Opioid misuse and abuse is a serious societal problem and public health threat. Globally, Canada is second only to the United States in per capita consumption of prescription opioids; painkillers such as oxycodone, hydrocodone, fentanyl and morphine. This has led to a significant increase in opioid-related deaths and a critical need for addiction treatment services across the country.
The problem has been amplified by the diversion of prescription fentanyl products (primarily transdermal patches), as well as the influx of pharmaceutical grade fentanyl into the illicit drug market which has led to an alarming number of deaths and overdoses across Canada, giving rise to what has been coined the opioid crisis. It has been reported that in Ontario alone, more than 700 people died from opioid-related overdoses in 2014.
Fentanyl is a powerful synthetic opioid analgesic that is similar to morphine but is 50 to 100 times more potent. Even when manufactured in controlled settings, its chemical composition renders it highly toxic and addictive. Where the drug is manufactured in uncontrolled facilities, a slight change in the chemical composition of fentanyl can cause its toxicity to increase, which can have fatal results.
The federal and provincial governments have taken a number of actions to address these issues. Earlier this year, naloxone, which is used as an overdose antidote, was made more widely available to first responders and the public. In July, the federal minister of Health signed an interim order allowing naloxone nasal spray to be sold in Canada and announced Health Canada's Action Plan on Opioid Abuse.
The federal government is looking at issues such as unauthorized importation, illegal use, controlled use and proactive measures to lessen the number of opioid-related incidents nationally. This includes legislative amendments to the Controlled Drugs and Substances Act (CDSA) which would place six chemicals used in the production of fentanyl on the schedule of substances prohibited by the CDSA and Precursor Control Regulations. The federal government hopes to better control, monitor and prohibit the unauthorized importation and exportation of opioids.
In October, the province of Ontario announced its "opioid strategy." The strategy aims to lessen the harm of opioids in the community through regulation, surveillance and reporting. It builds on the Narcotics Safety and Awareness Act, 2010 which allowed for enhanced data collection and monitoring of opioids and the Safeguarding our Communities Act, 2015 which places stricter controls on the prescribing and dispensing of fentanyl patches. For example, as of Oct. 1, patients are required to return used patches to their pharmacy before more can be dispensed.
Other strategies include the delisting of high-strength formulations of long-acting opioids from the Ontario Drug Benefit Formulary and the introduction of Suboxone as a first-line treatment for opioid addiction. Unlike methadone which can only be prescribed by physicians who have special authorization, Suboxone may be prescribed by primary care physicians. In addition, the province announced plans to create or enhance 17 chronic pain clinics.
The overuse of opioids is a pervasive problem that cannot be resolved simply by increasing regulation. Underpinning these issues are concerns about the indiscriminate or improper prescription of opioids, particularly for chronic non-cancer pain. Physicians have come under a high level of scrutiny for their prescribing practices, including the assessment and monitoring of patients, use of opioid misuse screening tools and treatment agreements and consultation and collaboration with other healthcare providers and specialists. The College of Physicians and Surgeons of Ontario is investigating over 80 doctors after the province's narcotics monitoring system flagged physicians with unusually high prescribing practices. The college has yet to consider the accuracy of the data and to assess whether physician practices meet acceptable standards, policies and guidelines.
The controversy attached to opioid prescribing has led to some physicians adopting a "no narcotics" prescribing practice. This can also be problematic as it may result in inadequate or ineffective treatment for pain. Patients are entitled to receive safe and effective pain management, whether for chronic pain or palliative care. In this respect there has been some backlash toward the opioid strategy by physicians who fear that some of the new strategies, for example the delisting of high dose opioids, may negatively affect how palliative care patients are treated, or may cause physicians to prescribe a greater amount of low-dose opioids to assist in proper treatment.
These are extremely complex, multi-faceted issues that require a highly co-ordinated response. Legislative changes alone will not address the problem, but are only a start.
Previously published in The Lawyers Weekly - November 2016
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