Prescription Opioid Related Misuse, Harms, Diversion and Interventions in Canada: A Review

Background: The non-medical use of and harms related to prescription opioid (PO) analgesics – keymedications to treat severe and chronic pain - are an emerging public health concern globally. PO useis proportionally highest in North America, where, consequently, nonmedical PO use (NMPOU) andmorbidity/mortality are high and well documented for the United States. Canada is the country with thesecond highest PO consumption rate in the world – with steeper recent increases in PO use than the US -mainly driven by substantial increases in the use of strong opioids (e.g., oxycodone). Indications and selectdata of NMPOU and PO-related morbidity and mortality have emerged in recent years, yet a systematicand comprehensive collection of relevant data to characterize the phenomenon in Canada does not exist.Objectives: This paper comprehensively reviews the available data in Canada regarding NMPOU, andPO-related harms, diversion, and interventions, and discusses implications for interventions and policy.Study Design: Narrative literature/data review.Setting: Canada.Methods: Publicly available data and information – either from journal publications, “grey literature”(e.g., government/technical reports) or Web sites reporting relevant data on Canada - were searchedand narratively reviewed.Results: Indicators on NMPOU and PO-related harms in Canada are highly fragmented, and notnearly as systematic and comprehensive as they are in the US; virtually no national statistics/data arecollected. Available –largely provincial/local - data indicate that PO misuse is increasingly common in keypopulations, including general adult and student populations, street-drug users, First Nations/AboriginalPeoples, and correctional populations. Co-morbidities – e.g., pain, mental health problems, polysubstanceuse – among people reporting NMPOU appear to be high. Substance use treatment admissions forthose with problematic PO use have risen substantially where reported. Opioid-related mortality (andoxycodone-related mortality, specifically) have increased considerably in Ontario where relevant data fromthe mid-1990s onward have been examined. In Canadian populations reporting NMPOU, sourcing of POsoccurs through various diversion routes, including from family/friends, “double-doctoring,” or street drugmarkets. In addition, losses and theft/robberies from pharmacies and licensed medications dealers appearto be on the rise. Finally, interventions (i.e., provincial PO guidelines, prescription monitoring programs,substance use treatment services) are fragmented and inconsistently applied throughout the country, andcurrently fail to effectively address the growing problem of NMPOU and PO-related harms across Canada.Limitations: This review did not rely on systematic review methodologies.Conclusion: Corresponding to its increasing and high overall PO consumption levels, NMPOU and POrelated harms in Canada are high based on available data, and likely now constitute the third highestlevel of substance use burden of disease (after alcohol and tobacco). The data and monitoring situationin Canada regarding NMPOU and PO-related harms are fragmented, un-systematic, and insufficient.While major and concerted policy initiatives – primarily from the federal level - are absent to date, theseurgently require vastly improved national data indicators and monitoring in order to allow for andevaluate evidence-based interventions on this urgent and extensive public health problem.Key words: Prescription opioids, pain, non-medical use, epidemiology, public health, morbidity,mortality, treatment, policy, Canada