capstone project
Opioid Crisis in Canada
The role of prescription opioids and Prescription Monitoring Programs (PMPs) to address the problem.
abstract
The opioid crisis in Ontario, intensified by COVID-19, has led to over 40,000 deaths since 2016. This study examines the role of prescription opioids and the effectiveness of Ontario's Narcotics Monitoring System (NMS) in improving surveillance and intervention. Qualitative assessments suggest enhancing data quality and targeting high-risk groups are key for mitigating the crisis.
INTRODUCTION
The opioid crisis in Canada has claimed over 40,000 lives since 2016, with 3,970 deaths in the first half of 2023 alone. Driven by overprescription, Canada's opioid use ranks second globally. Efforts to reduce medical opioid supply led to a surge in illicit opioids, increasingly contaminated with fentanyl, now the primary cause of overdose deaths. Long-term opioid use can lead to dependence and tolerance. This multifaceted crisis impacts social, economic, and health sectors, necessitating a diverse approach. This review focuses on prescription opioids and explores how health informatics, like prescription monitoring programs, can help mitigate the crisis.
Background
Opioid crisis: The opioid crisis involves the overuse, abuse, and addiction to opioid substances. Opioids are a class of drugs that act on the nervous system to relieve pain, often prescribed for severe or chronic pain management. However, their addictive nature and potential for misuse have contributed to a crisis of epidemic proportions. The crisis encompasses both prescription opioids, such as oxycodone, hydrocodone, and morphine, as well as illicit opioids like heroin and fentanyl. (Opioids | National Institute on Drug Abuse, 2024).
Canada has one of the highest opioid use rates in the world, but it also has a high proportion of individuals with chronic pain. It is important to monitor prescription of drugs, such as opioids, that are associated with a potential for addiction to ensure that overprescribing and inappropriate prescribing are avoided, but also to avoid under prescribing without a valid reason. (Public Health Agency of Canada, 2018).
Figure 1: Government of Canada, “Maps: Number and rates (per 100,000 population) of total apparent opioid toxicity deaths by province and territory in 2023,” Federal, provincial, and territorial Special Advisory Committee on the Epidemic of Opioid Overdoses. (March, 2024). Opioid- and stimulant-related harms — Canada.ca. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
Opioid-Related Deaths in Ontario and Canada, 2016 – 2023.
Figure 2: Opioid-Related Deaths in Ontario and Canada, 2016 – 2023. Federal, provincial, and territorial Special Advisory Committee on the Epidemic of Opioid Overdoses. (March 2024). Opioid- and stimulant-related harms — Canada.ca. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
Figure 3: Rates of opioid-related morbidity and mortality, Algoma Public Health, 2003 – 2022. Interactive Opioid Tool | Public Health Ontario. (n.d.). Public Health Ontario. https://www.publichealthontario.ca/data-and-analysis/substance-use/interactive-opioid-tool
LITERATURE REVIEW
In literary discourse, it is commonly asserted that the influencing factor that precipitated this public health crisis in Northern America was the overprescription of opioids for the treatment to pain to patients, particularly during the period of heightened pharmaceutical promotion and lax regulatory oversight, in late 1990s and early 2000s (Canadian Centre on Substance Use and Addiction, 2021; Bohnert et al., 2011). The crisis however has evolved in recent years, and opioids related deaths have been seen to be linked to the convergence of several factors like the increased accessibility and use of illicit synthetic opioids like fentanyl and its analogues (Jannetto, 2021; Fischer et al., 2018). The International Narcotics Control Board (INCB) had earlier forewarned in 2007, that the abuse of prescription drugs is expected to exceed that of illicit drugs globally. According to the report, the abuse of OxyContin (a trade name for narcotic oxycodone hydrochloride) already surpassed that of heroin in the United States. (INCB), 2007). According to research in the British Journal Of Pain, in 2021, Canda ranks fourth in the world for consumption of opioids: 333mg, about the weight of ten grains of rice, per person (Richards et al., 2021). Although a report by IQVIA (formerly Quintiles and IMS Health, Inc.,) in 2024, which looks at the trend of opioid prescription in Canada from 2019 to 2022, reported a slight decrease in the prevalence rate (calculated over the total population) of opioid use, from 11.9% in 2022 as to 12.5% in 2019. This equates to around eight prescriptions per person over the four years under examination. According to the report (as shown in fig. 4), the prevalence rate in the total population has been relatively stable, except for 2020 (11.4%), which may be explained as due to the decrease in medical consultations during the first wave of the pandemic. There was however a rebound to 12.1 % in 2021. From 2019 to 2022, an individual received approximately eight prescriptions on average. Ontario reports a decrease in prevalence rate from 12.3% in 2019 to 11.6% in 2022 (IQVIA, 2024). However, the death rate has been skyrocketing in these years. The Interactive opioid tool by Public Health Ontario (PHO) reports an increase in the rate of opioid related deaths as 10.7% in 2019 to 19.1% in 2021 and a decrease to 16.1% in 2022, calculated as per 100,000 population (PHO, 2024).
Figure 4: General statistics on opioid use in Canada. (IQVIA, 2024)
Figure 5: Yearly rate (per 1,000) of prescription opioids for pain in Ontario, 2013-2021. (Ontario Drug Policy Research Network, 2024)
Figure 6: Prevalence of opioid dispensing by province (Comparison between 2019 and 2022). (IQVIA, 2024)
Government actions: While the government of Canada has not formally declared the opioid crisis as a public health emergency, the federal government and certain provinces have responded in various ways to address the issue. In 2016, the province of British Columbia declared a public health emergency in response to the rising number of opioid-related overdose deaths. This resulted in increased distribution of naloxone kits among communities, more access to suboxone and methadone therapy, extensive public education initiatives, and the establishment of numerous overdose prevention service sites (BC Centre for Disease Control, 2017). On a federal level, in 2016, the government opted to replace the enforcement-centric National Anti-Drug Strategy with the Canadian Drugs and Substances Strategy, which takes a public health approach to address substance use issues. This new strategy emphasizes compassion and encourages collaboration across sectors, considering the social factors that contribute to the crisis’s escalation (Health Canada, 2017). In recent years, some of the response of the government to the crisis include relaunching the Canadian Drugs and Substances strategy which is based on four pillars – prevention and education, substance use services and supports, evidence and substance controls, all of which work together to help increase public health and public safety. The government also launched the Youth Substance Use Prevention Program as part of the CDSS to address substance use prevention among youth. Other engagement of the government includes releasing national data on opioid-related deaths and hospitalizations, updating modeling projections on opioid-related deaths, and investing significant funding to support initiatives addressing substance use issues (Health Canada, 2023). All of which are aimed at aimed at saving lives, increasing access to treatment and harm reduction services, enhancing public awareness, and supporting research initiatives to inform policy decisions.
In Ontario: In 2016, in response to the escalating opioid crisis, the provincial government formed advisory committees and developed a comprehensive strategy to prevent addiction and overdose. They expanded access to naloxone and safer opioid treatments, provided training to primary care providers, and appointed a Provincial Overdose Coordinator. Additionally, $17 million annually was invested in chronic pain management programs. (Government of Ontario, 2017) In 2017, the government delisted high-strength opioids from the drug formulary, launched the Interactive Opioid Tool for public health data, and announced $222 million in additional funding over three years to combat the crisis. These measures demonstrated a concerted effort to address the multifaceted challenges posed by opioid addiction and overdose. (Government of Ontario, 2017)
The SCS Sites: To mitigate the opioid crisis, as part of the federal government's harm-reduction interventions were the introduction of Supervised consumption sites (SCS) also known as safe injection sites. SCS are evidence-based interventions that allow drug users to bring their drugs and use them in a clinical safe environment, Under the supervision of a health professional (Russell et al., 2020). The first site in Ontario was opened in Toronto in 2017. According to the Canadian Drug Policy Coalition (CDPC) .... ‘Within months, 20 sites were operating in the province’ (CDPC, 2024). However, in 2018, the subsequent government that was openly opposed to the SCS, placed an arbitrary cap of 21 on the number of SCS. It also introduced a new model for overdose prevention titled – Consumption and Treatment Sites (CTS). The CTS, building on the existing SCS, would need to meet new additional provincial requirements to continue to exist and to receive funds. The Change in Policy was justified by conducting a review of the existing sites where the minister consulted with representatives of different sectors. As opposed to a harm-reduction approach, the decision was primarily centered on prioritizing and emphasized connections to treatment and rehabilitation along with other social services. However, findings from the reviews showed that SCS reduce illness and death from overdoses, lower rates of public drug use and needle sharing, improve the health of those who use drugs, are cost-effective, and reduce the strain on the health care system (Government of Ontario, 2018). The government policy would further hamper the system, hindering its ability to provide effective harm reduction interventions to the growing population experiencing severe consequences due to opioid overuse. For example, small communities in northern Ontario have the highest rates of opioid-related deaths among all ages and all sexes 40 per 100,000 population, with Sault Ste Marie among the top three cities with the highest deaths in 2022 (Public Health Ontario, 2024; Dufour & Migneault, 2023). This is a significant difference from the rate of the whole province, 16.7 per 100,000 population. Many of these communities in northern Ontario may lack the necessary capacity, infrastructure, and resources to meet stringent requirements (Russell et al., 2020). At the time of this literature, Ontario has only 17 provincially funded supervised consumption sites, with just one solitary site located in northern Ontario. This is despite hundreds of communities in the province showing the need for more CTS sites.
Patch for patch program Between 2012 –2015, to curtail the misuse and diversion of fentanyl patches used for the treatment of pain, certain counties in Ontario began implementing a patch for patch program. (Tadrous et al., 2019). This legislation was later passed in 2016 under the Safeguarding our Communities Act. (Government of Ontario, 2015). The program requires patients supplied with fentanyl patches to return old ones to the pharmacist to be issued new ones. Evaluations of the program demonstrated a decrease in the prescription rates of fentanyl patches. However, this reduction did not correspond to a decrease in opioid-related deaths or hospital visits during the specified period. (Tadrous et al., 2019).
methodology
This project aims to understand what previous literature, government reports and surveillances say about the opioid crisis, the role prescription opioids play in the crisis, what has been done by different stakeholders to address the issue and to propose a possible solution to the crisis.
We conducted a comprehensive review of publicly available opioid-related surveillance and epidemiological reports from provincial and territorial ministries of health. We also reviewed relevant and recent published literature, grey literature.
Academic search engines such as, Goggle scholar and PubMed and research databases and scholarly databases were used to get relevant articles to understand the crisis. We produced our evidence by contrasting these reports with published literature and we propose a possible solution from a health informatics point of view.
RECOMMENDATIONS
Effective implementation of Narcotic Monitoring System (NMS) in Ontario
History of Prescription Monitoring Programs in Canada: Canada has been grappling with the rising problem of prescription drug abuse, especially involving opioids and other controlled substances. To combat this, provinces and territories have been implementing prescription monitoring programs over the years.
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Early Programs (1986-1995): The pioneer of these programs was Alberta, which launched its Triplicate Prescription Program (TPP-AB) in 1986. Under this program, doctors were mandated to use special prescription forms in triplicate when prescribing certain controlled substances (Fischer et al., 2019).
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After the initial triple-designed prescription programs in 1988 and 1992 by Saskatchewan (Prescription Review Program of Saskatchewan) and Nova Scotia (Nova Scotia Prescription Monitoring Program), more advanced programs emerged. British Columbia introduced a comprehensive monitoring system in 1995, using a central database to track all prescriptions. Gradually, most other Canadian provinces and territories implemented similar programs, with only a few exceptions (Prince Edward Island, Yukon, and Northwest Territories). Simultaneously, New Brunswick embarked on the creation of an online system for monitoring prescription drug use. (Fischer et al., February 2019)
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Across Canada prescription monitoring programs are now in use. These programs aim to curb the misuse and abuse of controlled substances. They differ slightly in their specific details and how they are carried out, but their main goals are to offer educational resources, find instances where prescriptions may be used improperly and encourage responsible prescribing habits.
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These programs gather information about how controlled substances are prescribed and distributed. They assist healthcare professionals by giving them access to patients' prescription records, which aids in making better healthcare decisions. To deal with issues that cross jurisdictional boundaries, some of these programs also share data among different provinces and territories.
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Prescription monitoring programs in Canada have effectively minimized prescription misuse, as evidenced by declines in multiple prescriptions from different doctors ("doctor shopping"), risky drug combinations, and negative drug reactions. Balancing access to medications for genuine medical conditions while also preventing their misuse remains a challenge. In Ontario Narcotics Monitoring System (NMS) was activated on April 16, 2012, and is designed to perform real-time Drug Utilization Review (DUR) checks when pharmacies submit dispensing records.
It is a central database that tracks prescription and dispensing of monitored drugs within healthcare providers. It also includes real-time Drug Utilization Review (DUR) capabilities. When a pharmacy submits a dispensing record to the NMS, the system automatically checks for potential issues like prescribing from multiple doctors or multiple visits for the same medication (polypharmacy). If any issues are detected, the NMS immediately alerts the pharmacy while the prescription is being filled. This helps identify potential problems and prevent medication misuse. The NMS collects data on all dispensed monitored drugs, regardless of the method of payment. (e.g., publicly funded drug programs, private insurance, and cash payments). (Narcotics Monitoring System, 2016).
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During the period from July 2012 to December 2016, the NMS contained over 1.3 million prescriptions: 72.8% were for opioids, 21% were for benzodiazepines, 4.4% were for stimulants, less than 2% were for other medications. Approximately 97% of prescriptions in the NMS could be linked to other health claims databases because an Ontario health card was used at the time of dispensing. In 2016, 52.8% of individuals with an opioid-related hospitalization and 32.5% of those with an opioid-related death had a recent opioid prescription in the NMS (Martins et al., 2018).
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The proportion of opioid-related hospitalizations and deaths with a recent opioid prescription was significantly higher among:
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Males: 57.2% Vs Female: 48.0% for hospitalizations and Males: 45.6% vs. Females: 26.4% for deaths.
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Older individuals aged 45-64 years (Males: 66.9% vs. Female: 9.9% for hospitalizations, Males: 46.4% vs. Female: 11.6% for deaths). (Martins et al., 2018)
In 2022, opioid-related hospitalization rates and death rates was significantly higher among:
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Males: 25.4 Vs Female: 8.4 for death and Males: 16.9 vs. Females: 10.9 for hospitalizations
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Individuals in the age group of 25-44 years. Males: 47.7 vs females: 15.1 for deaths,/ hospitalizations was 25.5 vs females 11.5 (rates are calculated per 100,000) (Public Health Ontario, 2024).
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The NMS is meant for capturing data about patients receiving monitored drugs, not for inter-store transfers or inventory management. Pharmacies are required to submit various details to the NMS when dispensing a monitored drug, including the prescriber information, patient details, drug information, and pharmacy details. Timely and accurate data entry into the NMS is crucial for it to function as intended and provide meaningful insights.
Based on our team analysis, some of the best changes and improvements that could be made to the Narcotics Monitoring System (NMS) in Ontario to help address the opioid crisis is:
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1) Improve Data Quality and Timeliness:
Accurate and timely data entry by pharmacies into the NMS is important for access to real-time data by other stakeholders. Providing guidance, training, and incentives for pharmacies to improve the quality and timeliness of their NMS data submissions could enhance the system's utility.
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2) Expand Linkages to Health Outcomes:
The NMS data can be linked to other health databases to examine the relationship between controlled substance prescriptions and opioid-related harms, such as hospitalizations and deaths. Improving these data linkages could provide more comprehensive insights to inform evidence-based policies and interventions.
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3) Enhance Monitoring of Prescribing Patterns:
The NMS data revealed issues with some prescribers inappropriately prescribing controlled substances despite having terms or conditions on their licenses. Strengthening the monitoring of prescribing patterns through the NMS, and taking appropriate actions against problematic prescribers, could help curb the overprescribing of opioids.
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4) Identify and Target High-Risk Populations:
The NMS data showed that opioid-related hospitalizations and deaths were significantly higher among males and older individuals aged 45-64 years. Using this information, the NMS could be leveraged to target prevention and intervention efforts towards these high-risk groups.
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5) Improve Accessibility and Usability:
Enhancing the accessibility and usability of the NMS data would facilitate its use in decision-making and the development of effective strategies to address the opioid crisis. (Ontario Newsroom, October 2017)
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6) Naloxone distribution efforts:
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Identify geographic areas and healthcare settings with higher rates of opioid prescriptions and overdoses, allowing for more targeted naloxone distribution efforts.
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Analyze prescription patterns and risk factors to proactively provide naloxone kits to patients receiving high-risk opioid prescriptions, particularly younger male patients.
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Coordinate with pharmacies to ensure naloxone kits are readily available and that pharmacy staff are trained on how to educate patients on their use (Ontario Newsroom, October 2017).
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By implementing these types of changes and improvements, the Narcotics Monitoring System in Ontario could become a more powerful tool in the fight against the opioid epidemic.
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Figure 7: Kroll User Interface (Ontario Narcotic Monitoring System, 2020)
Figure 8: Kroll User Interface, (Ontario Narcotic Monitoring System, 2020)
Figure 9: Kroll User Interface, Kroll User Interface (Ontario Narcotic Monitoring System, 2020)
CONCLUSION
The opioid crisis in Ontario, Canada is a significant public health issue that requires a multifaceted approach to address. The key findings and recommendations from the search results are:
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Opioid-related deaths and hospitalizations have increased significantly in Ontario, particularly during the COVID-19 pandemic, with higher rates among males and older adults.
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The Narcotics Monitoring System (NMS) in Ontario is a comprehensive database that captures data on controlled substance prescriptions, which can be linked to health outcomes. However, there are opportunities to improve the NMS:
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Enhance data quality and timeliness by providing guidance, training, and incentives for pharmacies to improve their NMS data submissions.
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Expand linkages between the NMS data and other health databases to gain more comprehensive insights into the relationship between prescriptions and opioid-related harms.
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Strengthen monitoring of prescribing patterns through the NMS and take appropriate actions against problematic prescribers.
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Leverage the NMS data to identify and target high-risk populations for prevention and intervention efforts.
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Improve the accessibility and usability of the NMS data for healthcare providers and policymakers to facilitate evidence-based decision-making.
Ongoing challenges include balancing access to medications for legitimate medical needs while preventing misuse and addressing the social determinants that contribute to the opioid crisis.
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Our review highlights the severity of the opioid crisis in Ontario and the need for a comprehensive, evidence-based, and collaborative approach to address this public health emergency. Improving the Narcotics Monitoring System and aligning government policies with harm reduction principles could be key to mitigating the crisis.