Re: Prescription factors contributing to new long-term opioid use in BC

We appreciate the contribution of Dr Xu and colleagues in their article “Prescription factors contributing to new long-term opioid use in British Columbia between 2013 and 2017.”[1] Their work highlights historical prescribing trends and invites dialogue about opioid prescribing and policy in our province.

We offer this letter in the spirit of collaboration, hoping to deepen the conversation around the role of prescribing in the context of BC’s complex and evolving toxic drug crisis.

We would like to clarify a few points raised in the article. The introduction references a report that shows a 17.6% national prevalence of long-term opioid use; however, the source cited is referring to the proportion of individuals already prescribed opioids who go on to longer-term use.[2] In contrast, the 7.2% prevalence reported in this study refers specifically to opioid-naive patients—an important distinction that could easily be misinterpreted without additional context. In the discussion, these figures appear to be conflated, which may lead readers to overestimate the prevalence of long-term opioid therapy in the broader population.

We also note that the study may have included opioid formulations typically used for cough suppression (e.g., codeine syrups) or opioid agonist therapies (e.g., methadone, buprenorphine). Long-term adherence to medications used in managing opioid use disorder is clinically appropriate and often lifesaving. Clarifying whether these formulations were excluded would help readers better understand the findings, especially in interpreting unexpected prescribing patterns (e.g., among pediatric patients).

We encourage attention to the role of opioids in evidence-based care. Opioids remain a cornerstone of cancer pain and palliative care. In 2022, more than 237 000 people in BC were living with cancer,[3] and many rely on opioids for effective symptom management.[4] Understanding the clinical indications behind prescribing—and how they relate to patient outcomes—is key to evaluating the appropriateness of current practices.

The article references US-based trends in opioid mortality to frame the significance of the findings.[5] We respectfully suggest caution here. While international comparisons can be informative, BC’s public health landscape is notably different. Overdose deaths in BC are now overwhelmingly driven by the unregulated drug supply, particularly illicit fentanyl and its analogues. A BC-based study found that nearly 79% of drug toxicity deaths in BC involved nonprescribed fentanyl, while only 2% were linked solely to prescribed opioids without any illegal substances.[6] Contextualizing local prescribing data within this broader public health reality is essential to avoid misdirected policy responses.

Finally, recent BC-based research, including work by Dr Slaunwhite and colleagues,[7] shows that prescribed opioids can reduce mortality among people with opioid use disorder. Prescribing metrics that do not account for clinical context may unintentionally undermine care for patients who already face significant stigma and structural barriers.

We thank the authors for their work and hope these additions help support an even more nuanced and patient-centred conversation about opioid use and policy in British Columbia.
—Rita McCracken, MD, PhD
Family Physician and Assistant Professor, UBC
—Pippa Hawley, MD, FRCPC
Palliative Medicine Specialist, BC Cancer
—Dimitra Panagiotoglou, PhD
Assistant Professor, McGill University
—Ruth Lavergne, PhD
Associate Professor, Dalhousie University
—Tara Gomes, PhD
Assistant Professor, University of Toronto
—Sandra Peterson, MSc
Research Analyst, UBC

This letter was submitted in response to “Prescription factors contributing to new long-term opioid use in BC.” Read the author’s response in “Prescription factors contributing to new long-term opioid use in BC. Authors reply.”

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References

1.    Xu RZ, Bone JN, Courtemanche R, et al. Prescription factors contributing to new long-term opioid use in British Columbia between 2013 and 2017. BCMJ 2025;67:54-63.

2.    Canadian Institute for Health Information (CIHI). Opioid prescribing in Canada: How are practices changing? Ottawa, ON: CIHI, 2019. Accessed 14 April 2025. www.cihi.ca/sites/default/files/document/opioid-prescribing-canada-trends-en-web.pdf.

3.    BC Cancer. Cancer statistics online dashboard. Accessed 14 April 2025. www.bccancer.bc.ca/health-info/disease-system-statistics/cancer-statistics-online-dashboard.

4.    Government of British Columbia. Palliative care for the patient with incurable cancer or advanced disease—Part 2: Pain and symptom management. BC Guidelines. Updated 19 September 2023. Accessed 14 April 2025. www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/palliative-pain-management.

5.    Bricker DA, Crawford TN, Castle A, et al. PRESTO: Promoting Engagement for the Safe Tapering of Opioids. Pain 2023;164:2553-2563. https://doi.org/10.1097/j.pain.0000000000002961.

6.    Crabtree A, Lostchuck E, Chong M, et al. Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in British Columbia, Canada. CMAJ 2020;192:E967-E972. https://doi.org/10.1503/cmaj.200191.

7.    Slaunwhite A, Min JE, Palis H, et al. Effect of risk mitigation guidance for opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: Retrospective cohort study. BMJ 2024;384:e076336. https://doi.org/10.1136/bmj-2023-076336.