Palliative-care doctors decry Ontario’s new opioid policy

Theglobeandmail.com
July 25, 2016
By Karen Howlett

Palliative-care doctors are calling on the Ontario government not to cut off access to high-dose opioid medications for their patients, saying those nearing the end of life or suffering from cancer pain “deserve better.”

Ontario will become the first province to stop paying for all opioids that exceed the equivalent of 200 milligrams of morphine a day under its public drug plans. The policy change, first reported by The Globe and Mail, takes place against a backdrop of rising addiction rates and overdose deaths across Canada.

Stephen Singh, director-at-large of the Canadian Society of Palliative Care Physicians, said he was “appalled” to read about the government’s decision to no longer fund high-dose opioids. Rather than eliminating funding altogether for these painkillers, he said, the government should allow palliative-care physicians to continue providing the opioids for their patients at no cost.

“Our patients under palliative care deserve better than this,” said Dr. Singh, who practises in Brantford, Ont.

The Ministry of Health has posted a notice on its website saying 24- and 30-milligram capsules of hydromorphone, transdermal patches that deliver 75 and 100 micrograms of fentanyl an hour, and morphine in 200-milligram tablets will be delisted from the province’s drug formulary as of January.

The issue for palliative-care physicians is that patients who have difficulty swallowing pills will be forced to take more lower-strength hydromorphone or morphine to replace the higher-dose versions. Darren Cargill, section chair of palliative medicine at the Ontario Medical Association, explained that he will have to “wallpaper” patients with multiple fentanyl patches to deliver the same pain relief they get from a single higher-dose patch.

Dr. Cargill said the government needs to strike a balance between addressing the needs of palliative-care patients who require these pain medications to remain comfortable and the widespread abuse of prescription opioids.

“Simply delisting these medications was a very shortsighted response to a very, very complicated problem,” the Windsor, Ont., physician said.

A Ministry of Health spokeswoman suggested the changes are not cast in stone. Ministry officials plan to meet with health-care providers, including those in the palliative-care community, she said, “to assess any unintended consequences” and ensure that patients can “continue to access appropriate care.”

Other medical experts praised the government for targeting the abuse and diversion of high-dose opioids, which are attractive to traffickers because they give users a bigger high and sell for more money. These drugs are especially prone to abuse by virtue of their strength, said David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto.

Dr. Juurlink said he thinks the changes to Ontario’s drug formulary will also deter physicians from overprescribing opioids. Delisting the full portfolio of high-dose opioids, he said, will serve as a reminder to physicians that there is a reason the province is no longer funding them. “They are extremely dangerous. Not only do we not have data to show that these help patients,” he said, “we have very sound data to show that doses of this sort hurt patients.”

Ontario is the biggest per-capita user of prescription painkillers in Canada. In 2015, doctors wrote 8.1 million prescriptions for opioids, enough for nearly every person between the ages of 15 and 64 in the province, according to figures compiled for The Globe by IMS Brogan, which tracks pharmaceutical sales.

Tara Gomes, an epidemiologist at Toronto’s St. Michael’s Hospital, called the ministry’s changes a “positive step in trying to reduce the likelihood of people experimenting with drugs having a fatal overdose.”

Several other provinces are monitoring Ontario’s announcement. The Alberta government says it plans to conduct a formal review of the changes, while Saskatchewan will look at whether it should adopt similar measures. In British Columbia, the government says it is reviewing Ontario’s move but has no immediate plans to change its coverage of the drugs.