1. 2012;15;ES191-ES203Prescription Opioid Related Misuse, Harms, Diversion and Interventions in Canada: A Review
   Narrative Review
   Benedikt Fischer, PhD, and Elena Argento, MPH.

BACKGROUND: The non-medical use of and harms related to prescription opioid (PO) analgesics – key medications to treat severe and chronic pain - are an emerging public health concern globally. PO use is proportionally highest in North America, where, consequently, nonmedical PO use (NMPOU) and morbidity/mortality are high and well documented for the United States. Canada is the country with the second 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 select data of NMPOU and PO-related morbidity and mortality have emerged in recent years, yet a systematic and 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, and PO-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 searched and narratively reviewed.

RESULTS: Indicators on NMPOU and PO-related harms in Canada are highly fragmented, and not nearly as systematic and comprehensive as they are in the US; virtually no national statistics/data are collected. Available –largely provincial/local - data indicate that PO misuse is increasingly common in key populations, including general adult and student populations, street-drug users, First Nations/Aboriginal Peoples, and correctional populations. Co-morbidities – e.g., pain, mental health problems, polysubstance use – among people reporting NMPOU appear to be high. Substance use treatment admissions for those with problematic PO use have risen substantially where reported. Opioid-related mortality (and oxycodone-related mortality, specifically) have increased considerably in Ontario where relevant data from the mid-1990s onward have been examined. In Canadian populations reporting NMPOU, sourcing of POs occurs through various diversion routes, including from family/friends, “double-doctoring,” or street drug markets. In addition, losses and theft/robberies from pharmacies and licensed medications dealers appear to 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, and currently 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 PO-related harms in Canada are high based on available data, and likely now constitute the third highest level of substance use burden of disease (after alcohol and tobacco). The data and monitoring situation in 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, these urgently require vastly improved national data indicators and monitoring in order to allow for and evaluate evidence-based interventions on this urgent and extensive public health problem.