Confronting the Opioid Crisis

Here’s a number that should give us pause: 2,923.

That is the number of apparent opioid-related deaths from January to September last year, according to data released yesterday by the Public Health Agency of Canada. As reported on the front page of today’s Globe and Mail, total deaths for 2017 will likely pass 4,000 — an increase of more than 35 per cent since 2016. Credible estimates put opioid fatalities in Canada over the last two decades at 30,000.

This is a full-blown public health crisis. And it’s becoming more complex: three-quarters of the deaths last year involved fentanyl, compared to half the year before. Widespread supply of fentanyl-laced street drugs has complicated available solutions and raised the threat of this epidemic to a level unimaginable a few years ago.

But hopeful signs are emerging. Earlier this year, Health Quality Ontario published a report showing that doctors in Ontario wrote 25,000 fewer ‘new start’ prescriptions in 2016 than in 2013 — a modest but important shift in practice.

As a Faculty, we’ve been tackling this issue in undergraduate and postgraduate medical education, and through continuing professional development. And many of our faculty members are working with the province to expand and refine effective treatment and harm reduction strategies, as was clear at a Massey Grand Rounds symposium on opioids last week.

In our Foundations curriculum, first- and second-year medical students learn about the origin of the opioid crisis and how it has evolved, in seminars and online emodules. They master competencies related to opioids in several weeks of the curriculum including pharmacology, neurology and pain. And they learn different approaches to pain management, how to recognize opioid use disorder and when to consider harm reduction strategies.

In clerkship, third- and fourth-year students expand their knowledge of opioids through clinical courses on anesthesia, psychiatry, and emergency and family medicine, delivered in seminars, online, in clinical encounters and through texts. They can access seminars on methadone, back pain and management of opioid overdose, and they learn how to broach the subject of substance abuse with patients and discuss interventions. 

All residents at U of T cover opioid prescribing in the end-of-life care module of PGCorEd, a mandatory web-based learning curriculum. In addition, more than two dozen residency programs include training on opioid prescription or addiction (or both), according to a recent internal survey. Many of these programs have added specialty-specific content and new methods of training related to opioids over the last decade — including seminars on concurrent disorders in child and adolescent psychiatry, opioid use disorder in pregnancy, and how to use the opioid manager from the Centre for Effective Practice and the 2017 national opioid guideline.

For physicians already in practice, our Faculty was one of the first to offer a continuing education program on safer opioid prescribing. The program includes three live webinars and a skills development workshop that cover key aspects of opioids in practical instruction. We also offer an opioid dependence treatment certificate in partnership with CAMH, which includes several courses over 39 hours of accredited training.

It hasn’t been an easy road. In the late 1990s, many physicians embraced the idea that new opioids were better than existing drugs for the treatment of chronic non-cancer pain. Evidence for that claim was never strong, but aggressive marketing by the pharmaceutical industry helped make it dogma among practitioners keen to relieve the suffering of patients.

Physicians were also slow to respond. U of T Medicine Professors Irfan Dhalla and David Juurlink published a study in 2009 showing that opioid deaths in Ontario skyrocketed after the introduction of long-acting oxycodone. But the next year, new national guidelines on opioid safety arguably focused on how to prescribe rather than ways to limit exposure to opioids or treat dependence. As well, skittishness has sometimes coloured the physician response to patients who need help for addiction.

But physicians and faculty are engaging around this issue at the community level like never before. The Ministry of Health and Long-Term care just announced the opening of the first of four approved overdose prevention sites. Naloxone kits that can quickly reverse an overdose are now available at many pharmacies and community centres, and through police and fire services across the province. There are now almost three dozen rapid access addiction medicine clinics in Ontario, where patients can quickly get treatments including methadone and buprenorphine to combat withdrawal, without an appointment or physician referral.

Our faculty and students have been advocating for these public health efforts for years, and it’s encouraging to see the province embrace some of them in a coordinated opioid strategy. I hope we can build on that momentum to expand these efforts provincially and nationally, and to explore other ideas including de-listing more long-acting opioids from drug plans, adoption of safer practice standards by the medical regulatory colleges, and stronger public health interventions to identify and reach those most at risk for prescription and illicit drug overdose.

Let’s treat this epidemic with the seriousness, compassion and conviction it deserves.

Trevor Young
Dean, Faculty of Medicine
Vice Provost, Relations with Health Care Institutions