An urgent call to increase access to evidence-based opioid agonist therapy for prescription opioid use disorders

published on November 7, 2016 by M. Eugenia Socías MD MSc, Keith Ahamad MD in CMAJ

As Fischer and colleagues highlight in a linked Analysis article, the use of prescription opioids among Canadians has increased dramatically in the last two decades, placing our country behind the United States as the second highest consumer of prescription opioids in the world.

Paralleling this stark increase in prescription opioid use, the prevalence of opioid use disorders and related health and social harms has also increased substantially, with some estimates suggesting that prescription opioid use disorders account for the third highest overall burden of disease attributable to substance use in Canada (after tobacco and alcohol). To make matters worse, the introduction of fentanyl into the illicit-drug market has drawn attention recently because of a spike in overdose deaths in Canada’s largest provinces. Importantly, accidental opioid-related overdose deaths now exceed deaths from alcohol-related motor vehicle collisions in many Canadian provinces, and fentanyl has been involved in many of these deaths. This alarming rise in overdose deaths underscores the immediate need for a coordinated, evidence-based approach to address the harms associated with untreated opioid use disorders.

Given the complexities of the opioid epidemic, no single solution will prove effective, and concerted efforts will be required to tackle the underlying factors driving this public health crisis. An effective strategy should focus concomitantly on the prevention and early identification of cases of opioid use disorders, as well as ensuring access to evidence-based comprehensive addiction care that includes pharmacotherapies (i.e., opioid agonist therapy), naloxone for overdose prevention, other harm-reduction approaches (e.g., safe injection sites) and psychosocial supports.

Fischer and colleagues provide an extensive analysis of the current Canadian response to the opioid crisis and suggest specific upstream interventions to address the prescribing side of the problem. Drawing on lessons from other jurisdictions, the authors make a strong call for tighter restrictions on opioid prescribing through enforceable evidence-based guidelines and mandatory implementation and use of real-time monitoring programs for prescription drugs. We agree that promoting appropriate and safer opioid-prescribing practices should be a key element in the Canadian response to the opioid crisis, particularly to prevent future harms. However, the overdose epidemic related to both prescription and illicit opioids will continue unless we simultaneously target those who have already developed opioid use disorders and expand access to evidence-based addiction treatment.

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