1. Brian Emerson Medical Consultant, Population and Public Health Division BC Ministry of Health 250.952.1701 brian.emerson@gov.bc.cabrian.emerson@gov.bc.ca Opioids - A Public Health Priority 1

2. Disclosures Ministry of Health employee Co-chair, Prevention Implementation Team, First Do No Harm national strategy on pharmaceutical drug harms Member FPT Working Group Prescription Drug Abuse No pharmaceutical company or other commercial connections Have grown poppies 2

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4. Outline 1. Context/Problem Historical, International, National 2. BC Perspective 3. Interventions 4. Role of Public Health, particularly Public Health Physicians 4

5. Key Messages Chronic pain widespread and challenging. Pharmaceutical company promotion drove widespread and high doses prescribing. Increasing population levels of consumption correlate with increasing mortality and morbidity. Consequence - iatrogenic epidemic of opioid associated overdoses, deaths, and addiction. 5

6. Key Messages Outnumber impairment-related MVC deaths in BC. Significant cause of premature life lost. High daily dose important risk factor. Substantial prevention opportunity. Comprehensive, coordinated approach needed. Public health physicians important role to play. 6

7. Historical, International, National Perspectives Chronic pain widespread – approx. 20% prevalence, definitional challenges. Bio-psycho-socio-economic components. “Adverse selection” – Those most likely to receive long term opioid therapy are also those most at risk of developing problems with use. 7

8. Historical, International, National Perspectives 1990s deceptive and aggressive pharmaceutical company promotion of opioids for treating chronic pain, using palliative cancer treatment paradigm Purdue fined $634 million Result - opioids prescribing widespread and using long term and high dose therapy Consequence - iatrogenic epidemic of opioid associated overdoses, deaths, and addiction 8

9. Historical, International, National Perspectives Been here before – latter half of 1800s opioid consumption soared 540% - minimal regulation, iatrogenic morphine addiction. Multiple measures introduced. Physician educable “By 1919, narcotic overprescribing was the hallmark of older, less competent physician.” (Kolody et al 2014) National initiatives have been working in the last 3 years to coordinate efforts across the country (First Do No Harm strategy and FPT work, recent cross- jurisdictional fentanyl work). 9

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12. Prescription Opioid Analgesic Use Among Adults: United States, 1999–2012 NCHS Data Brief ■ No. 189 ■ February 2015 http://origin.glb.cdc.gov/nchs/data/dataBriefs/db189.pdf 12

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15. Highest consumption countries 2011 (mg per capita of morphine equivalence) Canada 810 United States 750 Denmark 485 Australia 430 http://www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf http://www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf page 30. 15

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18. 20-year study period, 5935 people whose deaths were opioid-related in Ontario. The median age at death was 42 years, 64.4% were men and 90.0% lived in an urban neighborhood. During study period, opioid-related death increased dramatically, rising 242% from 12.2 deaths per million in 1991 (127 deaths annually) to 41.6 deaths per million in 2010 (550 deaths annually). 18

19. Annual Rate Opioid Mortality Ontario 1991-2010 19

20. Proportion Opioid-related deaths by age group 1992, 2001, 2010 20

21. Summary points Lack of evidence of effectiveness for opioids to treat chronic non-cancer pain when used over long durations, increasing concerns regarding addiction and overdose. Considerable societal burden - most opioid- related deaths occur in people younger than 55 years of age. Recreational use of opioids among adolescents increasing, approximately one in seven high school seniors and university students reporting past non-medical use of these drugs. 21

22. By2010 opioid-attributable YLL (21 927 years) exceeded that to alcohol use disorders (18 465 years) and pneumonia (18 987 years), and greatly exceeded that from HIV/ AIDS (4929 years) and influenza (2548 years) in Ontario. One in eight deaths among young adults were attributable to opioids underlines the urgent need for a change in perception regarding the safety of these medications. 22

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25. BC Perspective Major and possibly increasing contributor overall accidental overdose deaths. Approximately 100 accidental prescribed pharmaceutical opioid-associated deaths/year out of annual average of 300 accidental poisoning deaths in BC (2006 to 2010). Outnumbers deaths due to alcohol-related motor vehicle crashes ( MVC= 63 in 2013). Total pharmaceutical opioid related deaths/yr approximating all MVC deaths (MVC=270 in 2013) Significant cause of premature life lost (most occurring in individuals aged 40 to 59). 25

26. Kolodny et al 2015 26

27. Interventions Primary Prevention – Prevent new cases Improve medical practice to reduce exposure – prescribe more cautiously – prescriber education, correct misperceptions of safety – under appreciated risks and exaggerated benefits – lack evidence effectiveness and evidence of risks Guidelines, standards. Washington State “Yellow flag” at 120 mg/day morphine equivalent dose for new patients with chronic pain. Reduce non-medical exposure – prescribe more cautiously – less supply for diversion, change risk perception 27

28. Primary Prevention Continued Improve GP access to pain specialists. Provide “pain proficiency” training to GPs, who then become mentors/consultants, particularly in rural areas. Identify inappropriate prescribing. 28

29. Secondary prevention – Early identification of people with possible opioid use disorder – use Prescription Monitoring Programs Use prescription data combined with insurance restrictions to prevent “doctor shopping”. 29

30. Tertiary prevention – prevent OD deaths, deterioration, infections etc. Improve treatment - remove barriers to medication assisted treatment i.e. methadone, expand access to buprenorphine Increase access to overdose “harm reduction” programs and naloxone i.e. take home naloxone. Watch for unintended consequences – shift to heroin use, other potent opioids, non- pharmaceutical fentanyl.. 30

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32. DISCUSSION - Role of Public Health, particularly Public Health Physicians 1. Health Promotion 2. Health Protection 3. Prevention – primordial, primary and secondary 4. Harm-reduction 5. Health Assessment and Surveillance 6. Emergency Preparedness and Response 7. Research 8. Services for people who develop problems with substances 32