Opioid Prescribing has Turned a Corner in Alberta

A condensed version of this editorial was published in the Edmonton Journal and Calgary Herald on January 11, 2018.

Over-use of opioids is an ongoing crisis in Alberta. Nearly 500 people died from accidental poisoning related to opioids in the first nine months of 2017. Three-quarters of opioid-poisoning deaths involve illicit fentanyl, which is commonly laced into other drugs so users don’t know it’s there. We have two inter-related problems: over-use of opioids and other drugs, and an illicit drug supply that is toxic in a way we’ve never seen before.

Over-prescribing of opioid painkillers contributed to the crisis starting in the late 1990s, in part because physicians were told to treat pain more aggressively, and that opioids were a safe way to do it. The medical profession didn’t set out to do harm but we helped create the crisis, and now we need to do everything we can to help solve it. Canada has the second-highest prescription opioid use per capita in the world, and Alberta has the highest per capita consumption among the provinces.

The first thing we need to do is prescribe opioids more appropriately, and that means less. In Alberta we have the most current data in the country, and it shows a remarkable change is happening. In just 12 months from September 2016 to September 2017, the number of Albertans prescribed any of the five main opioid painkillers dropped by 7% – that’s 9,000 fewer people prescribed opioids in a given month (mainly codeine). Total volume prescribed dropped 14%, measured in “Oral Morphine Equivalents.” On a per capita basis, the changes are around 9% and 16%.

These are big changes after two decades of increases, and they’re broadly similar to the latest data from Ontario as well. Physicians are changing their practices in response to the opioid crisis, more specifically in response to new evidence and guidelines, and guidance from provincial regulators.

The reduction in prescribing is good but it brings risks of its own. Lowering an opioid-dependent patient’s dose too fast or withdrawing the medication altogether risks leaving the patient to turn to illicit drugs; we never want to see that happen. Opioids are an appropriate therapy when they’re used in accord with the evidence. We want physicians to prescribe based on the latest evidence and guidelines, not to stop prescribing opioids altogether, or make sudden changes in the care of individual patients to meet any numerical target. The welfare of the individual patient comes first. Any patient or doctor with concerns or questions should contact us directly.

Prescribing responsibly also means that the amount of prescribed opioids diverted to the street is less,  which may result in more demand for illicit supply.  We need to reduce diversion – it’s part of why we’re in this crisis in the first place – but the transition puts some people at risk.

To mitigate this risk, we must greatly expand access to treatment for people with opioid use disorder. The number of patients receiving the two main opioid replacement therapies, methadone and Suboxone, increased more than 20% in the latest 12 months to September 2017, and the number of physicians prescribing the treatment drugs increased by 33%. 

The reduction in prescribing of opioid painkillers and the increase in access to treatment are important, encouraging trends. They reflect the commitment of individual physicians across the province to do the right thing for patients, but there is much more to be done.

We have removed regulatory barriers to prescribing Suboxone, allowing primary care physicians to provide this treatment without prior approval.  We are also working with experts to streamline methadone prescribing and enable emerging evidence-based treatments for opioid use disorder such as sustained-release oral morphine and supervised injectable opioid agonist treatment by ensuring these treatments are offered by trained physicians in appropriate settings. These steps are intended to support actions Alberta Health and Alberta Health Services have taken to expand access to treatment.

We need to identify people at risk regardless of what they’re using or where they’re getting it, and get them whatever kind of help is appropriate. Physicians have the same duty to provide compassionate care to people who use substances as to every patient; appropriate care includes harm reduction (e.g. providing overdose prevention and response training as well as naloxone kits for patients presenting with an opioid overdose.)

Most importantly, as healthcare providers we must address the stigma faced by people who use substances (illicit and prescribed) when they need care. We must seek to understand the challenges patients who use substances face when they interact with our healthcare system. Only when we truly understand our patients can we garner the trust needed to provide safe, effective and compassionate care. 

Dr. Scott McLeod
Registrar, College of Physicians & Surgeons of Alberta

Alberta patients with an opioid painkiller prescription
(By month, January 2015 to September 2017)

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Source: CPSA – Alberta Triplicate Prescription Program (TPP) data for the 5 highest-volume prescribed opioid painkillers

The number of patients prescribed any of the five highest-volume opioid painkillers each month fell by 9,000 or 7% in the third quarter (July-Sept.) of 2017 compared to the same quarter a year earlier.

  • In Q3 2017 (July-Sept. 2017), 118,000 people had a prescription on average each month compared to a monthly average of 127,000 in Q3 2016.
  • Alberta’s population is growing by nearly 2% per year so on a per capita basis the reduction was about 9%.
  • Almost all the reduction in patients was in codeine (6,500 fewer patients per month) and oxycodone (2,400 fewer).
  • The number of hydromorphone, morphine and fentanyl patients overall was flat – see next graph for detail.

Detail for hydromorphone, morphine, fentanyl
(By month, January 2015 to September 2017)

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Source: CPSA – Alberta Triplicate Prescription Program (TPP) data for the 5 highest-volume prescribed opioid painkillers. (same data as previous graph)

The number of patients with a prescription for hydromorphone increased through 2016 but went flat around Sept. 2016. Morphine and fentanyl patients have been declining slowly since mid-2016.


Alberta total opioid Oral Morphine Equivalents (OME) prescribed
(By month, January 2015 to September 2017)

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Source: CPSA – Alberta Triplicate Prescription Program (TPP) data for the 5 highest-volume prescribed opioid painkillers.

The total volume (OME) prescribed of the five highest-volume opioid painkillers fell by 14% in the third quarter of 2017 (July-Sept. 2017) compared to the same quarter a year earlier.

  • In Q3 2017, about 161 million OME were prescribed per month, down 26 million or 14% from 187 million OME in Q3 2016.
  • Alberta’s population is growing by nearly 2% per year so on a per capita basis the reduction was about 16%.
  • Total volume of all five opioids fell: oxycodone, hydromorphone, morphine, and fentanyl by around 15%, and codeine by 9%.

Alberta patients with a prescription for opioid replacement therapy
(By month, January 2015 to September 2017)

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Source: CPSA – Alberta Triplicate Prescription Program (TPP) data

The number of patients prescribed the two main opioid replacement therapies, methadone and Suboxone, increased by more than 1,200 or 22% to 6,975 in Q3 2017 (July-Sept. 2017) compared to 5,717 in the same quarter of 2016.