Norm Buckley, Scientific Director at the Michael G. DeGroote Institute for Pain Research & Care, and Jason Busse, Director of the Michael G DeGroote National Pain Centre at McMaster University, discuss the complexities of chronic pain management and addressing the opioid crisis
The National Advisory Council on Prescription Drug Misuse was formed to address the opioid crisis in Canada. Led by the Canadian Centre on Substance Abuse (now known as the Canadian Centre on Substance Abuse and Addiction), the Coalition on Prescription Drug Misuse (Alberta), and the Nova Scotia Department of Health and Wellness, in partnership with Health Canada’s First Nations and Inuit Health Branch’s Prescription Drug Abuse Coordinating Committee (PDACC), the Council released First Do No Harm: Responding to Canada’s Prescription Drug Crisis in March 2013. Half of the recommendations addressed issues regarding chronic pain, recognizing the link between opioid prescribing and chronic pain. The Council recommended establishing competencies for healthcare professionals, improving healthcare professional curricula for pain and addiction, ensuring access to optimal care for pain as well as addiction, and supporting research that would optimize evidence-based care of patients.
First Do No Harm set out a national strategy addressing both pain and mental health issues, including addiction. For several reasons, it was difficult for governmental bodies to assign (or assume) organizational responsibility for the issue. Was it a law enforcement issue addressing illegal substances and diversion, or was it a health issue recognizing addiction as a health issue and the physical and social harms arising from covert usage of substances? When the substances are also prescribed for conditions including pain, where does the responsibility lie? Is optimal treatment for pain and mental health disorders available throughout our geographically and socially diverse country?
Collaborative efforts to address the opioid crisis
In September 2016, the Canadian Institutes of Health Research (CIHR) hosted a Pain Summit. The objectives were to identify opportunities to enhance the impact, coordination, and infrastructure of pain research across Canada, to inform the development of an evidence-based Canadian pain research agenda, and to encourage the development of new collaborations and initiatives. Unfortunately, after this Summit, the leadership at CIHR changed at multiple levels, including the most senior, and the recommendations of the Summit were not pursued.
In November 2016, an Opioid Conference and Opioid Summit were co-hosted by the Federal Minister of Health, the Honourable Jane Philpott, and the Ontario Minister of Health and Long-Term Care, the Honourable Eric Hoskins. This was a national dialogue on actions to address and reduce the harms related to opioids in Canada.
The Summit brought together over 30 organizations and nine provincial/ territorial ministries of health, resulting in the Joint Statement of Action to Address the Opioid Crisis. Organizations made commitments to address those issues within their control- for example, the Association of Faculties of Medicine of Canada (AFMC) undertook to review medical curricula and enhance content in the areas of pain, addiction, and appropriate prescribing. Federal legislation shifted the focus on substance use from enforcement to public health. The National Anti-Drug Strategy became the Canadian Drugs and Substances Strategy. In the 2017 budget, one hundred million dollars was invested in the strategy over five years, with an ongoing annual budget of $22.7m and supplements to British Columbia and Alberta, two provinces particularly hard hit by the opioid crisis. Health Canada’s Substance Use and Addictions Program (SUAP) provides financial support to provinces, territories, non-governmental organizations, and key stakeholders to strengthen responses to Canada’s drug and substance use issues regarding health promotion, prevention, harm reduction, and treatment.
Through SUAP, projects have been undertaken to address problematic opioid use, including McMaster University’s update of the Canadian Guideline for Opioids and Chronic Non-Cancer Pain, released in May 2017. In June 2017, a SUAP call for proposals was launched to address substance use issues related to licit and illicit psychoactive substances, with a particular focus on opioids. Federal Ministers of Health hosted roundtable discussions beginning in July 2017 with people directly impacted by the crisis, including frontline workers and people with lived and living experience, to discuss the root causes of problematic opioid use, barriers to seeking support, best practices, and ways to address stigma. Legislative changes streamlined application requirements for supervised consumption sites, required registration to import pill presses, provided the ability to quickly control new dangerous substances entering the illegal market, allowed the opening of mail weighing 30g or less if suspected of containing unauthorized controlled substances and offered legal protections for individuals who seek help during an overdose (the Good Samaritan Act).
Through the CIHR, the Government of Canada supported the development of a National Guideline for the Clinical Management of Opioid Use Disorder. New Public Health Programming assigned $5 billion over ten years to provinces and territories for mental health and addiction services and new funding for community-based initiatives to reduce rates of hepatitis C and HIV among people who use drugs. In September 2018, Federal Health Minister the Honorable Ginette Petitpas-Taylor convened a national Opioid Symposium with a focus on people with lived experience, including four panels organized by the Canadian Association of People Who Use Drugs, Moms Stop the Harm, Community Addictions Peer Support Association, Pain BC and the Chronic Pain Network. The presentations highlighted the importance of listening to the people most impacted by the crisis and meaningfully involving them in developing effective solutions.
Canadian Pain Task Force
Minister Petitpas-Taylor, Health Canada, and federal partners committed to exploring the establishment of a Pain Task Force, addressing the stigma associated with opioid use, and exploring options for safer alternatives to the contaminated drug supply. The Canadian Pain Task Force was announced in March 2019 and delivered its first report in June 2019 and its final report – An Action Plan for Pain in Canada – in June 2021. Significant attention has been directed at the recommendations, including allocating $5 million to raise public awareness and create a national body (Pain Canada), peer support networks, and strategies nationwide. Safe supply initiatives, supervised injection facilities, decriminalization of possession and use of substances, update of opioid prescribing guidelines, guidelines for the medical use of cannabis products, increased availability of interdisciplinary treatment for chronic pain, expansion of peer support networks, mentoring networks for clinicians, increased curriculum attention to pain and addiction and increased continuing education for healthcare professionals have been implemented to various degrees at local, provincial and national levels. Sadly, despite these strategies, deaths associated with the use of substances, especially those contaminated by highly potent illicitly produced opioids, have continued to rise. The social stigma for patients with substance use issues, mental health disorders, and chronic pain attending healthcare settings has not been resolved. Clinical practice guidelines for opioids and chronic pain, claiming to use the same evidence and processes, provide conflicting recommendations. Interventions to mitigate harms associated with recreational drug use (e.g., safe supply, supervised consumption sites) are often viewed through political biases rather than evidence.
Management of chronic pain and the use of opioids, both therapeutically and recreationally, remain complex and contentious topics that will require ongoing collaboration among patients, clinicians, researchers, and policymakers. Efforts to improve concordance between evidence and practice are an urgent priority.
