After peaking in 2016, the number of opioid prescriptions is declining, noted The duty by studying RAMQ data. But many problems persist on the ground, experts note.
“I see a clear improvement in the safety prescription, but I think we could do much better,” says the DD Anne-Marie Pinard, holder of the Chair of Leadership in Chronic Pain Teaching and anesthesiologist at the University Hospital of Quebec.
When she started practicing, at the turn of the 2000s, the DD Pinard saw patients arriving with “absolutely spectacular doses”. It was “the time sky is the limit “, she says, shaking her head, a time when doctors still believed that opioids were not addictive. “There are lots of things we didn’t know. »
Quietly, studies have come to demonstrate the opposite. People died in what became known as the “opioid crisis.” There have been lawsuits against pharmaceutical companies. Doctors adopted guidelines and began to change the way they did things. But it took time “before the message spread,” she explains.
Reduction in prescriptions
Figures from the Régie de l’assurance santé du Québec (RAMQ), obtained by The duty, bear witness to this slow evolution. In 2010, just over 332,000 distinct patients went to pharmacies to get prescription opioids. This figure increased until 2016, when Quebec reached a historic peak, with more than 380,000 patients. However, considering the number of patients registered with RAMQ drug insurance, the percentage of people using prescription opioids has still decreased.
Since then, the figures have been falling again, with a significant and sudden dip in 2020, a pandemic year, when the majority of operations were canceled. The latest figures, which are from 2022, indicate that there were 345,014 distinct patients taking opioids. That’s still a bit more than in 2010, but still represents a decrease of almost 10% from the 2016 peak.
But, if we take into account the number of patients registered for RAMQ drug insurance in 2010 and 2022, we note that the percentage of people consuming prescription opioids has still decreased.
I see a clear improvement in the safety prescription, but I think we could do much better.
Indeed, their number, which increased from 3.3 million in 2010 to 3.9 million in 2022, allows us to observe a decrease in prevalence between 2010 and 2022, going from a little more than 10% to 8, 85%, with a peak of 10.6% in 2016.
When we consider the number of molecules prescribed, we arrive at a slightly higher number of patients, which suggests that the same patient can be administered several opioids.
The data do not indicate in which circumstances the different molecules are prescribed, namely whether it is to treat acute postoperative pain or for chronic pain. “A patient who takes three times less opioids than in 2017 is a patient who is doing better, but he does not appear in the statistics, so it is difficult to make the figures speak,” underlines the DD Anne-Marie Pinard.
Furthermore, these figures only represent patients who have RAMQ drug insurance — almost half of the population — and not those who have private insurance.
Maintain balance
“With what I see in my practice, I would have expected a greater reduction,” says, astonished, Marie-Claude Vanier, full clinical professor at the Faculty of Pharmacy at the University of Montreal. “Maybe it could go down a little faster, but it can’t go down all at once either. »
Like several specialists with whom The duty spoke, she reminds us that we must maintain a certain balance. “Yes, we want doctors to prescribe less, but, on the other hand, they must continue to support patients who have developed the problem [de dépendance]. So there is a part of the prescriptions which is still justified and which will decrease, perhaps gradually or very gradually. »
Anaïs Lacasse, pharmacoepidemiologist in chronic pain at the University of Quebec in Abitibi-Témiscamingue, believes that we should not throw the baby out with the bathwater, recalling that many patients make optimal use of opioids and that they benefit from it.
“We should not aim to reach a specific threshold in terms of opioid use and we should not abolish this option from the toolbox,” she summarizes. The important thing is to prescribe the right medication, to the right patient, at the right time. »
Lower doses
On the ground, pharmacist Philippe De Grandpré sees a drop in prescribed doses. “If you ask me the difference between 2010 and 2023, for me, in my practice, it is clear that there are fewer patients on high doses of opioids. »
But there are still some, he notes. “This is what we call legacy patients, patients who were told by their doctor in 2005 that it was okay to take high doses and who developed a really strong dependence. So there are still probably prescriptions that seem very bad, but in the end, it’s because we’re stuck with the problem and we can’t do better to support them. »
He cites American studies which demonstrate that forced withdrawal, when the patient is not ready, can lead to suicide or the use of even more dangerous street drugs. “There is no easy answer,” says the pharmacist, with nuance.
Strong demand for withdrawals
These patients who have been taking high-dose opioids for years, the DD Pinard also sees them in her pain treatment clinic. “I do a lot more withdrawals than I prescribe treatments [aux opioïdes], she explains. However, weaning takes a long time, and the family doctors who follow these patients are not all equipped to support them. »
Patient demand for withdrawal is so high that she receives calls every day. “I can’t take them, otherwise I’d just be doing this all day, and we have a lot of other roles to play. »
In some cases, patients who take large doses of opioids no longer have a family doctor, which makes things even more complicated, she explains.
She also notes that doctors are generally more aware of the harmful effects of opioids, but that they do not necessarily have more tools to prescribe them adequately and initiate withdrawal in patients who need it. “It’s as if we had the conscience, but not the means, for our ambitions,” she says. If there is no structure in place, I don’t believe it will magically improve. »