Oxycontin withdrawal foreseen
Drug maker’s replacement of ‘Hillbilly heroin’ could lead to a run on ER services, critics say
The pending removal from the market of one of the most abused prescription drugs in Canada could make the tragedy of under-treated pain worse and lead to other unintended consequences for which we aren’t prepared.
Starting Thursday, the manufacturer of Oxycontin – the prescription pain reliever known as “Hillbilly heroin” for its ability to produce a heroin-like hit when snorted or injected – is phasing out the drug and replacing it with OXYNEO, a reformulated version that its maker says is harder to crush or liquefy.
Six provinces – but not Quebec – have almost simultaneously announced plans to restrict access to OXYNEO.
Leaders in the pain-management medical community are calling that move a misguided and emotional response that could lead to unforeseen fallout – such as a run on emergency services for people going into withdrawal, or wider prescribing of less-controlled, but potentially more harmful, opioids.
Some of those opioids are as much as six times more powerful than morphine.
The controversy is exposing deep divisions in the medical community. Some doctors say the limits being imposed on a drug dispensed 1.6 million times in 2010 alone can’t come soon enough.
Dr. David Juurlink said opioids in general, and long-acting oxycodone (the active ingredient in Oxycontin) in particular, are being prescribed at dangerously high doses and often for long periods of time, without good evidence from randomized, controlled trials that the benefits of such a practice outweigh the risks.
Restricting access isn’t likely to make a meaningful dent in the problem of opioid abuse, said Juurlink, head of clinical pharmacology at Sunnybrook Health Sciences Centre in Toronto.
Addicts, the Toronto doctor said, will simply switch to something else. What it will do, he predicted, is lead to fewer prescriptions for long-acting oxycodone.
What doctors have been taught about the prescribing of opioids such as oxycodone has come largely from pharmaceutical companies and doctors paid to speak on their behalf, Juurlink said, “and what we’ve been taught is wrong.”
Although some chronic-pain patients clearly do benefit, “there are also a number of patients who do not,” he said.
By some estimates, more than 100,000 North Americans have died in the past 25 years as a result of prescription opioids, he said.
Opioids slow the transmission of pain signals to the brain.
They also alter the sensation of pain. They produce, on average, about a 30-per-cent reduction in chronic-pain intensity.
Their side effects include nausea, dizziness, sedation, constipation and fatigue, and new research has started linking their long-term use with osteoporosis and immune-suppressing effects.
Today, Canadians are among the highest users of prescription opioids in the world.
In the past decade alone, our opioid consumption has more than doubled, and the biggest increases have been for the heavy-hitters, including oxycodone (which is 1½ to two times more potent than morphine) and hydromorphone (five to six times more potent than morphine), according to a recent study by British Columbia and Ontario researchers.
Among the provinces, Alberta had the overall highest opioid use rate in the country in 2010, Quebec the lowest – but nowhere are the rates falling.
Prescriptions for oxycodone are increasing in all provinces.
According to Ontario’s Health Ministry, between 300 and 400 people die each year in the province from opioid-related overdoses and the opioid most frequently found during autopsies in recent years is oxycodone.
Jokes about doctors’ dreadful handwriting are as common as old magazines in waiting rooms. But there’s nothing funny about some of the problems that result when patients, pharmacists and nurses can’t understand a doctor’s prescriptions.
The first national study of patient safety in Canadian hospitals found that one in 13 in-patients suffers harm because of a medical error. In some cases, this means a longer hospital stay or additional pain and discomfort. In others, it results in preventable deaths. Drug-related errors are responsible for a quarter of the incidents of patient injury.
In fact, only surgery causes more preventable harm in hospitals. Out-patient prescription errors are harder to measure, but community pharmacists estimate that between 10% and 15% of prescriptions they fill contain some kind of error.
Illegible handwriting is one of the major culprits, but so are other bad prescribing habits, such as abbreviations for timing and dosage, and the use of similarsounding trade names for drugs rather than their full chemical identifiers. When computers are integrated into the prescribing process, these potentially dangerous mistakes can be prevented. Prescription software makes it impossible for doctors to use abbreviations for dose information, and prompts doctors to double check that they’ve ordered the right drug.
Richard Alvarez is the president and CEO of Canada Health Infoway, a non-profit organization created by provincial premiers in 2001 to promote the best possible integration of IT into health care across the country. “Our priority is to get drug information systems available across Canada that would do several things,” he explains. “Primarily, they’ll allow a physician, a nurse or a pharmacist to view a patient’s entire medication history, to see if what is being prescribed or dispensed is the right drug for that patient’s situation, and to correct it if not.”
Robert Mcqueen owns and operates a pharmacy in Edmonton, and has been at the forefront of integrating IT into his practice. Almost a decade ago, his store was one of the first to compile prescriptions in a central database, which flagged any errors and returned the results the next day. Since September 2011, though, these transactions can happen in real time, which helps Mr. McQueen provide better service to his customers, and prevent inappropriate dispensing of drugs, be it from error or deliberate prescription abuse.
“If someone comes in with a prescription that includes a narcotic, you can now see immediately if they’ve just filled a prescription for another narcotic somewhere else,” he says. “It gives us more complete information.”
Allergies and medical conditions are also associated with each record, which helps ensure a patient with a chronic disease isn’t given a potentially harmful drug that’s prescribed by a doctor who doesn’t know the full medical history.
Prescription databases also flag potential interactions between different drugs, a function that becomes increasingly important as the population ages. The aver- age senior fills almost tions each year, a n has doubled since 19 electronic records, d pharmacists have to patient’s memory to they don’t prescribe drugs that are safe on but potentially dang combined with anoth
Today, fewer than adian doctors give computer printout to drugstore, or fax th
t 40 prescripnumber that 90. Without doctors and o rely on the o make sure or dispense n their own, gerous when er. half of Canpatients a o take to the he printout themselves. While those legible documents eliminate miscommunication between doctors and pharmacists, they still allow errors to creep in when the information is entered manually at the pharmacy. The ultimate goal is for doctors to create an electronic prescription, that will automatically be sent to the right pharmacy and entered into the patient’s personal health record. When the prescription is filled, this information too is logged in the patient’s history, so doctors can verify that patients are getting the medication as prescribed, and refilling it at the right time.
“Some of the doctors i n my building are allergists, and they tell me they spend a lot of their time trying to figure out if the patient was compliant,” says Mr. Mcqueen, meaning that the patient took the medication as directed, or whether the medication didn’t work. “They can now look at the database and see when the prescriptions were filled, so they know whether they’re chasing down a problem with compliance, which is totally different than a problem with the drugs that are prescribed.”
In 2010, an Infoway study showed that to date, provincial drug information systems have yielded savings of $436-million. When these systems become completely available online across the country, they will save between $2-billion and $3-billion per year. Much of the savings will result from better provider productivity.
When electronic records and prescriptions are the norm, pharmacists won’t need to call doctors back to verify prescriptions, or delay dispensing until they’ve been able to reach a doctor. In addition, electronically submitted prescriptions won’t need to be entered manually at the pharmacy. Based on studies in regions with electronic prescribing, Infoway also estimates that switching to electronic prescribing will cut prescription abuse by 60%.
When medical error harms patients, costs to the system rise still further, and patients themselves become less productive, with a lower quality of life. But for those who who suffer permanent injury, or who die as a result of a drug error, the costs are incalculable.