No magic pill

Prov­ince one of two in Canada to see in­creas­ing rates of daily doses of opi­oids in 2016

Moose Jaw Times Herald - - FRONT PAGE - SARAH LADIK

Daily doses of opi­oid drugs are up in Saskatchewan, ac­cord­ing to a new study by the Cana­dian In­sti­tute for Health In­for­ma­tion (CIHI).

While the num­bers are very small — the prov­ince saw in in­crease in half-a-per cent from 2015 to 2016 in daily doses per 1,000 peo­ple — Saskatchewan is one of only two ju­ris­dic­tions that saw in­creases at all.

“When we look na­tion­ally, what we saw was a de­crease in the to­tal num­ber of doses dis­pensed and an in­crease in the num­ber of pre­scrip­tions,” said man­ager of phar­ma­ceu­ti­cals in­for­ma­tion with CIHI Jor­dan Hunt. “We did see that trend to­wards smaller pre­scrip­tions in Saskatchewan as well, but what we didn’t see was the de­crease in to­tal quan­tity dis­pensed that we did see in some of the other prov­inces.”

That be­ing said, Hunt noted that al­though there were sig­nif­i­cant drops in On­tario, Bri­tish Columbia, and Nova Sco­tia, Saskatchewan was not an out­lier in terms of the rest of Canada. Other prov­inces saw small drops in the same met­ric and Newfoundland saw a rise of less than one per cent.

Phar­ma­cist man­ager of the pre­scrip­tion re­view pro­gram with the Col­lege of Physi­cians and Sur­geons of Saskatchewan Ju­lia Bare­ham said that while track­ing this in­for­ma­tion about opi­oid pre­scrip­tions is use­ful, the data can be prob­lem­atic.

“Some­times th­ese num­bers may be slightly mislead­ing when they don’t tell the whole story, but I think where there’s smoke there’s fire, and it at least demon­strates some trends and how we’re go­ing up ver­sus down,” she told the Times-Her­ald on Wed­nes­day.

She pointed out that one of the sources for this par­tic­u­lar in­for­ma­tion did not cover 40 per cent of Cana­dian phar­ma­cies, but that another source was likely largely com­plete. Bare­ham also ar­gued that the po­tency of opi­ates most of­ten pre­scribed in the prov­ince may af­fect how doses are cal­cu­lated.

“The re­al­ity of what hap­pens with th­ese drugs is that over a while, you de­velop a tol­er­ance and we’ve got to slowly in­crease your dose to achieve the same re­sults,” she said. “If we have an ag­ing pop­u­la­tion, and we’re even­tu­ally tran­si­tion­ing over to those more po­tent opi­oids over time, that might ex­plain why we see that in­crease.”

The most-used opi­oid in Saskatchewan is hy­dro­mor­phone, which is five times stronger than mor­phine. It doesn’t tax a pa­tient’s kid­neys as much as other forms of opi­oids and, for this rea­son, is of­ten used for older adults who may have re­duced kid­ney func­tion to be­gin with.

“I’m thrilled we’re not the high­est, and also thrilled we’re not the low­est. In BC, we saw pre­scribers be­ing afraid to pre­scribe and maybe pa­tients not get­ting their ap­pro­pri­ate treat­ment as a re­sult,” Bare­ham said. “Find­ing that bal­ance in the mid­dle is a chal­lenge, and even great physi­cians are go­ing to be duped.”

While the study did not track il­licit opi­oid use, Hunt noted that the preva­lence of the drugs on the street is in some ways tied to pre­scrip­tions writ­ten by physi­cians. Canada is the sec­ond largest con­sumer of opi­oids af­ter the United States, and the con­se­quences of their pre­pon­der­ance have been a mas­sive con­cern na­tion­ally.

“That’s not only to do with pre­scribed opi­oids, which is what we looked at — il­licit opi­oids do play a role,” Hunt said.

“But we know pre­scrib­ing opi­ates is part of the story there and is im­por­tant for us to mea­sure.”

For Bare­ham and the physi­cians she deals with, the ques­tion re­mains what the al­ter­na­tive is if opi­oids are be­com­ing prob­lem­atic. Of­ten best prac­tices in­di­cate that non-drug treat­ments can be of use, like phys­io­ther­apy and mas­sage, but in many cases, those ser­vices are not ac­ces­si­ble in Saskatchewan. Fur­ther­more, she said, for In­dige­nous pa­tients who fall un­der a na­tional health-care claims process, the cost of such treat­ments are not cov­ered by the state.

“What hap­pens when you have very com­plex pain, or com­plex chronic pain mixed in with a sub­stance-use dis­or­der?

“We re­ally strug­gle to sup­port th­ese pa­tients with the mul­ti­dis­ci­plinary ap­proach that they need,” Bare­ham said.

The an­swer to that in other ju­ris­dic­tions has been the cre­ation of pain clin­ics, de­signed to work with the most com­plex cases.

Saskatchewan has none and the only op­tion is in Al­berta, which presents other chal­lenges in terms of cost and travel.

“I cer­tainly don’t want to deny that I think there’s room for im­prove­ment in the pre­scrib­ing of opi­oids, but in de­fence of my pre­scribers, we don’t have a pain clinic in Saskatchewan,” Bare­ham said. “What do you do when you’re Dr. Smith and you have this su­per com­plex pa­tient and over time, their pain has just crept up? Where do we send them?”

Still, fol­low­ing changes in the United States that were also adopted by some prov­inces, there are now Cana­dian guide­lines in place for physi­cians pre­scrib­ing opi­oids. Bare­ham said the col­lege has also re­cently run a con­fer­ence with top ex­perts in the field in Saska­toon and that her job is to mon­i­tor the prac­tice of pre­scrib­ing and of­fer ed­u­ca­tion on as­sess­ment and other op­tions when she sees anom­alies.

Since 2005, the prov­ince also has had in place a com­puter pro­gram for health­care providers that tracks the med­i­ca­tion pa­tients are pre­scribed and dis­pensed. The idea is to iden­tify pos­si­ble abuse and to make sure each pa­tient is be­ing ad­e­quately treated.

“I’ll be cu­ri­ous to see what it looks like when we run th­ese num­bers again in a year,” she said.

“It’s so hard to talk about cause and ef­fect.”

Hunt also noted that the changes to guide­lines will likely re­sult in a cor­re­spond­ing change for the next study, but that there are some pos­i­tive trends to be seen in last year’s data.

“The num­ber of pre­scrip­tions we see and the quan­tity we see, it is of con­cern. The one thing that’s en­cour­ag­ing is that we are see­ing that trend to­wards shorter pre­scrip­tions,” he said. “Usu­ally that means more in­ter­ac­tions with the health-care sys­tem, with your pre­scriber, and more op­por­tu­ni­ties to as­sess how treat­ment is go­ing, as­sess ef­fec­tive­ness, and con­sider whether it needs to be con­tin­ued and to con­sider al­ter­na­tive treat­ments.”

Some­times th­ese num­bers may be slightly mislead­ing when they don’t tell the whole story, but I think where there’s smoke there’s fire, and it at least demon­strates some trends and how we’re go­ing up ver­sus down. Ju­lia Bare­ham, Phar­ma­cist Man­ager of the pre­scrip­tion re­view pro­gram, Col­lege of Physi­cians and Sur­geons of Sasak­tchewan


De­fined daily doses per 1,000 pop­u­la­tion for top six opi­oids, 2016, and per­cent­age change from 2015 to 2016, Canada from Pan-Cana­dian Trends in the Pre­scrib­ing of Opi­oids, 2012 to 2016.

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