This article first appears in the blog Dr. Merrilee Fullerton on Health Care. You can view the original post here.
May 26, 2017 – The latest news reports confirm our greatest fears: the opioid crisis has been escalating for years and the provincial government and health care officials are caught flatfooted dealing with this issue.
Fentanyl is Ottawa’s deadliest drug, a dangerous drug which is 30 – 50 times more powerful than heroin. It has been available on Ottawa streets for years and there is a growing bootleg market for the tablets. In 2015, 17 of 45 (38%) opioid-related drug overdoses had fentanyl in the victims’ bloodstream. The latest figures show there has been 319 emergency department visits to Ottawa hospitals in the first three months of 2017!
So, it is good news that Ottawa’s fifteen hundred firefighters will begin carrying Naloxone kits by the end of June. They will carry the easily administered nasal spray version of the opioid antidote naloxone saving time to first response and possibly saving lives. But our leadership in this community – and at Queen’s Park and the Ministry of Health – cannot be complacent with this band aid approach. .
Addressing opioid use and abuse will require new resolve as naloxone-resistant fentanyl compounds emerge and move across boarders often in tiny but deadly amounts. Here are some important things to consider.
New types of fentanyl compounds resistant to the antidote are being manufactured off shore. One such compound is Acrylfentanyl. It has surfaced in the U.S. and there are concerns that it may be making its way to Canada as experts in B.C. are warning. Acrylfentanyl requires more naloxone to reverse and it lingers longer in the body. This means that not only may multiple doses of naloxone be needed but that they may also be ineffective.
Naloxone kits are not the end solution. They are simply a tool to be used for now. Our health officials must ask themselves why Canadians are the second highest consumers of prescription opioids on a per capita basis in the world. Our government must to do a better job of anticipating “what next?”.
On physicians, prescriptions and our health care realities
It has been easy to blame Canada’s physicians for over-prescribing. Efforts to reduce and control opioid prescribing have been ongoing in Ontario for over twenty years. Despite this, according to a recent Health Quality Ontario report, 1 in 7 people filled a prescription for opioids in 2015/16 and more than 9 million opioid prescriptions were filled—the highest rate ever in Ontario. Why is this?
It is simplistic to blame physicians for over-treating pain although in some cases this may contribute. This is not to absolve physicians from responsible and safe prescribing of opioids but to suggest that there are many other factors involved in opioid use in Ontario.
Conditions in Ontario’s health care system are contributing to this increase through long wait times for care. Patients waiting for definitive treatment for months or years with painful conditions seek relief. Physicians can attempt to provide it through a variety of means starting with non-opioid interventions including physio, acupuncture, exercise therapy as well as psychological support to name just a few. However, severe pain for degenerative conditions requires more robust pain relief efforts. The risks of addiction and dependence must always be weighed with benefit in the judicious use of opioid prescribing.
Of note, the rate of opioid prescriptions filled is higher in rural parts of Ontario and there is a shift toward more potent opioids such as hydromorphone. Prescriptions for hydromorphone increased by 29 per cent in Ontario while codeine prescriptions dropped by 7 per cent.
Lack of timely access to care in rural areas can result in unintended negative consequences and solutions should address this aspect of our health care system.
The drop in prescriptions of codeine, a traditionally acceptable pain reliever, may be in part explained by increased awareness over the past several years that standard doses of codeine may be toxic for people with the CYP2D6 genotype. With more point of care testing it may be possible to more safely prescribe codeine when it is a better option based on a patient’s unique genetic profile.
Difficulties with timely access to care in Ontario also have an impact on prescribing patterns. The overcrowding in emergency rooms across Ontario can result in more opioid pills being prescribed per prescription to prevent patients from having to return to the ER for additional pain relief. Difficulties accessing primary care may result in patients seeking stronger pain relief and more of it “just in case” they need it. While it is easy to comment on these prescribing practices as having negative consequences, the reality is that the environment in which we live has an impact on behaviour.
Prescribing by dentists and dental surgeons should also be considered in efforts to address excessive opioid availability in our communities especially for our youth. Wisdom teeth extractions should not result in every young patient receiving 25 opioid pills when smaller quantities would be sufficient in many cases and when even a less potent medication may suffice.
Health officials must consider the human behaviour contributing to opioid prescribing patterns but also reflect on systemic and social factors that may be contributing to the high rates. Even if opioid prescribing patterns by physicians were ideal all the time, the reality is that illicit fentanyl has changed the landscape of opioid abuse across Canada. As non-prescription fentanyl and its analogues from thousands of illegal drug labs that operate without government oversight or regulation in foreign countries seep into Ontario, efforts to curb inappropriate opioid use must take a more comprehensive approach beyond physician prescribing patterns.
Seniors and prescription drugs
The aging of the population with associated rise in cancer cases and other diseases requiring palliation results in more need for severe pain control especially for pain related to tumour metastases. As more patients seek palliative care for comfort from diseases at the end of life, effective pain control is a necessity. It is not unusual to see cancer patients taking large doses of opioids since their tolerance to the drug increases over time and more of it is required to alleviate their suffering.
Robust palliative care includes use of potent opioid drugs but how “left-over” prescription opioid medications are handled will make a difference to the circulation of opioids in our communities. Ottawa Public Health’s “Secure Your Meds” campaign is an effort to encourage patients and their families to lock up medications and to return expired and unused drugs. It is reported that 13 per cent of Ottawa high school students used prescription drugs non-medically and two-thirds of students got them from a family member or from someone they lived with.
We must do better
There are no easy answers to this opioid crisis. However, the government and public health officials need to redouble their efforts to address the issues surrounding the deadly trends of opioid abuse and drug overdoses. These trends cannot be tolerated. They are unacceptable. We must do better. There needs to be new urgency and a comprehensive approach to address this crisis.
Dr. Merrilee Fullerton is the Ontario PC nomination candidate for the new riding of Kanata-Carleton.
READ MORE: Dr. Merrilee Fullerton on health care in Ontario