 74 and older were least likely (8.8%). Three out of four respondents reported living with pain for at least 5 years. Over two-thirds (67.7%) said they had moderate to severe pain.

A 2021 Harris Poll found that twice as many Americans are using cannabis or CBD to manage their pain than opioid medication. Over-the-counter pain relievers were used by over half (53%) of those surveyed, followed by cannabis products (16%), non-opioid pain relievers (11%) and opioids (8%). Two-thirds of Americans with chronic pain (66%) said they had changed their pain management since the pandemic began, and were using more OTC pain relievers and cannabis products.

Neither the Harris or Canadian surveys specifically asked respondents if they were using cannabis for pain relief because opioids were harder to obtain. Opioid prescribing in the U.S. and Canada has declined significantly in the past decade due to more restrictive medical guidelines and fears about abuse.

Opioid Prescribing Limits Failed to Reduce Overdoses in British Columbia

By Pat Anson, PNN Editor

British Columbia’s opioid guideline failed to have any significant impact on overdoses, hospital admissions or deaths in the year after it was adopted, according to new research published in CMAJ Open. The study is the latest to show that opioid prescribing limits have been misdirected and ineffective in slowing North America’s opioid crisis.

The College of Physicians and Surgeons of British Columbia released strict professional guidelines for the “safe prescribing” of opioids and sedatives in 2016, after the Canadian province was hit by a wave of overdoses and deaths. The BC guidelines, which are similar to the CDC’s opioid guideline in the United States, warn doctors to be cautious about opioid prescribing and to avoid increasing doses over 90 morphine milligram equivalents (MME) per day.

Researchers at the University of British Columbia wanted to see how effective the BC guideline was in reducing overdoses, so they analyzed health data on over 68,000 patients on long term opioid therapy. A previous study by the same research team found a “modest” reduction in opioid use in the 10 months after the guideline was introduced, as well as more tapering.

Did the reduced prescribing result in fewer overdoses?  No.

Researchers found no significant change in opioid overdose hospital admissions, opioid overdose mortality, all-cause emergency department visits, all-cause mortality, or all-cause hospital admissions after the BC guideline was adopted. They also found no evidence that pain patients turned to street drugs after their opioid prescriptions were reduced or stopped.

“Concern has been expressed that policies focused on reducing prescribing of opioid analgesics could increase opioid-related deaths if patients unable to access prescription opioids for adequate pain relief turned to street drugs and were exposed to dangerously high levels of synthetic opioids. Our study did not find evidence that the standards and guidelines had the unintended consequence of increasing opioid overdose hospital admissions or opioid overdose mortality,” wrote lead author Richard Morrow, a senior research analyst at UBC.

Critics say the lack of evidence is proof that opioid prescribing has little to do with British Columbia’s overdose crisis.   

“The results are not unexpected and demonstrate the folly of limiting opioids to pain patients in a futile attempt to deal with overdoses from illicit street drugs. The policy has created considerable pain and anxiety along with a worsening quality of life for nothing,” said Marvin Ross, a patient advocate with the Chronic Pain Association of Canada. 

British Columbia’s Coroners Office expects 2020 to be a record breaking year for overdoses in the province, with about five drug deaths every day. A recent study found that the vast majority of BC’s overdoses involved illicit fentanyl and other street drugs. Only 2.4% of the nearly 1,800 fatal overdoses in BC from 2015 to 2017 involved opioid medication alone.

Stricter opioid prescribing policies have also been ineffective in slowing the overdose crisis in the United States. Prescription opioid use in the U.S. is at its lowest level in 20 years, while more Americans are dying from overdoses than ever before.

Health Canada Is Hiding the Truth About Rx Opioids

By Barry Ulmer, Chronic Pain Association of Canada

True or false? Doctors triggered our overdose crisis. Duped by pharma, they overprescribed narcotic pain relievers and turned innocent patients into addicts. Now we have a black market of stolen prescription drugs — they remain the problem — with a little heroin and street fentanyl mixed in.

True, says Health Canada, whose policy since 2016, made behind the backs of doctors and patients, has been to squeeze prescription opiate supply. Never mind that two million Canadians with serious pain can’t get effective treatment anymore, since most don’t need it anyway.

False, says science. Bad pain can need opiates when nothing else works. By choking legal supply in its haste to curb overdose rates and raise its own ratings, government lit a match to an illicit supply (meth, cocaine, heroin, narcotics) on slow boil since at least 1980. Fierce prescribing cuts now drive a robust black market of cheap heroin and street fentanyl, and a parallel crisis of untreated pain and suicide.

Who’s right? Here are the facts: since 2011, opioid prescribing has tanked while deaths still climb. Street drugs kill. Prescribed drugs don’t. Slashing prescriptions to contain addiction is daft.

Why hide the truth? Why torture people with pain and ignore illicit drugs? Doesn’t government want to combat preventable deaths? For years, we’ve asked Health Canada just that.

They dodged us at every turn. (Just listen to our bizarre 2018 call with the Minister's office.) Eventually, they sent us a list of studies they said justified deprescribing. In June 2019, we sent back our evaluation of the list. It didn’t match theirs. They said they’d get an assessment from independent experts. They didn’t. Then they said they had more research, a big batch; they’d send that, too. They didn’t.

Our Freedom of Information Request

In February, we filed a freedom of information request. We asked for specifics — studies, research, correspondence — that back Health Canada’s claim, as of 2016, that prescribing leads to overdose deaths.

Since we know the medical literature, we knew not to expect much. But this past September, we got 2,928 pages — sort of.  About a third were redacted: long series of pages along with almost all study publication dates, bibliographic details, and online links. It was padded with stuff like a 466-page global report from the UN in three languages. Most of it had nothing to do with what we’d asked for.

Most of it was also published long after 2016 — so it can’t have led to the official start of deprescribing. Only a quarter of it was Canadian, mostly an echo chamber of federally-funded agency reports all quoting each other, with some government-funded guidelines thrown in.

There was no correspondence whatever and little independent research. The bulk of it wasn’t research at all, just a circle jerk of commentary and opinion.  Here’s what we got:

• Mostly US/some UK stuff — commentary, media reports, policy, guidelines, limited research

• Papers using CDC drug abuse stats that CDC corrected and downgraded long ago

• Studies using outdated definitions of “opioid use disorder” that make everyone a “substance abuser”

• Duplicated and even triplicated papers

• Foreign-language papers

• Pre-publication “author manuscripts,” some unproofed and incoherent

• Observational rather than experimental studies

• Papers whose data and fine print directly counter their conclusions

• Papers drawing “new” conclusions by cherry-picking old literature

• Researchers quoting their own work as authoritative

• Papers asserting without documenting the dangers of opiates

• Studies drowning in limitations (which their authors often acknowledge)

• Government statements on generalities, synthesizing other government statements on generalities

• Hand-wringing from six Ottawa-funded agencies, and research these agencies funded in turn

• Serial papers from a handful of Health Canada-preferred researchers

• Much heavily-redacted head-scratching on cannabis

• Studies on acute — not chronic — pain

• Papers blaming patients for their pain

 What on-point studies we got often champion opioids.

Those that don’t typically reiterate prevailing anti-opioid claims, downplay the devils in their details, hype their conclusions, and are compromised by their authors’ conflicts of interest. (These conflicts are usually disclosed, since joining the bandwagon is valued over bias risk.)

On-topic items make our case, not Health Canada’s:

• Half of Canadian adults with chronic pain (a third with “very severe” pain) have suffered for 10 years plus

• Five comprehensive studies of studies (Cochrane reviews) plus a large German review endorse opioids    for five types of chronic pain; four more Cochranes didn’t find useable studies on other pain types

• Two Cochranes plus Canadian research say drugs used to combat substance abuse don’t relieve pain

• Newfoundland’s OxyContin Task Force report on six OxyContin-involved deaths in four years concludes that properly-prescribed pain medications are safe and effective

• With doses now “under the recommended thresholds, most US providers are careful in their prescribing”

• British Columbia, Alberta and Ontario coroners find repeatedly that most overdose deaths involve street fentanyl

• Early prescription use does not predict addiction in Vancouver IV drug users, some of whom develop pain after they begin using

• US data can’t predict addiction and death rates in Canada

• “Dental Rx’s addict young people” is a tooth-fairytale, say three studies. In one, just one of 97,462 kids  who got prescribed opioids after wisdom tooth surgery died within a year — cause not specified

• A review of 38 studies pegs “problematic use” at “<1 to 81%” (it’s entirely redacted)

• Claims of “significant increases” in prescription opioid abuse aren’t quantified. One “huge increase” was of low-dose formulations

• Guesstimates and “author consensus” fill data gaps. An Ottawa-funded researcher’s three papers all call for continued prescription slashing while acknowledging a serious lack of data

• Canadian researchers who routinely disparage opiates for pain tend to be just two or three government- funded teams mining a single public Ontario database to write variations on their theme

• Physical dependence is routinely called “opioid use disorder.” Occasionally, the distinction appears in small print. Clarification by the head of the US National Institute on Drug Abuse is here but redacted

• Three Canadian reports plus one from Seattle say “one-size-fits all” dosing is dangerous and “significantly” hikes overdose risk; cuts to legal supply since 2016 risk destabilization of patients; prescription slashing leads to the end of care

• A 2020 Canadian investigation into bias in “pro-opioid” prescribing guidelines conveniently stops just short of investigating bias in the “anti-opioid” American and Canadian guidelines of 2016 and 2017

• A Canadian sociologist tracks 20 years of news to show how “overprescribing” became a hot button. Our top three news outlets didn’t mention “inadequate pain care” until 2016. “Legitimate users” were either “dependent” or had overdosed on their prescriptions

• “Twenty-five years of pain education research — what have we learned?”: All 13 pages redacted

A descriptive list of all the items we got, and the release itself, are available on request.

What we didn’t get are the many large studies that sandbag Health Canada’s deprescribing policy, like these:

• Risks of developing persistent opioid use after major surgery are tiny

• In a huge sample, mortality risk from overdose is just 0.022% annually

• Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in BC

• Illegal street drugs, not prescriptions, now powering opioid abuse

• New survey data confirm that opioid deaths don’t correlate with pain pill abuse or addiction rates 

Health Canada has ignored pertinent studies that don’t suit them and misread others. No careful, independent research endorses deprescribing for any reason, and certainly not as a means to contain overdoses.

Health Canada provided its research only after years of hedging, when we finally resorted to an FOI request— and then only after six months. We believe they had no list and compiled one retroactively, especially since they padded it with off-topic items and with items that postdated their policy.

Prescribing practice and regulation in Canada is now based on the low-quality “investigations” of partisan, government-paid researchers. Canadians deserve better. Now that quality research unequivocally endorses their treatments, Canadians with pain must have effective care restored to them NOW. 

Barry Ulmer is Executive Director of the Chronic Pain Association of Canada, a patient advocacy group

Misleading Data and Bias in Canadian Opioid Reporting

By Marvin Ross, Guest Columnist

It is sometimes said that there are lies, damned lies and statistics. That prophetic statement, often mistakenly attributed to British Prime Minister Benjamin Disraeli, explains the complete confusion in the minds of the public about the use of opioid medication.

By conflating data on prescribed opioids with illicit opioids – an apples to oranges comparison -- the average person has no real understanding of the value of opioid pain relievers. How often do we hear people say they refuse to take pain medication for fear of becoming addicted?

One Canadian agency that confuses, conflates and even admits that its data is misleading is the Canadian Centre on Substance Use and Addiction (CCSA). The reports they publish suggest that prescribed opioids are a major problem to be avoided. They are out of step with some of the provincial coroners and federal agencies such at the Public Health Agency of Canada and Health Canada.

Let's first look at what these other agencies report.

Last month, British Columbia reported its highest number of illicit drug deaths ever, nearly 6 deaths per day, with the vast majority involving fentanyl and its analogues. In neighboring Alberta, 127 of the 142 deaths in the first quarter of 2020 involved fentanyl. Neither province talks about deaths from prescribed opioids, as the main issue is illicit drugs.

While fentanyl is a prescribed drug and has many legitimate uses, only 5% of all opioids prescribed in Canada is fentanyl. Given its frequency in overdoses, it must come from illegal sources.

The Public Health Agency divides their overdose statistics into those involving patients with prescribed opioids and those with substance abuse problems.  Prescribed opioids accounted for 0.02% of total hospitalizations, while for the substance abuse population it was 0.04% of hospitalizations.

There are distinct differences in age between the two groups. People in the prescribed group were usually men and women aged 60 and older. For those with substance abuse problems, the most prevalent age group is 20 to 39 years of age. It is well known that illicit drug use is more prevalent in younger people, as this data demonstrates.

Health Canada tracks reported adverse drug reactions for prescriptions and finds that analgesics are the least likely drugs to result in an adverse event. Only 1.8% of all adverse reactions involve pain medications.

Confusing Illicit Opioids with Legitimate Opioids

These statistics all demonstrate that the problem is illicit drug use and not valid prescribed opioids given to patients in pain. In contrast, the CCSA conflates legitimate and illicit opioids, and provides a totally biased picture of what is happening.

Their July 20 report is entitled “Prescription Opiods” with no mention of illicit opioids. But then they provide data that really pertains to the illicit kind.

In 2017, 11.8% of Canadians were prescribed opioids, down from 13% in 2015. Little changed was the proportion of patients who used their prescriptions for non medical uses, which is 3 percent. So, 97% of patients prescribed opioids used them properly.

Despite that, Canada, like the United States, introduced draconian prescribing guidelines to control the 3% and, of course, that negatively impacted the 97%.

There were nearly 16,000 overdose deaths in Canada between 2016 and 2019, according to the CCSA report, with emergency room visits for opioid poisoning doubling for the 25-44 age group. Given this is a report about prescription opioids, the impression the naive reader would get is that deaths and hospital visits all pertain to legally prescribed opioids.

Next, the CCSA points out that, while the number of opioid prescriptions in Canada has fallen, 5.5% of those taking them can still become addicted. That estimate for addiction is low, but there is other research suggesting that it is even lower. In keeping with their anti-opioid bias, they state that prescription “opioids can also produce a feeling of well-being, relaxation or euphoria (“high”).”

What people who take opioids for pain experience is a decrease in pain or no pain at all, if they are lucky. That's it – there’s usually no high and no euphoria. Addicts take these drugs for its high.

They then move on to talk about the healthcare costs associated with the use of opioids, but again do not differentiate between prescribed and illicit. This leaves the reader with the impression that anyone who takes opioids for any reason is costing the health system extra for adverse events, hospitalizations, overdoses and deaths.

In fact, they are mostly talking about illicit uses as the data they provide is not dissimilar to the data provided by the Public Health Agency or Health Canada. To hammer home the CCSA’s deception, the very next section deals with driving under the influence of prescription drugs.

In 2018, two prominent health experts completed a review of all the independent health agencies funded by Health Canada and recommended that three of them had outlived their usefulness. One of those was the Canadian Centre on Substance Use and Addiction, which they recommended be abolished. For some reason, it still exists.

I asked CCSA to explain their misleading statistics and it took them almost three weeks to respond. Research and policy analyst Samantha King, PhD, admitted the data is misleading unless readers take a deep dive into the footnotes.

“We are aware that for some of the data captured in the summary, including hospitalizations due to opioid poisonings and opioid-related deaths, there is no ability to differentiate between legal or illegal sources of opioids that are causing these harms. For this reason, these sections only refer to opioids in general and contain footnotes where appropriate, highlighting the limitations of the data,” King wrote to me in an email.

So, why call the report “Prescription Opioids” when, unlike coroners and other federal agencies in Canada, you cannot differentiate between illicit opioids and legitimate ones? All I can say is that it is fortunate that Canada's handling of the Covid-19 Pandemic is being handled by the Public Health Agency and not CCSA.

Marvin Ross is a medical writer and publisher in Dundas, Ontario. He is a regular contributor to the Huffington Post.

Study: Using Cannabis for Pain Relief Reduces Risk of Opioid Overdose

By Pat Anson, PNN Editor

Illicit drug users who use cannabis for pain relief are less likely to experience an opioid overdose or use heroin, according to a Canadian study recently published in the online journal PLOS ONE.

Researchers at the University of British Columbia (UBC) the BC Centre on Substance Use (BCCSU) interviewed nearly 900 illicit drug users in Vancouver who reported using cannabis between 2016 and 2018. Participants were asked whether they used cannabis to relieve pain, improve sleep, address nausea or for recreation. Most said they used cannabis for a medically therapeutic reason.

"We're seeing more and more in our research that people are using cannabis for therapeutic reasons," says lead author Stephanie Lake, a doctoral candidate at UBC's School of Population and Public Health. "We're also seeing that, for some individuals in our study, this therapeutic use corresponds with either less use of illicit opioids or a reduced risk of overdose."

Participants who used cannabis for pain relief had lower odds of a non-fatal opioid overdose and for injecting heroin daily. Previous research from the BCCSU found that many people at risk of overdose, particularly those living with pain, may be using cannabis to reduce their reliance on illicit opioids.

Another key finding of the study was that therapeutic cannabis users relied on illicit sources for their cannabis supply – even though medical marijuana was fully legalized in Canada in 2013. About half of study participants said that illegal dispensaries were their most important source of cannabis.

"The mounting evidence related to the motivations behind people's cannabis use strongly suggests that improving access to cannabis for therapeutic purposes could help reduce overdose risk associated with illicit opioid use," says M.J. Milloy, PhD, a research scientist at BCCSU who was senior author of the study.

"Authorities should pause their efforts to close unregulated sources of cannabis and eliminate the illicit market until barriers to legal cannabis are addressed, especially during the overdose crisis."

Vancouver was the first major North American city to be hit by a wave of overdoses involving illicit fentanyl, heroin and other street drugs. A public health emergency was declared in British Columbia in 2016. Since then, Vancouver has become a laboratory of sorts for novel ways at addressing addiction, such as providing a “safe supply” of prescription opioids and prescription heroin to illicit drug users.

“Our community and many others across Canada and the United States are experiencing an opioid overdose crisis rooted, in part, in inadequately or inappropriately-managed chronic pain and sparked by widespread exposure to an unregulated illicit opioid supply contaminated with potent opioid analogues,” researchers concluded. “Our finding may also reflect an opioid-sparing effect of cannabis, whereby opioids are not replaced, but the dosage or frequency of opioid required for analgesia is reduced with the use of cannabis.”

Other studies have debunked the idea that medical cannabis reduces opioid use. Two large studies published last year found no evidence that legalizing cannabis reduces prescription opioid use, overdose or mortality.

“We tested this relationship and found no evidence that the passage of medical marijuana laws — even in states with dispensaries — was associated with a decrease in individual opioid use of prescription opioids for nonmedical purposes," researchers found.

A 2018 study suggested that cannabis legalization could actually make the opioid crisis worse, concluding that “cannabis use appears to increase rather than decrease the risk of developing nonmedical prescription opioid use and opioid use disorder.”

Survey Repudiates Canada’s Pain Care Policies

By Dr. Lynn Webster, PNN columnist

A recent survey by the Chronic Pain Association of Canada (CPAC) demonstrates all too well that our Canadian neighbors are sharing in the misfortune of America’s man-made crisis in pain care.

The online survey was distributed to patients via social media during a two-month period in the summer of 2019. CPAC received 740 responses from all 10 provinces and the territory of Nunavut. Key findings add to the growing evidence that people in pain are suffering from policies aimed at reducing access to pain medication.

• Almost two-thirds of respondents (64%) reported they have not had adequate pain control in the past two years

• A similar number (66.2%) feel discriminated against and degraded because they require opiate medicines to cope with severe pain

• A third of patients (33.5%) have either been abandoned by their doctors or their doctors have refused to continue prescribing for them

• Close to half (47.8%) have been forced against their will to taper their doses

• Nearly 45% either have deteriorated relations with their medical providers or no longer have a doctor

• Almost 40% were not adequately treated for pain in emergency rooms

Substitutes for opiates have not helped. About 70% of patients surveyed say they are more disabled, can do less with their lives, and their quality of life has declined.

Desperate Solutions

Almost 40% of patients have considered suicide because of the increased pain, while 5.4% have actually attempted suicide. A third of respondents (33.5%) reported that they know of someone who did commit suicide because of increased pain.

One other “desperate solution” is that nearly 10% of patients have substituted dangerous street drugs for what they previously received as safe prescriptions. Nearly a third of respondents (30.8%) reported they know patients who are purchasing street drugs for this reason.

Based on these findings, CPAC Executive Director Barry Ulmer penned a letter to Canada's Minister of Health.

"I’m writing on the first day of Canada’s National Pain Week, when the country notes the tragedy of chronic pain, the right of all Canadians to have their pain relieved, and government’s obligation to ensure appropriate and timely care,” Ulmer wrote.

“Yet two million Canadians with ongoing pain serious enough to warrant treatment with opioid analgesics still suffer profoundly — and pointlessly — because federal policy dismisses their needs. In today’s opioid-averse regulatory climate, their access to care shrinks precipitously as Canada’s pain specialists vanish from practice, and especially from prescribing."

Ulmer's letter further describes how people in pain feel that they are being erroneously blamed for Canada’s overdose problem. Many are being forced to taper or discontinue their pain medications. 

The CPAC findings mirror the results of a U.S. survey by Pain News Network which was released on the third anniversary of the 2016 publication of the CDC opioid prescribing guideline.  

In a critique of Canada’s 2017 opioid guideline – which was modeled after the CDC’s -- the Canadian Family Physician reports the guideline has left the Canadian health care system unable to manage its high-dose opioid patients:  

“However well-meaning they are, the 2017 Canadian opioid prescribing guidelines were introduced to a health care system ill equipped to care for patients with chronic pain. 

Without a clear and implementable patient-oriented strategy, combined with universal training in safe and effective chronic pain and addiction management for all health care providers, well-meaning documents like the 2017 Canadian guidelines might inadvertently harm the very people they hope to help."

As in the U.S., Canadian doctors are refusing to prescribe the opioids that patients need and alternative treatments are insufficient. The pharmaceutical industry is being villainized and health care professionals who prescribe opioids are under pressure to inappropriately adhere to a one-size-fits-all solution for pain patients.  

It is understandable that politicians want to reduce the harm from inappropriate use of opioids, but it should not be at the expense of people in pain. This is a human rights issue that must not be ignored.   

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.”

You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences or Pain News Network.

More Bad Data on Rx Opioids from Health Canada

By Marvin Ross, PNN Contributor

Canadian health officials are still blaming opioid prescriptions for Canada’s overdose crisis. A new report by the Canadian Institute for Health Information (CIHI) that was funded by Health Canada points out that more than 9,000 people died from opioid-related overdoses between January 2016 and June 2018.

“While many of these harms may be due to the use of illicit opioids, such as heroin or fentanyl, prescription opioids are also contributing to the public health issue,” the CIHI report found.

The data the report presents shows significant declines in opioid prescribing, but no evidence that prescriptions are to blame for the overdoses.

For example, the total quantity of opioids prescribed in Canada between 2016 and 2017 dropped more than 10 percent, while the number of prescriptions fell more than 400,000.

From 2013 to 2018, there was an 8% decrease in the number of people prescribed opioids.

Fewer Canadians are taking opioids long-term and the number on daily doses over 50 MME (morphine milligram equivalent) also declined, which is likely the result of people being tapered.

There were signs of aggressive tapering. The proportion of patients taking over 90 MME fell significantly, from 25.7 percent to 16.6 percent. And more people stopped taking opioids for at least 6 months than ever before.  

But there was no discussion anywhere in the CIHI report of whether these decreases were medically beneficial for the patients involved -- which surely must be a consideration. Healthcare should be about improving care for people, not just cutting them off.  

We do know anecdotally that these changes are making pain care worse. I personally experienced the reluctance to treat pain when I recently cracked a knee cap.

“What about pain control?” I asked the ER doc. Over-the-counter Tylenol was her answer. She said Tylenol 3 – which contains codeine -- would give me constipation, so she would not prescribe it. Anything stronger, she said, would make me fall down and that would not be to my benefit.

The Toradol shot she gave me worked for a few hours. Fortunately, I had some Tylenol 3 at home leftover from a tooth extraction. Thank goodness for dentists, but taking the Tylenol 3 for something other than what it was prescribed for made me an opioid abuser.

Evidence Lacking

As for prescriptions being a significant cause of the crisis, the CIHI report provided a footnote to a report from the Public Health Agency of Canada, which states that illicit fentanyl and its analogues appear to be fueling the crisis. Males between the ages of 30 and 39 were the most prevalent victims of overdose death. Further, 82% of the deaths involved multiple drugs.

What do those figures have to do with chronic pain patients who tend to be older and female?

Here is their proof: In 2016, over 20 million prescriptions for opioids were dispensed, which is equivalent to nearly one prescription for every adult over the age of 18, making Canada the second-largest consumer of prescription opioids in the world after the United States.

That’s an interesting fact, but it does not show that prescribing to people who need analgesics has fueled the increase in overdose deaths. It only means there are a lot of Canadian adults in pain.

They also cite a 2015 survey, which found only 2% of those who had a prescription for opioids misused them. A more recent 2017 survey found that nearly a third of people who used opioid medication did not have a prescription. That proportion increased to almost 50% for teens under the age of 18, and 88% of those were illegal drug users.

As for the source of these unprescribed drugs, the Public Health Agency states:

“There are many routes that allow for prescription opioids to be diverted for nonmedical use, including sharing with family members, ‘double doctoring,’ prescription fraud and forgery, street drug markets, thefts and robberies and Internet purchases, making it difficult to estimate the proportion diverted. Through its surveys, Health Canada found that the most common source of opioids used without a prescription was a family member.”

They have no idea how these drugs get out there and admit there are many routes, but conclude that most come from family members who have a prescription for them.

What proof do they put forth? This is the reference they provide in a footnote to prove something that is contentious and disputed:

“Health Canada. Baseline survey on opioid awareness, knowledge and behaviours for public education research report. Ottawa (ON): Prepared by Earnscliffe Strategy Group for Health Canada; 2017. Unpublished report.”

When they say unpublished, I assume that this report was never submitted to a peer reviewed journal. Or if it was, then it was rejected. Scientific research should be published in peer reviewed journals where a panel of experts in both methodology and subject matter determine if the study is any good and will add to our collective knowledge of the topic. That is how science is advanced.

Regardless, the Earnscliffe report is buried on a government website and they tell us it cost almost $100,000. The report is largely based on an online survey with self-selected participation. Because of this, “no estimates of sampling error can be calculated, and the results cannot be described as statistically projectable to the target population.”

In other words, they cannot claim that any of their findings are valid. Just saying that opioid prescriptions are diverted from family members does not make it true. As the report indicates, even the teens who participated in the survey were conflicted about where illicit prescription opioids come from:

“The most common way of obtaining opioids illegally was from a friend or relative with a prescription, and the most common reason for taking them was pain relief. When teens were asked where they thought people their age get illegal opioids, the most common source was a drug dealer or other stranger.”

So much for the alleged proof that the illegal market is mostly comprised of drugs diverted from legal prescriptions. The findings here are similar to my experience, where I used a prescription given for tooth pain for a knee fracture. If I did not have the pills leftover, I would have obtained what I needed from a relative.

The initial published report went on to disprove their own hypothesis on the role of opioid prescriptions by saying that about 2% of Canadians used illegal drugs in 2015, including the “use of crack, cocaine, ecstasy, speed or methamphetamines, hallucinogens or heroin and therefore was not specific to opioids.”

The Canadian government is simply blowing smoke when it comes to proof that prescribing is fueling opioid overdoses. Canadians can only hope that after the federal election we get a new health minister who is a bit more logical. But I am not holding my breath.

Marvin Ross is a medical writer and publisher in Dundas, Ontario. He is a regular contributor to the Huffington Post.

The information in this column is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.