Opioid addiction in Canada
Prescription opioid use has skyrocketed across the globe, but seems to be especially problematic in Canada. Canadians consume more opioid analgesic medications than any other nation, after recently having surpassed the United States.
Opioid-related hospitalizations and mortality are also at an all-time high throughout the country, especially in Ontario and British Columbia. Prescription opioid use is evolving into what may well be Canada’s newest major public health crisis.
Bridging the gap between the past and present
Historically, addiction was considered to be a male-dominated disorder; women were generally less involved in drug use or were discouraged from speaking about it openly.
Historically, addiction was considered to be a male-dominated disorder; women were generally less involved in drug use or were discouraged from speaking about it openly. Moreover, it was not acceptable for women to participate in research studies, which further affirmed the patriarchal views characteristic of addiction during this time.
However over the last decade, we have seen a transformation among this population as a result of the increasing trend of prescription opioid use.
Patterns of opioid prescribing are higher among women compared to men, and in fact the proportion of women seeking treatment for opioid addiction has grown exponentially, to the point where the number of men and women in any given methadone clinic is roughly equivalent.
This has led to the evolution of a new class of opioid users that as a society we have been unable to keep up with. Much of what we understand about this particular patient population stems from earlier research, generating guidelines that have been used to set standards of clinical care and management of opioid addiction with methadone.
These guidelines were initially developed by Health Canada in the 1990s, with the most recent update completed in 2002, yet the most dynamic changes within this area have occurred within the last decade.
Perhaps the most puzzling is the fact that current clinical practice is still largely catered to a male-dominant population, despite the clear differences in needs of men and women that will influence their treatment outcomes. As a discipline, we ask ourselves, why has this not yet been addressed in addiction medicine?
A transforming field
We explored these issues in our recent article published in the journal Biology of Sex Differences, where we discovered distinguishing characteristics of men and women with opioid addiction attending methadone clinics across Southern Ontario.
Participants were recruited as part of the ongoing Genetics of Opioid Addiction (GENOA) study in affiliation with the Population Genomics Program at McMaster University.
Among 503 participants, nearly half (44%) who are currently receiving treatment for opioid use disorder with methadone had initiated their substance use by means of opioid analgesics that were prescribed by a physician.
In line with current trends, this was more apparent among women compared to men (51.6% vs. 37.7% respectively), presumably because of their higher rates of chronic pain and pain-related conditions.
Heroin use is less common among the opioid user population, and we have seen a decline in HIV rates (0.8%) that normally would have been caused by unsafe heroin injection practices.
An area that seems to be gaining momentum in addiction research is the increasingly prevalent use of cannabis, not unfamiliar to opioid users as well. In the past three months, 23% of participants in our study were using cannabis, which is higher than most rates shown in earlier studies. Not only were men more likely to use cannabis than women, they also used it more frequently than women did.
What did we find?
Women continue to experience a greater burden of disease with respect to opioid addiction, which was a transparent observation among our study participants. Women had a comparatively lower methadone dose, higher rates of benzodiazepine use, physical and psychological health problems, partner conflict, and were less likely to report employment. Women continue to receive the same standard of treatment as men despite their greater disadvantage.
For someone whose addiction originated from their pain condition, this means that they are likely to need more than a single daily dose of methadone to manage their addiction. In addition to requiring specialized pain and addiction management (such as a split dosing schedule), they would benefit from a psychiatric assessment to evaluate their mental health or other substance use problems (including benzodiazepines).
Evaluating the best interests of these patients, both men and women alike, with respect to substance use, health, and social functioning is fundamental.
Psychological counselling and social support in the form of family therapy may also be helpful for them, as an adjunct to an integrated treatment plan addressing all these relevant factors in relation to one another.
A key component in treating opioid users is the understanding that we are dealing with many different types of patients – whether it’s their drug of choice, specific drug use behaviors, socioeconomic background, medical conditions, or psychological state.
Evaluating the best interests of these patients, both men and women alike, with respect to substance use, health, and social functioning is fundamental to their clinical management of addiction and long-term positive outcomes.
Dr Zena Samaan is an Associate Professor in the Department of Psychiatry and Behavioral Neurosciences, as well as an Associate Member in the Department of Clinical Epidemiology and Biostatistics. She holds a Faculty position with the Population Genomics Program at McMaster University and The Peter Boris Centre for Addiction Research. Dr Samaan is also a Psychiatrist and member of the Royal College of Psychiatrists (UK).