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

We thank Drs McCracken, Hawley, Panagiotoglou, Lavergne, and Gomes and Ms Peterson for their thoughtful letter about our article on new long-term opioid use in BC.[1] Our understanding is that they are concerned our study may result in a policy response that would negatively impact patient populations benefiting from prescribed opioids. This was not our intention. We hope our reply to each discussion point will provide clarification. In our article, we aimed primarily to describe the specific BC data we had access to, and we were cautious to provide recommendations given the limitations of our data set.

We presented the prevalence of national long-term opioid use from the Canadian Institute for Health Information in the introduction to provide readers with context about long-term opioid use in Canada.[2] We agree this is a different patient population from the 7.2% of opioid-naive users that became new long-term opioid users within our 4-year study period.[1] Our focus was to determine the BC-specific initial opioid prescription practices, as this has been shown to be a strong predictive factor in ongoing opioid use.[3,4] Initial prescribing practices across the world vary substantially.[5] Opioids, in excess of clinical need, increase the risk of opioid dependency, recreational opioid use, opioid sharing and diversion, accidental overdose, and death.[6]

Our 2025 article was the second of two on this subject, and our methodology section was therefore more succinct, as we referenced our previous, more detailed report from 2021.[7] We used the World Health Organization Collaborating Centre for Drug Statistics Methodology’s Anatomical Therapeutic Chemical classification system to create a list of possible opioids.[8] For our study, only the classifications of “opioids” and “drugs used in opioid dependence” were used. “Cough and cold preparations” were excluded.

For our 2025 article, we felt our definition of new long-term users was clear: individuals who were opioid naive (no opioid prescriptions in the 180 days prior to the first opioid prescription) and not initially prescribed methadone or buprenorphine.[1]

In a previous study by Crabtree and colleagues, the authors found that for fatal drug overdoses in BC during the period of 2015–2017, only 2% were associated with a prescribed opioid (within 60 days of death), and another 6.7% were associated with a combination of prescribed and nonprescribed opioids.[9] While this is an important finding, the toxic drug crisis in BC has evolved, with more involvement of other drugs.[10] Moreover, in Gomes and colleagues’ analysis of opioid-related deaths between 2013 and 2016 in Ontario, 1 in 3 deaths were associated with an active opioid prescription, and 75% of deaths were associated with an opioid dispensed within the 3 years preceding death.[11] Although the aforementioned studies differ in how they analyzed opioid prescriptions in association with fatal drug overdoses, it’s important to recognize the possibility that opioid users often start their opioid journey with prescription opioids related to an acute injury or illness. Nonetheless, we agree that contextualizing our study data within a local context is key for any policy response.

Dr McCracken and coauthors emphasized the key role that opioids have in patient care, and we completely agree. We were careful not to comment on the appropriateness of long-term opioid therapy, given that we were not permitted access to prescription indication data.[1] Moreover, we did not specifically look at the patient population that would benefit from prescribed opioids for opioid use disorders, as described by Slaunwhite and colleagues.[12]

Despite not having data on indications and outcomes, we were still able to outline prescribing practices. We agree with Dr McCracken and coauthors that the article on its own should not lead to a specific policy response. Rather, we hope that future work will build on this study’s findings by incorporating indications, outcomes, and more recent data to better understand opioid prescribing practices.

Thank you again to Dr McCracken and her team for their letter. We also thank the BCMJ Editorial Board for providing our team an opportunity to reply.
—Rebecca Z. Xu, MD
Plastic Surgery Resident, University of Toronto
—Jeffrey N. Bone, PhD
Biostatistical Lead, BC Children’s Hospital Research Institute
—Rebecca Courtemanche, MSc, CCRP
Clinical Research Manager, UBC
—Leeor S. Yefet, MD
Neurosurgery Resident, University of Toronto
—Mary-Claire Simmonds, MBBS, FANZCA
Pediatric Anesthetist, Women’s and Children’s Hospital, Adelaide, Australia
—Eric Cattoni, MD, CCFP
Clinical Assistant Professor, UBC
—Gillian R. Lauder, MB BCh, FRCPC
Clinical Professor, UBC
—Douglas J. Courtemanche, MD, MS, FRCSC
Clinical Professor, UBC

This letter was submitted in response to “Re: Prescription factors contributing to new long-term opioid use in BC.”

hidden

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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. Opioid prescribing in Canada: How are practices changing? 2019. Accessed 5 May 2025. www.cihi.ca/sites/default/files/document/opioid-prescribing-canada-trends-en-web.pdf.

3.    Shah A, Hayes CJ, Martin BC. Factors influencing long-term opioid use among opioid naive patients: An examination of initial prescription characteristics and pain etiologies. J Pain 2017;18:1374-1383. https://doi.org/10.1016/j.jpain.2017.06.010.

4.    Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006–2015. MMWR 2017;66:265-269. https://doi.org/10.15585/mmwr.mm6610a1.

5.    Jani M, Girard N, Bates DW, et al. Opioid prescribing among new users for non-cancer pain in the USA, Canada, UK, and Taiwan: A population-based cohort study. PLoS Med 2021;18:e1003829. https://doi.org/10.1371/journal.pmed.1003829.

6.    Lewis ET, Cucciare MA, Trafton JA. What do patients do with unused opioid medications? Clin J Pain 2014;30:654-662. https://doi.org/10.1097/01.ajp.0000435447.96642.f4.

7.    Yefet LS, Bone JN, Courtemanche R, et al. Opioid prescribing patterns in British Columbia from 2013 to 2017: A population-based study. BCMJ 2021;63:336-342.

8.    World Health Organization. Anatomical therapeutic chemical (ATC) classification. Accessed 9 June 2020. www.who.int/tools/atc-ddd-toolkit/atc-classification.

9.    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.

10.    BC Coroners Service. Statistical reports on deaths in British Columbia. Unregulated drug toxicity death (to Jan. 30, 2025). Posted 14 March 2025. Accessed 5 May 2025. www2.gov.bc.ca/gov/content/life-events/death/coroners-service/statistical-reports.

11.    Gomes T, Khuu W, Martins D, et al. Contributions of prescribed and non-prescribed opioids to opioid related deaths: Population-based cohort study in Ontario, Canada. BMJ 2018;362:k3207. https://doi.org/10.1136/bmj.k3207.

12.    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.