Jerome C. Hill: Prescription opioids and Canada’s opioid crisis: A call for broadened research

Canada is in the midst of an opioid crisis and prescriptions have something to do with it. The question is, what?

In the October 2017 Canadian Agency for Drugs and Technologies in Health (CADTH) webinar lecture series, Dr. Hakique Virani presented “Canada’s Opioid Crisis: The Changing Reality Between Exam Rooms and Ivory Towers”. Here, Virani discussed the history, complexities, and current state of the Canadian opioid crisis, outlining a striking metaphor for the way in which researchers have struggled to explain its causes and outcomes.

Midway through the lecture, Virani plays a video of two teams clad in black and white jerseys, each passing a basketball between them. “You are responsible for keeping an eye on the ball carried by the white team and counting how many passes that white team makes”. At the end of the video he asks the audience for the number – “Did everyone get 13?” Following a muffled yes from the crowd, he continues, “Okay. Did you see the moon-walking bear?” At first there is a quiet laugh at the absurdity of the question. But low-and-behold, when the video is played again, a man dressed as a bear walks into the centre of the frame and begins to moonwalk. It had been there the whole time, we just missed it. And why? “It’s easy to miss something you’re not looking for” (1).

With this metaphor, Virani describes what he perceives as an overemphasis on opioid prescribing in research addressing the epidemic. The passing of the ball symbolizes prescription opioid data, the audience symbolizes Canada’s researchers investigating the crisis, and the dancing bear symbolizes the truth underlying the rise in addiction and overdose. According to Virani, researchers have been so preoccupied with establishing links between the crisis and prescribing data that they have missed the real-time changes in opioid-related deaths.

However, following this metaphor, the question remains: what exactly is the moon-walking bear?

That is, what is the information that we’re missing to aid us in understanding the stark rise in overdose in the last 5 years? Virani seems to suggest that the answer lies in moving away from the investigation of prescripton opioids. But perhaps it doesn’t (at least not entirely). Researchers may simply need to shift exactly what questions about prescription opioids they’re asking.

It is no secret that with the rise of the opioid crisis, there has been a rise in opioid prescriptions, and Virani acknowledges this. It has been found that physicians who prescribe more opioids are more likely to have prescribed the final opioid before an individual’s overdose death (2), that deaths from opioid overdose are more common in areas where opioids are more often prescribed (2-4), and that higher-doses and longer durations are correlated with increased drug-related mortality (5,6). Moreover, recent data suggests that prescriptions in Canada are continuing to increase (7). It is no question that opioid prescribing is tied to the Canadian opioid crisis (8). The question that might be missed, however, is how. As many links have been established between opioid prescribing and addiction, it is still uncertain exactly how prescriptions are having this impact.

This question is particularly confusing in light of the reported low rates of addiction amongst patients actually prescribed opioids (9). A 2012 systematic review found that a mere 0.5% of all opioid-prescribed patients developed an addiction (10). Other reviews have found incidences ranging from 0.8-26% (11).

So how are prescription opioids really influencing rates of overdose and opioid use disorder (OUD)?

There are a number of plausible answers to this question: diversion (8, 12), inadequate pain care (13), premature discontinuation of prescription opioids (14), doctor shopping (12) – however, research has not adequately examined which of these avenues is playing the greatest role in exacerbating the observed rise in addiction and overdose.

We need reviews aimed at investigating the primary ways in which prescription opioids enter and influence the lives of not only those who are prescribed opioids, but those that are not. These investigations are particularly important if we hope to introduce policy, programs, and healthcare training that effectively balance the need for improved pain care and safe opioid prescribing. Researchers need to refocus their attention onto this moon-walking bear.