Jump to comment:
- Page navigation anchor for RE: Problems with hydromorphone prescribing as a response to the opioid crisisRE: Problems with hydromorphone prescribing as a response to the opioid crisis
Nearly two years ago, Dr. Tyndall advocated in this Commentary for prescribing of hydromorphone by physicians as a response to the presence of illicitly manufactured fentanyl in the street opioid supply. The rationale is that fentanyl is toxic and unpredictable, whereas hydromorphone is a pharmaceutical product, uncontaminated, and is available in known dosing. Nearly two years later, the opioid crisis has not abated. Between Jan 1st 2018 and March 31st 2019, 5670 Canadians died an apparent opioid-related death.(1) Fentanyl in the illicit opioid supply continues to be pervasive. The scale of grief and loss for their families and communities of individuals represented in these statistics is horrifying. In response, some physicians have started prescribing hydromorphone tablets to people using illicit fentanyl with the intent to reduce the risk of exposure to this poisonous drug supply.(2) A term to describe this practice is hydromorphone maintenance therapy (HMT). HMT is dispensed at a pharmacy at intervals of one to several days, all as take-home doses for use by the person in their home. Doses are in the ranges of 16 to 24 tablets of 8 mg hydromorphone daily. Most patients prescribed HMT will crush and inject the tablets.(3) The practice of HMT has not been peer-reviewed.
Current accessible options to treat Opioid Use Disorder for people using fentanyl are oral Opioid Agonist Treatments (OAT) with buprenorphine, methadone, or Slow Release Oral Morphine (SROM). F...
Show MoreCompeting Interests: Received honoraria from Indivior for speaking engagements. - Page navigation anchor for What constitutes a public health response to the opioid overdose epidemic?What constitutes a public health response to the opioid overdose epidemic?
I read with interest Dr. Tyndall's recent commentary in CMAJ which calls for the use of a regulated, low-barrier distribution of pharmaceutical-grade opioids to address the immediate challenges extant to today's opioid overdose epidemic. Of concern, however, is the statement that "the public health response to any poisoning epidemic should be to provide safer alternatives for people at risk." This statement follows a preceding paragraph that states that a number of "upstream" interventions are "critical to our response", but that the outcomes of these are longer-term and--to paraphrase--aren't meeting the immediate need.
The immediate thought that occurred to me was whether words "should be" might have been better phrased as "should include." Indeed, to distil down a complex problem that requires a comprehensive public health response to a single downstream intervention misunderstands the basic function of public health practice. Additionally, the pieces identified by Tyndall as being "upstream" but too far on the time horizon in fact constitute key elements of a public health response.
Public health's response to the opioid overdose epidemic must continue to be multifaceted. The response continues to be built on effective surveillance and evaluation to describe the shape and size of the issue and monitor the outcomes of interventions. Layered on this is partnership with the he...
Show MoreCompeting Interests: None declared.