Invisible and Older Faces of Canada’s Opioid Crisis

Opioids, commonly referred to as “narcotics,” are potent medications used widely to treat pain — but they also have strong potential for misuse and addiction. Over the past decade, the opioid crisis in Canada has become a major, growing public health emergency. Two comprehensive factors have contributed to the acceleration of the opioid crisis in Canada. First, opioid prescription rates have risen steadily over the past 30 years to today’s extremely high levels, and despite recent decreases in opioid prescription rates, Canada remains one of the largest consumers of prescription opioids in the world. Second, there has been a steep rise in the use of street opioids, many of which are extremely potent (i.e., fentanyl), which have been linked to skyrocketing rates of opioid overdoses and deaths across Canada.

As more attention is being paid to the opioid crisis in Canada, various responses have been launched in an attempt to curb some of these alarming trends. However, older adults have been largely left out of the conversation. Simply put — older Canadians in this crisis have been left out of sight and out of mind. With this report, Out of Sight, Out of Mind, the National Institute on Ageing (NIA) aims to raise awareness of the serious risks to older adults related to the opioid crisis, and to explain why this group will require particular attention in order to stem the crisis.

While current perceptions of the opioid crisis tend to focus on younger adults consuming non-prescribed opioids and experiencing high rates of overdose, many people are unaware that older Canadians actually bear the largest burden from opioids — mostly from prescription sources. Compared to all other age groups, older adults have the highest rate of prescription opioid consumption, as well as the highest rates of side effects, overdoses and mortality associated with prescription opioids. This is strongly related to the fact that older adults experience more chronic pain compared to any other age group, and opioids are very commonly used in this population to manage pain symptoms. There are several factors that make older adults more likely to experience an overdose when using opioids, including age-related metabolic changes; a higher likelihood of also taking multiple other medications — including other sedatives — which increases the risk of dangerous drug interactions; and higher rates of more severe chronic pain that require higher doses of opioids to manage symptoms. Together, these factors put older adults at higher risk of overdose, hospitalization, and death when consuming opioids. Older adults are also at greater risk of other side effects from opioids, including nausea and constipation, which can negatively impact their overall quality of life.

 Given the high rates of prescription opioid use among older adults, alongside the higher risk of negative outcomes linked to opioid use in this age group, Canadian healthcare professionals need to re-examine pain management strategies that are taught to current and future prescribers. In this report, they detail a concerning, ongoing over-reliance on opioid therapies for older Canadians, while the use of other methods — such as topical analgesics or multidisciplinary pain clinics — remains seriously lacking in Canada. This over-reliance on opioids persists despite some evidence suggesting pain in many older Canadians often goes undertreated. The National Institute on Ageing (NIA)also reviewed research on which groups of older adults are at greater risk of consuming opioids longer-term for the management of pain symptoms, and the current challenges with deprescribing opioids in older adults. Unfortunately, much work is left to be done in this area worldwide, and there is a particular dearth of data on these issues in the Canadian context.

Related to the current over-reliance on using opioids in older Canadians are the underappreciated and rising rates of opioid use disorder (OUD), which is the technical term for the disease of opioid addiction. Research suggests this is a growing problem in Canada, but awareness surrounding OUD in older adults is lacking. Further, while the proportion of Canadians living with OUD is likely underreported, research suggests the number of older adults in Canada with OUD will likely grow in the years to come. However, the current public health response to the opioid crisis in Canada largely ignores older adults living with OUD. This report discusses these issues and reviews the prevention, screening, and treatment sections of the recently developed Canadian Guidelines on Opioid Use Disorder Among Older Adults, produced by the Canadian Coalition for Seniors Mental Health.

Another key group that has been largely left out of the discussion thus far is older Canadians living in long-term care (LTC) homes who use opioids. While recent research indicates that opioid prescriptions are increasing in Canadian LTC settings, there remains little research about policies, guidance, and training on the appropriate prescribing and use of opioids in these settings. In this report, they discuss research from other jurisdictions and highlight key considerations for improving opioid prescribing policies in Canadian LTC settings.

The National Institute on Aging also explored research on older adults’ knowledge of opioids, as well as their perspectives on opioid-related policies. Sadly, there is once again a paucity of research and policy on this front in Canada, but research done elsewhere suggests that many older adults know little about opioids and the potential risk of serious outcomes such as overdose.

There are also important opioid policy implications for older adults that require specific consideration. For instance, a recent national poll of older Americans found that many older adults hold onto unused opioids out of fear they will need them again and that many opioid disposal options are inaccessible to older Americans. Further, opioids remain the medication of choice in suicide attempts among older adults in the U.S. and Canada.

In response to the scarcity of Canadian data about opioid use and outcomes in older adults, the NIA obtained and analyzed data from the Canadian Institute for Health Information (CIHI) on opioid-related prescriptions, hospitalizations, and emergency department visits from 2015 to 2020. Their analysis suggests that, despite variations between provinces and territories, there is a high rate of prescription opioid use among older Canadians. Between 2015 and 2020, prescription rates for older adults have tended to decline overall, particularly for some stronger formulations (i.e. fentanyl and oxycodone), and increased or remained stable for others (i.e. hydromorphone), while rates of some lower-strength opioids (i.e. codeine) have shown some decline but remain high.

The NIA’s analyses found that older Canadians experience very high rates of opioid-related harms — particularly adverse events from prescription medications. Combined with findings on prescription rates, their analyses provide an important, high-level perspective on some of the impacts of the Canadian opioid crisis on older adults. Opioid-related deaths in Canada spiked during the COVID-19 pandemic. In this report, they outline how the “twindemic” of the COVID-19 pandemic and opioid crisis epidemic has likely had a disproportionate — albeit under-investigated — impact on older Canadians. As was the case with our COVID-19 pandemic responses, societal ageism has likely played a role in the widespread lack of research, policy, awareness and understanding of the opioid crisis in older Canadians to date.