The opioid crisis in Canada has been an issue for nearly a quarter of a century. Here, Norm Buckley and Jason Busse from the Michael G DeGroote Institute for Pain Research and Care, and the National Pain Centre discuss the issue, its effects both general and on specific communities, and what can be done about it
Over the past twenty-five or so years, there has been a remarkable arc in the medical use of opioids in Canada, from prescribing for only very specific instances (e.g., end-of-life care) to much more widespread use (e.g., chronic noncancer pain), and now there is greater reluctance to provide opioid analgesia. This coincides with growing awareness of the unmet need for chronic pain care and promotion of the use of opioids by commercial interests.
Production of sustained-release forms of opioids containing large doses, along with widespread use, was associated with the diversion of prescription opioids into illicit or recreational markets, and opioid-related deaths began to be more frequently associated with these drugs rather than historic illicit drugs such as heroin.
Attention was paid to physician prescribing practices and pharmaceutical marketing strategies, and the public press reported on issues to do with deaths caused by overdose of prescription medications, along with the need for greater attention to issues of both addiction treatment and pain care, including alternatives to pharmaceuticals for pain.
Tragically, even though prescribing has declined between 2010-2023, the number of deaths associated with opioids has soared. Most deaths are now associated with highly potent synthetic opioids acquired through illicit markets and often mixed with other drugs or sold as other drugs without user awareness of their high potency.
Issues within the opioid crisis in Canada and globally
These issues are complex and intertwining, and they have unfolded in a setting in which attempts to manage healthcare delivery and training of healthcare professionals interact with public distress about the increase in deaths associated with opioid use. There are also challenges to effectively addressing the criminal production and distribution of drugs intended for illicit use.
The opioid crisis has occupied public attention since the early 2000s. At that time, prescription opioids had been appearing in the recreational or illicit use ‘market’, believed to have been diverted from prescription use. Attention, especially in the public press, was focused on diversion by patients, liberal use, or physicians prescribing inappropriately high doses that enabled diversion.
The rates of both overall use and problematic use have been reported in Statistics Canada surveys such as the Canadian Alcohol and Drugs Survey (CADS – from 2019), the Canadian Tobacco Alcohol and Drugs Survey (CTADS – from 2013-2017) and the Canadian Alcohol and Drug Use Monitoring Survey (CADUMS – 2008- 2012). ‘Any use’ of opioids has declined from 20% of the reporting population in 2008 down to 14% in 2019, while the problematic use of opioids has varied between 2-6% over the years from 2012-2019.
While the rate of problematic use remains low, deaths associated with opioids have dramatically increased, in part due to the intrusion of highly potent synthetic narcotics into the illicit markets, with a drop in the diversion of prescription opioids. There were 2,819 opioid-related deaths in 2016 in Canada, which rose to 7,328 in 2022. In 2023 so far, there have been an average of 21 opioid-related deaths per day. Opioid addiction and ‘recreational’ use of drugs, both prescription and non-prescription, has been a constant issue, but the impact in terms of death due to opioid overdose has escalated dramatically.
The impact on different Communities
Between 2000 and 2017, opioid-related deaths increased by 592%, from 20 per million population to 118 per million. Deaths rose particularly dramatically between 2015 and 2017. Over the period from 2000 to 2017, opioid-related deaths, emergency department (ED) visits and hospitalisations due to opioid use (both illness and admission for treatment of OUD) have risen continuously. Deaths from opioid use and overdose are highest in the provinces of British Columbia, Ontario, and Alberta.
In 2016, British Columbia had 985 deaths per 100,000 population, Ontario 867/100K, and Alberta 611/100K. Other provinces were lower, with 140/100K in Quebec and much fewer in other provinces.
In addition to geographic variability, there is also an unequal representation of deaths across the socioeconomic spectrum. The burden of overdose and death is borne significantly in equity-seeking communities and the lower socioeconomic classes.
Indigenous populations experience a dramatically greater impact: Despite representing just 2.6% of the total population, Indigenous Peoples account for 10% of overdose deaths. Indigenous women are eight times more likely to have a nonfatal overdose and five times more likely to experience a fatal overdose than non-Indigenous women. The severity of this crisis is likely understated owing to poor disaggregation of data on Indigenous Peoples in many settings.
Being male, being younger (ages 20 to 24), having fair or poor mental health, having unmet needs for help with mental or emotional health or substance problems, being a smoker, or being unattached and living with others were significantly related to problematic opioid pain relief medication use.
From 2000 to 2017, lower income levels were associated with higher rates of opioid-related mortality, emergency department visits and hospitalisation rates, although the gap between income levels for mortality decreased over time.
Public press reporting of the opioid crisis has also changed in tone and content over time. In an analysis of reporting in three major Canadian national news sources from 2000 to 2018, commentary initially focused on the needs of patients with chronic pain, the value of opioids in their care, and the relative lack of treatment alternatives.
The focus shifted to comment upon the increasing frequency and doses of prescriptions, the appearance of prescription opioids in illicit markets, aggressive marketing by pharma companies, the misuse of opioids by ‘drug addicts’. Then attention was paid to the impact of criminal actors on the use of opioids, then on the complexity of the problems of addiction and the entry of highly potent illicit sources of synthetic opioids (such as fentanyl), with the almost complete disappearance of physicians and prescribing from the discussion.
Working on the problem
The solution to the opioid crisis is not straightforward. Access to effective analgesics is important for the portion of individuals who experience chronic pain and derive benefit from these medications. There is also a need to make non-pharmaceutical treatments for pain more readily available and to a broader spectrum of the population; currently, many effective treatments are only available through third-party coverage rather than offered within universal care, and waitlists are often significant enough to be associated with deterioration in function and quality of life.
Recreational use of illicit pharmaceuticals, like the use of other substances such as alcohol, tobacco, and now (with legalisation) recreational use of cannabis products, is a fact of life in Canada as in much of the world. The shift from recreational use to dependence and addiction does occur for a portion of the population, with often dramatic and tragic consequences.
More work is being done to predict which individuals are at risk to provide appropriate support and treatment, but this area of healthcare is still early in its development. There is also a need to provide more effective care for addiction and access to ways and means to avoid the tragic consequences of the use of unknown substances in unsafe settings.
All of these complex issues are also unfolding in a politically charged atmosphere in which there is a lack of concrete evidence to direct interventions, and there are political, moral, and cultural values held by the various groups and individuals involved. This makes it extremely challenging to effectively examine interventions that are controversial for various reasons (e.g., safe supply), and challenging to implement programs even if the available evidence is in support of the action proposed.
In the next and final article in this series, we will review the various actions undertaken by the federal and provincial legal, healthcare, and regulatory systems in Canada between 2005 and the present to provide additional context for the issues at play.
