Weighing a new opioid strategy
People at end-of-life care at Hospice Niagara face pressing issues.
And pain management — sometimes medically controlled though high-dose opiates— can be top of the list.
But those same opiates, when abused by others, are fast becoming a health crisis on their own in Niagara and elsewhere.
Ontario’s Ministry of Health recently announced it would quit paying for high-dose opioid medications by removing them from the Ontario Drug Benefit Formulary.
“Looking at palliative patients, this concerns me,” said Tina Van Egmond, director of care at the St. Catharines hospice. Patients in the hospice are “in a controlled environment where we can monitor them,” she said.
As a result, very few end up using opiates in an abusive way, she said. In palliative outpatient cases where there might be an issue, physicians ideally create pharmaceutical-use “contracts” with their patients and are monitored, said Van Egmond. Inside the hospice, the new provincial funding restrictions could lead to more pain pills having to be taken to have the needed relieving effect.
“More pills or patches is really not a comforting thing for patients,” Van Egmond said. “And it’s also an issue with medication safety, because you’re always looking for the safest way to administer medication.
“When you’re giving them more pills, it’s harder to keep track of their dosages. When you give them more fentanyl patches it’s harder to sometimes find out where they are on the body.”
That provincial drug benefit formulary covers drug costs for people who are 65 or older, receives social assistance or have high drug costs relative to their income.
When you’re giving them more pills, it’s harder to keep track of their dosages. When you give them more fentanyl patches it’s harder to sometimes find out where they are on the body.” Tina Van Egmond, director of care at the St. Catharines hospice
The affected drugs — to be defunded by January — include 200-milligram tablets of morphine, 24-milligram and 30-milligram capsules of hydromorphone and 75-microgram per hour and 100-microgram per hour patches of fentanyl.
The change doesn’t affect lower doses of the drugs, which the ministry said can actually be more effective than high doses.
Ontario’s Health Minister Dr. Eric Hoskins said earlier in a written statement reported by The Canadian Press that delisting the drugs is an “important first step” in limiting high doses of opioids, which he noted are linked to overdose deaths.
The high dosages will still be available in the province, but won’t be refunded to patients under the Ontario Drug Benefit Formulary, leaving those patients to pay out of pocket or use insurance to buy them.
Van Egmond said that can also be troubling, as a number of clients don’t have that coverage and are without third-party insurance.
“It’s a huge concern when people at the end of life (or their loved ones) are having to pay out of pocket to deal with that,” she said.
Van Egmond adds another issue is that drug prices aren’t proportional to dose sizes, meaning the costs overall will increase for patients without coverage.
It presents another stressor for patients and families having to research how to possibly get alternative funding for needed drugs.
‘“It kind of goes against the palliative-care philosophy, where the goal is comfort and holisic care,” Van Egmond said.
For St. Catharines addictions physician Dr. Fraser MacKay, on the front-line in treating people addicted to opioids, the change is welcome.
MacKaye adds, however, he can appreciate concerns arising on the palliative-care side.
“From my perspective, there’s no question this is a very positive move,” said MacKay, also a partner in area Segue addictions clinics.
“I appreciate the decisions the government has made and in the longrun will be a positive development.”
MacKay adds “will the transition be difficult for some people, yes it will be.” He adds when a patient reassesses their pain management protocol with a physician, options other than medication solutions might be considered.
“Specifically I am talking about manual therapy, physio,” he said. “And counselling … is significant with the chronic pain community, and more programming needs to be available for them.”
Dr. Janice Giesbrecht, medical director of oncology with the Walker Family Cancer Centre, said the drugs “can be used safely in cancer patients who require this level of pain control.
“It is always done with careful monitoring of dose and side effects and safe prescribing policies,” Giesbrecht said in a Thursday email to Postmedia Network.
“We will work with our patients to ensure they receive appropriate medication for their pain management needs.”
We will work with our patients to ensure they receive appropriate medication for their pain management needs.” Dr. Janice Giesbrecht