This post originally appeared on VICE Canada.
Palliative care doctors in Ontario are hoping the provincial government will back off a plan that would stop them from prescribing high doses of opioid painkillers like fentanyl and hydromorphone for patients near the end of life.
The Ministry of Health quietly put up a notice in July announcing, effective next January, the cost of powerful narcotics—morphine 200 mg tablets; hydromorphone 24 mg and 30 mg capsules; fentanyl 75 mcg/hr and 100 mcg/hr patches; and meperidine (Demerol) 50 mg tablets—will no longer be covered by the provincial drug plan. This is part of the province's strategy to combat misuse of the powerful narcotics.
However, this change isn't likely to make a large dent in street use, according to Dr. Glen Maddison, a palliative care physician in Sarnia, Ontario. People suffering with severe pain, perhaps in the last stages of cancer, are not likely to sell their fentanyl patches to abusers, he says. They need every bit of pain relief they can get for themselves. "Diversion is very, very rare," among his patients, he tells VICE.
Though fentanyl patches and other prescription opioids are certainly the source of some of the growing number of opioid overdoses in Canada, much of the fentanyl on the streets is a bootleg version of the drug, believed to be derived from China. Because of this, putting restrictions on prescribed opioids will not affect a significant portion of the illicit opioid trade.
Maddison believes the government is making a mistake in removing access to high-dosage opioids for patients with terminal illness. He, along with other palliative care doctors, has written to complain to the ministry about this unintended consequence of the new plan.
Related: Watch our documentary on Fentanyl, 'The Drug Deadlier than Heroin'
Almost all of Madison's palliative patients have their medications covered by a private-health plan or the provincial one, so the "delisting" could come at a serious cost to patients and their families. Costs for pain meds such as fentanyl patches can reach up to about $75 USD per month, he estimates.
Sure, Maddison could use more patches at a lower dose for patients in severe pain, but that doesn't make for effective pain control and can be pretty unpleasant for the patient. "Wallpapering" a patient with fentanyl patches is less effective, and the more patches on a person the greater the chance he or she will come loose, he explains. On top of that, patches have to be moved every three days.
But now the government may be offering a second chance to palliative doctors and patients. A recent email to VICE says the ministry wants to "make sure Ontario patients can continue to access appropriate pain care, and consideration will be given to using systems already in place," including something called the "Facilitated Access Program."
"That's what we've been lobbying for," Maddison says. "That means they're listening." Facilitated Access, in place since 2007, allows doctors and patients speedy access to high-dose opioids for terminal patients, which might be restricted for others. Keeping that in place will help get patients the pain relief they need, he believes.
But not everyone agrees with Maddison and other palliative doctors who've been giving out a similar message since the changes were announced.
"The palliative care people are making far too much of this," says David Juurlink, a professor of medicine at the University of Toronto, a staff physician in internal medicine and pharmacology at Toronto's Sunnybrook hospital and medical toxicologist.
"If you are receiving these extraordinarily high dosages (such as those being cut out by the government), then the drugs are doing you more harm than good," Juurlink told VICE. A typical opioid dose equal to 200 mgs of morphine, taken twice a day, leaves a patient at "greater risk of dying from the meds than from anything else."
Juurlink says if doctors up the dose of these painkillers to the level the government is taking aim at, the patient has really become resistant to them, and something else should be tried.
While their difference of opinion is clear, one thing Maddison and Juurlink agree on is that the province isn't going to gain much ground on the "patients" who fake or exaggerate the pain from a non-fatal illness so they can sell fentanyl, hydromorphone, or oxycodone to addicts or those on the road to addiction.
Patch-for-Patch is about to go province-wide in Ontario. The idea passed the legislature last December, and a ministry spokesperson tells VICE it should be running next fall. Most of the resellers don't fit the palliative care category. "I support the government for trying to do something, but this is the wrong thing," Maddison says. Other measures may do a better job of limiting diversion, such as a local Patch-for-Patch program for fentanyl. It requires all patients in Sarnia to return their used patches to the pharmacy before new ones are provided. Patch-for-Patch has been a "fantastic" success, and patients are "totally with it," according to Maddison. David Juurlink agrees with the idea, calling it a "very sensible" step toward controlling street sales of fentanyl by "predators."
While delisting the high-dose drugs will not do much to stop bootlegged fentanyl from being sold on the street, it will help "nudge" doctors who are thinking of prescribing the drug for non-terminal patients with pain complaints.
According to figures compiled for the Globe and Mail, Canadian doctors wrote a staggering 19.1 million opioid prescriptions in 2015. Canada is the second largest per-capita consumer of legal opioids in the world.
While he's aware of the risks with these potent medicines, Maddison and other palliative care doctors across Ontario insist these are an important tool in pain management, and they aren't letting up on the government.
"Please think seriously about this," Maddison said in an appeal to the government. "This is just hurting those who are most vulnerable."
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