It was just a regular softball practice. Standing near second base, Sara, who was 15 at the time, watched her teammate hit a hard line drive, and before she could get her glove up, the ball flew directly into her left eye socket. She didn’t even have time to close her eye. At the hospital, doctors told Sara she had major damage to her eye, and a series of fractures to her orbital socket and along the upper left side of her face.

The first start

The fractures were healing on top of the nerve, causing pain that radiated from under her eye, into her jaw, ear, and scalp. She took Tylenol 3, which contains the opioid codeine, in the hospital that night, and was prescribed seven days worth of Tylenol 3 from the emergency department doctor. “I guess they weren’t comfortable with prescribing for more than that,” she says. The fractures were expected to take six weeks to heal completely. “Because of that,” Sara says, “they said I could just take Advil. I started taking extreme amounts of Advil and ended up getting an ulcer.”

About six months later, Sara had ongoing pain from her injury, and went to a pain clinic in Toronto, where doctors tried different medications, including nerve medications, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. “At that point, my parents and my doctors gave me very firm warnings about the paths you could go down by getting addicted to opioids,” Sara says. “At first, taking opioids felt like a failure, like I’m not able to handle my pain well enough.” Since this injury was mostly nerve pain, Sara says she never really found relief from the opioids, so the doctors decided it wasn’t worth it to continue on them.

Surgery

In 2011, Sara had surgery to remove the bone fragments that were compressing the nerve above her eye. She was given the opioid hydromorphone in hospital to manage the pain. “I had a really, really intense pain coming out of that surgery,” she says. Sara left the hospital with a prescription for a few days’ worth of hydromorphone.

Three years later, in 2014, Sara was prescribed opioids after surgery to remove a benign tumour near her eye, which was causing her a lot of pain. That time, she took hydromorphone tablets for about six weeks, prescribed first by the surgeon for two weeks, and then by the doctor at the hospital pain clinic. She followed a schedule to carefully decrease her daily dose, near the end of the prescription. She briefly took opioids shortly afterward, after getting four fillings at the dentist, which flared up the pain in her face from the softball injury. The dentist prescribed her Tylenol 3 for a few days.

The fall

The next year, in 2015, Sara slipped and fell during a hike, severely injuring her lower back. The emergency department doctor wrote her a prescription for a few days’ worth of Percocet, which contains the opioid oxycodone. After the initial pain from the injury, Sara kept reaggravating her back every four or five months. “All I had to do was lift my bag and it would give me a pain flare that would have me lying flat on my back,” she says.

The pain, Sara says, took hold in different ways. She had constant nerve pain down her legs, feet and toes, which felt like a deep tightness. Her legs would go numb sometimes. And then there was a deep pain in her bones that “felt like somebody was hammering my back at every step.” After two years of on-and-off pain, Sara had spinal surgery in the summer of 2017. She awoke after the surgery in extreme pain and was given a few different opioids while in hospital.

When she left the hospital, Sara was given a prescription for two days’ worth of opioids. “From there, we had to make an emergency visit to my family doctor’s clinic and ask her to help us with pain medication and management to make it through to our pain clinic appointment,” Sara says. “It was a very, very rough time. My pain was very out of control. It was basically like blackout pain. It was just a nightmare.”

Through the pain clinic at the hospital, Sara was prescribed opioids, but also had access to a physiotherapist and a psychologist, which together allowed her to regain the three things she was struggling with: mobility, pain, and emotions. “Stress and anxiety can worsen pain,” Sara says. “It’s really easy to get depressed in these situations. Every day, I try to stay positive. Although I fell down so far, I’m also coming back up.” Sara, who was in a wheelchair after the surgery, wondered if she would ever walk again.

Rising

When she was eventually able to walk 10 steps, Sara realized how far down she had fallen from her previously active self. She thought about how she had to leave school, which was a big part of her identity, and about the friendships she had lost. “I went from driving myself wherever I wanted and working and feeling capable and intelligent to feeling slow and confused. Everyone else was continuing with their lives and I was on pause.”

Sara’s condition improved, and she has now reduced the amount of opioids she takes. “I’m working very hard on non-pharmaceutical solutions to what I’m going through. I’m getting better, and I’m so thankful for that. My family has been so amazing throughout this whole thing. I’m so thankful for them, so I try my best to be positive.” Sara’s goal for the future is to stop taking opioids completely.

Helping

There is a stigma associated with opioids, Sara says, especially as a young person. “All we’re trying to do is cope with pain,” she says. Everywhere Sara turned, she faced questions about why she needed the medication, and about the doses. “There had to be some doctor willing to stick their neck out for you to give you an opioid prescription,” Sara says.

Three types of responses

“You get one of three reactions to an opioid: ‘It’s gross, it makes me sick, and I vomit,’ or ‘it reduces my pain, it’s a good choice.’ And then you get, ‘this feels amazing,’ and for this group, even for the low doses, it is sometimes hard for many of them to stop. You’re starting to see prescribers develop a strategy to know who is at risk in that third group. Does your patient have a history of anxiety or depression? How many drinks do they have per week? How intense is their pain? How much does the pain interfere with their life? Prescribers need to understand the subset of the population who is at risk for inappropriately persisting on their opioid medication, and those for whom the opioid provides benefit.”

“How easy is it for the people in the first two groups to stop taking opioids? It is usually dose-dependent. We do a good job of prescribing, but not as good of a job describing and managing the potential consequences.”

Starting on opioids

“When it comes to the family physician, based on the data, it appears as though we have developed a practice where we sometimes treat chronic [long-lasting] pain the way we treat acute [sudden] pain. I think primary care doctors should do their best to move away from the prescribing of opioids for chronic pain as a first-line treatment. By using guidelines such as the Canadian Pain Society neuropathic pain guidelines, patients can be started on other classes of drugs, and move the opioid medication into the background. The need for the opioid can be reassessed based on the patient’s response.”

“Looking at the variation and complexity of surgical interventions, there is a wide variation in postoperative prescribing practices by surgeons. Some surgeons prescribe only Tylenol 3 [containing the opioid codeine] and others send patients home with prescriptions of hydromorphone.

From a harm reduction standpoint, there are grounds to question these practices. Perhaps it’s best to discharge patients with a less potent opioid when clinically appropriate.”

“From the dentists’ and dental surgeons’ perspective, other than after maxillofacial surgery [such as surgery for a broken jaw] or facial reconstruction, is there a need to prescribe opioids?

There are very effective and potent anti-inflammatory medications in conjunction with acetaminophen that can be used to manage pain effectively after tooth extractions and root canals. Use of opioids in these situations should be avoided if at all possible.”

A plan to stop

“An informed discussion regarding the risks of opioids, as well as how to wean off your medication, should be had at the outset of prescribing opioids. The rare but most serious complication is that you might die from respiratory depression. After that, it’s that you’re going to develop physiological tolerance and stay on them long-term. When you start on opioids, you need to know how to stop. Even if you’re on an opioid for two weeks, you might experience some withdrawal symptoms when stopping.”

Other options

“When it comes to the treatment of chronic pain conditions, we must ensure that we start with non-pharmacological and non-opioid medication options before we jump to an opioid medication. The options are many – massage, physiotherapy, ice, heat, acetaminophen, muscle relaxants, anti-convulsants, antidepressants, cannabinoids – there’s a whole host of possibilities, some are covered by the government currently, while others are not. Most importantly, let’s not forget to mention the psychological impact on people suffering with chronic pain, and the role of psychotherapy and mental health interventions. Patients often discover that once they add several non-opioid options, they gain even more control over their pain and improve their quality of life.”

“It began last year when I was walking the dog. It was Boxing Day. I slipped on black ice and fell hard. I went back to work, but the pain wasn’t getting any better, so I went in for an X-ray. They confirmed that I had fractured one of the vertebrae in my spine. But what they also saw was a very large mass in the right upper lobe of my lung. It had essentially occupied half of my lung, and had pushed my heart over to one side. The panic that ensues when you know what it might be was pretty intense.”

“I had no symptoms from it because I had run a half-marathon three weeks before, and skied two weeks before. The thoracic surgeon organized a biopsy, which confirmed that this was a benign type of tumour, but it was compressing my heart and other things, so it needed to come out. It was 16 centimetres. If I had let it go another centimetre, I would’ve had the largest one ever [at that hospital].”

A pain crisis

“The surgery was long and complicated – a nine-hour procedure. I lost 13 units of blood. The recovery in hospital was relatively easy. I was in for three days. The problem was when I went home, within 48 hours, I was in a terrible pain crisis. They had to cut into my neck to get the tumour out, so I was having terrible arm pain. There was also a burning pain, like someone scalded my skin. At that time, I was on 30 milligrams a day of the opioid hydromorphone, and that just wasn’t cutting it.”

“I had a good family doctor, and spoke with him and with the surgical team, and between the two of them they agreed to adjust the medication. It was escalated, but it didn’t really have much effect on relieving the pain. What it did produce was tiredness, and severe constipation – a terrible side effect of opioids.”

“I went to that emerg, and they suggested that I see the pain management team. In that visit, we came up with a plan, which was to provide adequate opioids, but supplement that with medication which would relieve some of the neuropathic [nerve] pain, and also begin to cut down on some of the anxiety, because the more pain you get, the more anxious you get. At my peak when I was unwell, I was on 120 milligrams a day of hydromorphone, which even for my practice in cancer care is a pretty big dose.”

Reducing the dose

“The major challenges in reducing pain meds don’t happen immediately, but as you get down to almost nothing you get problems with withdrawal. I knew what to expect, but it didn’t make it any easier. You feel fluey. You feel hot and cold, tired and shaky. There are medications that can help with some of those effects and they work pretty well. But I also had the commitment to myself and my family that drugs alone cannot make you better. You don’t always need a doctor – what you need is knowledge and understanding about the problem.”

“In time, and with some physio and mindfulness training, I was able to gradually get the dose down. My goal was really threefold: I wanted to restore my health, I needed to get back to work because I needed some purpose in what I was doing, and I needed to be more like the family person I was before. When you lose control and you’re not who you are, it’s very disturbing. We began reducing the doses of the opioids, in a scheduled and logical fashion. Over a period of the next three or four months, I was able to get off all opioids. I still take Tylenol. I went back to work full-time and competed in a marathon with two of my daughters.”

More than medication

“Getting the right care by the right team, and having strong family support, all of those components are important. What you do not want to do is rely on medication only. It doesn’t work. It has long-term potential serious side effects and you don’t need it. What you do need are alternative strategies. I’m very lucky, I didn’t have a malignant tumour. But I know there are a lot of people who have extensive surgery like I had who have a tough time getting off pain meds, and that’s a tragedy of our system, because it doesn’t have to be that way.”

“Before I had the surgery, I thought, I’d have the diagnostics and then the surgery, and the rest is kind of icing. I learned that’s not the case. Pain and symptom management are an essential component of major surgery. Full stop. When you haven’t gone through that, you don’t really appreciate it. The alternative is you would probably end up on opioids forever, and that’s not acceptable.”

“I’m not perfect now, but I come to work every day, and I’m happy that I’m able to do more of the things that I was doing before. My daughters and I are doing another run together, a half-marathon in Key West in January. Will I ever be 100%? Maybe not, but that’s OK, too. My only regret is that I asked for my specimen as a paperweight and I couldn’t get it.”

When starting a patient on opioids, Dr. Frank Warsh always keeps three things in mind: the patient’s preferences, the opioid prescribing guidelines, and the patient’s own body.

Every patient is different, and there’s a range of responses to different opioids and doses, Warsh says. A patient who has been taking moderately high doses of opioids might be functioning well, while another patient could take a much lower dose and experience serious side effects. The London-based family doctor is confident in his ability to prescribe the right dose, duration and type of opioids, as long as he takes the time to assess the patient carefully. He is especially careful to make sure he is considering the patient’s preferences in his decision-making process.

Some of the most difficult prescribing decisions for Warsh are those for patients who have pain but also a history of problematic drug use. “One patient I can recall had a history of drug addiction, and she previously had opioids cut off because of so-called ‘red flag’ behaviours,” Warsh says. “The patient had diabetes, though, and over time developed nerve damage. No doubt about it, she was in pain. She tried all the other modalities in good faith – physiotherapy, mindfulness, and non-opioid medications – but nothing worked. What do you do? In the end I contracted with the patient to take opioids daily at the pharmacy. Over time, we found a dose that worked and let her take the medications at home because she demonstrated that she was using them as prescribed.”

Warsh says it’s more challenging when patients have multiple health conditions, past trauma, and other issues. “Maybe they shouldn’t have been prescribed opioids in the first place,” he says, “but they were, and now they are where they are.”

The Methods Notes provide a brief description of the methods used in this report. 

Data sources

The analyses for this report were conducted by the Institute for Clinical Evaluative Sciences (ICES) and included data from the following administrative databases; the Narcotics Monitoring System (NMS), the Corporate Provider Database and the Registered Persons Database. Population estimates were from Statistics Canada. For more detailed descriptions about each database used, please see the Technical Appendix.

Narcotics Monitoring System, Ministry of Health and Long-Term Care

The Narcotics Monitoring System is a transaction-based system that collects dispensing data on opioids, controlled substances, and other monitored drugs from pharmacies and other dispensaries across Ontario. The information collected in the NMS includes prescriber identification, patient identification, pharmacy and pharmacist identification, date the drug was dispensed, drug identification number and the amount of drug dispensed. The NMS does not include information about monitored drugs dispensed to an in-patient of a public hospital or to prisoners or inmates (i.e., prescriptions written for people confined to correctional institutions, penitentiaries, prisons or youth custody facilities). The Ministry of Health and Long-Term Care maintains the NMS, which began collecting data in April 2012, and reporting became mandatory July 1st, 2012.

Corporate Provider Database, Ministry of Health and Long-Term Care

The Corporate Provider Database (CPDB) is a repository of healthcare provider data. The CPDB contains information on the providers’ reported specialties and postal code of practice. The Ministry of Health and Long-Term Care maintains the CPDB, with the College of Physicians and Surgeons of Ontario providing regular updates on provider credentials.

Registered Persons Database

The Registered Persons Database (RPDB) is a historical listing of the unique health numbers issued to each person eligible for Ontario health services. This listing includes corresponding demographic information, such as date of birth, sex, address, and date of death (where applicable). ICES creates an enriched postal code dataset that uses RPDB postal code data in conjunction with other administrative data holdings to generate the best known postal code on July 1st of each year for eligible individuals in the RPDB.

Population estimates, Statistics Canada

Population estimates for Ontario and LHIN regions from Statistics Canada Table 109-5355 – Estimates of population (2011 Census and administrative data). CANSIM Accessed July 2017.

Analysis

Prescribers

The report focuses on opioid dispenses and recipients among Ontario healthcare professionals who prescribed opioids to control non-palliative pain. This is a count of the number of healthcare professionals who prescribed at least one opioid drug in one of the included years (2013, 2014, 2015, 2016) excluding prescriptions that were for people who had received palliative care in the previous year, prescriptions that were to manage opioid use disorder (methadone maintenance treatment or suboxone) and prescriptions for cough medications that contain opioids. Information on the prescriber type was drawn from the NMS and from the CPDB (for physicians). In the report, we group prescribers into family physicians, surgeons, dentists and other doctors and other non-doctors (for example, the “other doctors” category includes internal medicine, psychiatry, and other physician specialties as well as doctors practising family practice and surgery but are missing these codes in the ICES data. Examples of professions included in the “other non-doctors” category includes nurses and pharmacists).

Exclusions (palliative care services, treatment of opioid use disorder, cough formulations containing opioids)

This report focuses on prescriptions for opioids that were to control non-palliative pain. As such, we excluded prescriptions that were to manage opioid use disorder, prescriptions for cough medications that contain an opioid and prescriptions that were to patients who had received palliative care. Prescriptions filled were categorized as being for palliative care if the patient had received a palliative care service in the prior 12 months either in hospital or from a physician. Prescriptions that were either for methadone for maintenance therapy or that were for naloxone/buprenorphine (suboxone) were excluded since they are for the management of opioid use disorder. Prescriptions that were for cough formulations that included an opioid were excluded since they were presumed to be for managing cough.

Opioid recipients

The report also describes the number of people in Ontario who were prescribed and dispensed at least one opioid drug to control non-palliative pain in 2013, 2014, 2015 or 2016. The total number of people prescribed an opioid is reported as well as the number of people prescribed by one of the prescriber groups. A person will be counted only once in the total provincial number for any one year. When reporting numbers of recipients by provider type, a person will be counted once for each provider group. As such, the sum of people prescribed an opioid by provider type will be greater than the provincial number. Rates per population are calculated by dividing the number of individuals who were prescribed and dispensed an opioid by the size of the population in Ontario or in the LHIN region and are reported using a 10,000 population denominator.

Opioid dispenses

The report describes the number of dispenses for opioid drugs to control non-palliative pain in 2013, 2014, 2015 or 2016. The measure was calculated as a total count as well as a count by prescriber type. The counts and rates per population were reported for Ontario and the 14 individual LHINs. Rates per population are calculated by dividing the number of dispenses for opioid drugs by the size of the population in Ontario or in the LHIN and are reported using a 10,000 population denominator.

New starts

The report describes prescriptions that were categorized as new starts for patients. For a person to be considered as newly started on an opioid, they had to have not been prescribed an opioid to manage pain in the six months prior to the prescription. The look back excluded prescriptions that were for cough medications that contained opioids or prescriptions for methadone maintenance treatment or suboxone. Patients who were identified as having received palliative care in the 12 months prior to the index prescription in a given year were also excluded. In this report, we further classified the new starts by dosage (morphine equivalents), days supplied and the type of opioid prescribed.

Days’ supply

For all new starts, the days’ supply field in the NMS estimates the number of days of treatment and was used to categorize the days supplied for a patient by a prescriber. For patients who were newly started on an opioid, if they filled prescriptions for the same opioid by the same prescriber more than one time on the same day, the days supplied for the two prescriptions were added together to calculate a total days’ supply. Days’ supply were categorized into 3 or fewer days, 4–7 days, 8–14 days or greater than 14 days supply.

Dosage (morphine equivalents)

For all new starts, the dosage or morphine equivalent (MEQ) daily dose was calculated based on the type of drug prescribed, the days supply and the quantity. For patients who were newly started on an opioid, if they filled prescriptions for the same opioid more than once or two different opioids by the same prescriber on the same day, the sum of the days’ supply and quantity were used to calculate the MEQ. MEQ was categorized into less than or equal to 50 MEQ, 51-90 MEQ or greater than 90 MEQ.

Drug type

For all new starts, the type of drug prescribed was identified using the DIN (Drug identification number) in the NMS. The opioid types included in this report were:

• Codeine
• Codeine combinations
• Fentanyl patches and tablets
• Hydromorphone
• Meperidine
• Morphine
• Oxycodone
• Oxycodone compounds
• Tramadol
• Methadone for pain
• Other

Health Quality Ontario thanks Sara, Sheldon, Dr. Frank Warsh and Dr. Hance Clarke for sharing their experiences and insights for the quotes and stories in this report.

This report was developed by a multidisciplinary team from Health Quality Ontario, including Michael Beckett, Susan Brien, Sara Clemens, Naushaba Degani, Gail Dobell, Ryan Emond, Terri Goveia, Louise Grenier, Michal Kapral, Ryan Monte, and Binil Tahlan.

Health Quality Ontario thanks the many dedicated people who contributed to this report, including those who reviewed drafts or provided input at different stages of development: Maureen Boon, Bjug Borgundvaag, Hance Clarke, Maaike de Vries, Mario Franco Elia, Tara Gomes, Jordan Hunt, Karey Iron, David Kaplan, Mae Katt, Pamela Leece, and David Mock.

Notes: Some of the indicators in this report were derived using health administrative datasets from Ontario. These datasets were linked using unique encoded identifiers and analyzed at ICES.

ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the Ontario Ministry of Health and Long-Term Care is intended or should be inferred.