By Barry Ulmer, Chronic Pain Association of Canada

True or false? Doctors triggered our overdose crisis. Duped by pharma, they overprescribed narcotic pain relievers and turned innocent patients into addicts. Now we have a black market of stolen prescription drugs — they remain the problem — with a little heroin and street fentanyl mixed in.

True, says Health Canada, whose policy since 2016, made behind the backs of doctors and patients, has been to squeeze prescription opiate supply. Never mind that two million Canadians with serious pain can’t get effective treatment anymore, since most don’t need it anyway.

False, says science. Bad pain can need opiates when nothing else works. By choking legal supply in its haste to curb overdose rates and raise its own ratings, government lit a match to an illicit supply (meth, cocaine, heroin, narcotics) on slow boil since at least 1980. Fierce prescribing cuts now drive a robust black market of cheap heroin and street fentanyl, and a parallel crisis of untreated pain and suicide.

Who’s right? Here are the facts: since 2011, opioid prescribing has tanked while deaths still climb. Street drugs kill. Prescribed drugs don’t. Slashing prescriptions to contain addiction is daft.

Why hide the truth? Why torture people with pain and ignore illicit drugs? Doesn’t government want to combat preventable deaths? For years, we’ve asked Health Canada just that.

They dodged us at every turn. (Just listen to our bizarre 2018 call with the Minister's office.) Eventually, they sent us a list of studies they said justified deprescribing. In June 2019, we sent back our evaluation of the list. It didn’t match theirs. They said they’d get an assessment from independent experts. They didn’t. Then they said they had more research, a big batch; they’d send that, too. They didn’t.

Our Freedom of Information Request

In February, we filed a freedom of information request. We asked for specifics — studies, research, correspondence — that back Health Canada’s claim, as of 2016, that prescribing leads to overdose deaths.

Since we know the medical literature, we knew not to expect much. But this past September, we got 2,928 pages — sort of.  About a third were redacted: long series of pages along with almost all study publication dates, bibliographic details, and online links. It was padded with stuff like a 466-page global report from the UN in three languages. Most of it had nothing to do with what we’d asked for.

Most of it was also published long after 2016 — so it can’t have led to the official start of deprescribing. Only a quarter of it was Canadian, mostly an echo chamber of federally-funded agency reports all quoting each other, with some government-funded guidelines thrown in.

There was no correspondence whatever and little independent research. The bulk of it wasn’t research at all, just a circle jerk of commentary and opinion.  Here’s what we got:

• Mostly US/some UK stuff — commentary, media reports, policy, guidelines, limited research

• Papers using CDC drug abuse stats that CDC corrected and downgraded long ago

• Studies using outdated definitions of “opioid use disorder” that make everyone a “substance abuser”

• Duplicated and even triplicated papers

• Foreign-language papers

• Pre-publication “author manuscripts,” some unproofed and incoherent

• Observational rather than experimental studies

• Papers whose data and fine print directly counter their conclusions

• Papers drawing “new” conclusions by cherry-picking old literature

• Researchers quoting their own work as authoritative

• Papers asserting without documenting the dangers of opiates

• Studies drowning in limitations (which their authors often acknowledge)

• Government statements on generalities, synthesizing other government statements on generalities

• Hand-wringing from six Ottawa-funded agencies, and research these agencies funded in turn

• Serial papers from a handful of Health Canada-preferred researchers

• Much heavily-redacted head-scratching on cannabis

• Studies on acute — not chronic — pain

• Papers blaming patients for their pain

 What on-point studies we got often champion opioids.

Those that don’t typically reiterate prevailing anti-opioid claims, downplay the devils in their details, hype their conclusions, and are compromised by their authors’ conflicts of interest. (These conflicts are usually disclosed, since joining the bandwagon is valued over bias risk.)

On-topic items make our case, not Health Canada’s:

• Half of Canadian adults with chronic pain (a third with “very severe” pain) have suffered for 10 years plus

• Five comprehensive studies of studies (Cochrane reviews) plus a large German review endorse opioids    for five types of chronic pain; four more Cochranes didn’t find useable studies on other pain types

• Two Cochranes plus Canadian research say drugs used to combat substance abuse don’t relieve pain

• Newfoundland’s OxyContin Task Force report on six OxyContin-involved deaths in four years concludes that properly-prescribed pain medications are safe and effective

• With doses now “under the recommended thresholds, most US providers are careful in their prescribing”

• British Columbia, Alberta and Ontario coroners find repeatedly that most overdose deaths involve street fentanyl

• Early prescription use does not predict addiction in Vancouver IV drug users, some of whom develop pain after they begin using

• US data can’t predict addiction and death rates in Canada

• “Dental Rx’s addict young people” is a tooth-fairytale, say three studies. In one, just one of 97,462 kids  who got prescribed opioids after wisdom tooth surgery died within a year — cause not specified

• A review of 38 studies pegs “problematic use” at “<1 to 81%” (it’s entirely redacted)

• Claims of “significant increases” in prescription opioid abuse aren’t quantified. One “huge increase” was of low-dose formulations

• Guesstimates and “author consensus” fill data gaps. An Ottawa-funded researcher’s three papers all call for continued prescription slashing while acknowledging a serious lack of data

• Canadian researchers who routinely disparage opiates for pain tend to be just two or three government- funded teams mining a single public Ontario database to write variations on their theme

• Physical dependence is routinely called “opioid use disorder.” Occasionally, the distinction appears in small print. Clarification by the head of the US National Institute on Drug Abuse is here but redacted

• Three Canadian reports plus one from Seattle say “one-size-fits all” dosing is dangerous and “significantly” hikes overdose risk; cuts to legal supply since 2016 risk destabilization of patients; prescription slashing leads to the end of care

• A 2020 Canadian investigation into bias in “pro-opioid” prescribing guidelines conveniently stops just short of investigating bias in the “anti-opioid” American and Canadian guidelines of 2016 and 2017

• A Canadian sociologist tracks 20 years of news to show how “overprescribing” became a hot button. Our top three news outlets didn’t mention “inadequate pain care” until 2016. “Legitimate users” were either “dependent” or had overdosed on their prescriptions

• “Twenty-five years of pain education research — what have we learned?”: All 13 pages redacted

A descriptive list of all the items we got, and the release itself, are available on request.

What we didn’t get are the many large studies that sandbag Health Canada’s deprescribing policy, like these:

• Risks of developing persistent opioid use after major surgery are tiny

• In a huge sample, mortality risk from overdose is just 0.022% annually

• Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in BC

• Illegal street drugs, not prescriptions, now powering opioid abuse

• New survey data confirm that opioid deaths don’t correlate with pain pill abuse or addiction rates 

Health Canada has ignored pertinent studies that don’t suit them and misread others. No careful, independent research endorses deprescribing for any reason, and certainly not as a means to contain overdoses.

Health Canada provided its research only after years of hedging, when we finally resorted to an FOI request— and then only after six months. We believe they had no list and compiled one retroactively, especially since they padded it with off-topic items and with items that postdated their policy.

Prescribing practice and regulation in Canada is now based on the low-quality “investigations” of partisan, government-paid researchers. Canadians deserve better. Now that quality research unequivocally endorses their treatments, Canadians with pain must have effective care restored to them NOW. 

Barry Ulmer is Executive Director of the Chronic Pain Association of Canada, a patient advocacy group