Neil Chanchlani: Britain’s opioid crisis—lessons to be learnt from Canada

The Times has recently launched Britain’s Opioid Crisis, a campaign to highlight the growing problem of opioid use within the UK. Following in North America’s footsteps, UK national headlines now read ‘Britain’s opioid epidemic kills five every day’, ‘Overworked GPs fuel opioid crisis by giving too many painkillers’, and ‘Opioids in the UK: poverty and pain’. Analysis of data from the NHS and Office for National statistics suggest that there has been an increase in opioid prescriptions and opioid-related deaths in the last two decades compared to previous years.

In 2017, the Canadian government issued a statement of action to address the opioid crisis, and the US Department of Health and Human Services declared the US opioid crisis a public health emergency. In North America, management strategies to combat opioid prescribing and short- and long-term effects of opioid addition are in place, but many argue that the problem has reached a very challenging point from which it will be difficult to return. Who do we target – low or high risk groups? Do we focus on prevention or treatment? What policy initiatives can be effectively instituted?

And where do we stand in the UK? Probably not far behind. It’s important that we are having this conversation now—before opioid usage, addiction, and related deaths statistics reach the same levels as in the US and Canada—not just in public health circles, but within the mainstream media too.

There are many experts disseminating the data, translating study findings for the public, and attempting to think of solutions to the important questions raised by the data. I am not one of them. However, I have learnt some important lessons from my experience of appraising an influx of opioid-related original research, review, commentary, and news articles over the past few years.

Firstly, we need to better contextualise the problem globally. Much of the data on opioids comes from prescription rates from local and/or national healthcare-based registries, but prescriptions are only one part of the problem. When we define the opioid crisis, we must also consider the use of illicitly obtained opioids. We know this group is often overlooked because accurate data on them are unavailable. But how can we begin to understand the epidemiology of a health problem where we systematically exclude over half of the cases? The same is true for opioids diverted from friends and family who have legitimate prescriptions but give them to others.

We also need to talk about disease as well as treatment. Relative comparisons of prescriptions rates over time have some value in the discussion. We know that opioid prescribing rates in the UK are on the rise. But to accurately represent the data over time, we cannot ignore parallel changes in true disease epidemiology that correspond with changes in opioid prescribing. We know that many people with chronic diseases are living longer. Arguably, some of these people will require opioids to undergo day-to-day activities.  We also know that there are increasing numbers of older people undergoing elective and emergency surgery. Some of these patients will appropriately require a short course of opioids. It seems incomplete to mention the changes in opioid prescribing without also considering the changes in medical necessity and management.

Education of health professionals, in any discipline, is welcome. As clinicians, it can be difficult to know where to start. Appropriate training is key, aimed at doctors from different specialties in various settings. There is no typical “culprit” and we are seeing opioid misusers across all specialties, including older people, pregnant women, adolescents, patients with chronic disease, and patients receiving post-operative care.

As the discussion develops politically, there needs to be a simultaneous medical discussion; doctors need to feel equipped to ask difficult questions, who to suspect, and how to appropriately de-escalate pain treatment if possible. CMAJ has published a variety of resources for Canadian doctors. Some of these are country-specific recommendations, but what we learnt was that working with our frontline physicians was key to disseminating important clinical recommendations for daily practice.

The Medicines and Healthcare products Regulatory Agency UK opioid expert group is currently reviewing all the available evidence on the use of opioids with an aim to provide information for patients and health professionals on over-prescription and misuse. In the meantime, we must continue the conversation we are having on opioid use in the UK, listen to our US and Canadian colleagues who bring a wealth of experience and lessons learnt, and most importantly, never forget that at the end of every statistic is a patient who has been affected. We must aim to do our best to better both the data and patient care.

Neil Chanchlani is a PhD candidate at the University of Exeter and associate editor, CMAJ

Competing interests: His clinical research fellowship is funded by Crohn’s and Colitis UK