Thread by @hakique

By now, everyone agrees (or should) that harm from opioids is a most pressing public health issue. But between smart people there’s disagreement on what role prescribing plays. Some thoughts on that (THREAD): /1

Yesterday, @CPSA_CA Registrar Dr. McLeod’s op-ed described changes in opioid prescribing in Alberta.
# of individuals prescribed opioids – ⬇️ 9000
Total morphine equivalents dispensed to population – ⬇️14% /2
edmontonjournal.com/opinion/column…

These indicators have tracked well with deaths. More prescription opioids in a population, more exposure, more harms. We were right to be concerned in Canada and the U.S. /3

It’s clear. The first exposure to opioids for many people who develop addiction came via a prescription. That was the case for too many, like Darcy May who died at 33. His parents spoke to @GlobalEdmonton. /4
globalnews.ca/news/3959303/a…

“A day doesn’t go by that I don’t blame myself.” That’s what Darcy’s dad, Brent, said. Stigma has parents not only grieving, but believing they’re at fault.
They’re not. /5

As Dr. McLeod wrote: “Doctors didn’t set out to do harm, but we helped create the crisis, and now we need to help solve it.”
We’ve done things (like overprescribe) *and not done things* (like treat addiction well), and people were hurt. /6

This isn’t all about addiction, though. People die from prescribed opioids without being addicted to them. That happens. A lot. Surely a large proportion dying in older groups were medicating as prescribed, some with drug-drug interactions increasing risk. /7

All this to say, I don’t think the smart people advocating for reduced opioid prescribing hate patients, despite prevalent ad hominem attacks. There are good reasons to prescribe less, and particularly to initiate opioid therapy in fewer people. /8

BUT, a heavy focus prescribing interventions won’t solve the problem. On their own, they’ll make this situation worse. Not everyone who thinks this is in the pocket of Big Pharma. /9

They’re also right that associating single variables with population outcomes (how we do clinical intervention studies) is problematic. The variables are multiple, and context is changing quickly. /10

Increased opioid prescribing used to mean increased opioid deaths in the population. But not so now. Where prescribing DEcreased, deaths INcreased. /11

A reassuring indicator in one context is concerning in another. It’s a little like how clinically, in certain contexts, normal transaminases may be a bad sign more than a good one. /12

The big change in context here is the toxicity of the illicit market with bootleg fentanyls. It seems to me that market got creative around the times “abuse deterrent” oxy arrived in the US and Canada. Talked about that at #CADTHtalks. /13

These illicit market changes have everything to do with criminal drug policy that urgently needs reform if we’re ever to get out of this epidemic. /14

And while we await that, at least we know Canadians support harm reduction to keep our neighbors, friends, and loved ones alive. (Even ½ of Conservatives are in favor, by the way, so chew on that.) /15

Stigma underlies all of this. It’s why we chase numerical targets instead of patient-centred ones when we’re uncomfortable. It’s why we drag our feet to improve access to treatment, and jail people who need inclusion, not the opposite. /16

Pain also drives it. From injury or ailment, or because life sucks for lots of people. So long as there’s inequity and exclusion, we’ll continue to have problems with substance-related harm. That won’t be dealt with in short order, but we’d best get started. /17

Now that I’ve once again broken my own 12-day old resolution to stick to <140 characters and avoid rambling threads (sorry, @DavidJuurlink), I know my point is less compelling, but here it is anyway… /18

Maybe we ought to leave our entrenched debate positions for a bit (since it seems everyone agrees more than disagrees) and save some lives. /end