Review of Coroner Inquest Recommendations into Opioid Prescribing Practices in Ontario: Ongoing Health Policy Gaps.

The rate at which opioids are being prescribed and the safety of prescription opioid use are serious and ongoing problems for individuals, communities and health systems across Canada. In 2011, a coroner's inquest was held in Brockville, Ontario, Canada, to examine the issue of prescription opioid diversion and abuse. Following the inquest, the jury provided 48 recommendations pertaining to prescribing and monitoring of opioids. The ensuing discussion highlights health policy gaps that remain to be addressed seven years after the inquest, in educational resource-sharing, high-dose prescribing, development and use of abuse-resistant formulations and coordination and monitoring of policy interventions.