Safety of fentanyl initiation according to past opioid exposure among patients newly prescribed fentanyl patches

Freisen and colleagues have provided invaluable insight into unsafe opioid prescribing in Canada over a time when we have seen unprecedented increases in prescriptions for these medications(1) and consequently the number of associated harms, including death(2,3).

As an opioid prescribing educator, I certainly agree with Lucyk and Nelson's contention in their linked commentary(4) that we require improved prescriber education. However, given the breadth of the crisis before us, our approach to unsafe prescribing needs to be far more comprehensive, rational and coordinated.

An excellent example of the disconnectedness of our current efforts comes from British Columbia and the decision of that province's regulatory college to set new standards for opioid prescribing for chronic non-cancer pain based on the recently released CDC guidelines(5). These new standards include what essentially amounts to a maximum dose of 90 MEQ (milligrams of morphine equivalent). Yet, as just one example, that province still carries transdermal fentanyl on formulary in doses more than four times this maximum in the form of 100mcg fentanyl patches (400 MEQ). We know with certainty that decisions about what is available on formulary influences prescribing practices(1,6). With multiple inconsistent factors influencing prescriber behaviours how can we expect a consistent response from physicians? In no other area of medicine do we see, or would we tolerate, such divergence and inconsistency of prescribing practices(7).

As we continue to recognize the lack of good evidence for the use of strong opioids in chronic non-cancer pain (despite what Lucyk and Nelson claim in their commentary about the effectiveness of fentanyl) and the significant harms associated with their use, it is time that policy makers, regulators, educators, prescribers and the public come together to form a consistent, rational and safe approach to the use of these potent medications.

References

1. Gomes T, Mamdani MM, Paterson JM, Dhalla IA, Juurlink DN. Trends in high-dose opioid prescribing in Canada. Can Fam Physician. 2014 Sep 1;60(9):826-32.

2. Sproule B, Brands B, Li S, Catz-Biro L. Changing patterns in opioid addiction: characterizing users of oxycodone and other opioids. Can Fam Physician. 2009 Jan 4;55(1):68-9, 69.e1-5.

3. Dhalla IA, Mamdani MM, Sivilotti ML, Kopp A, Qureshi O, Juurlink DN. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ. 2009 Dec 2;181(12):891-6.

4. Lucyk S, Nelson L. Consequences of unsafe prescribing of transdermal fentanyl. CMAJ. 2016 Jun 2;188(9):638-9.

5. https://www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf

6. Fischer B, Jones W, Murphy Y, Ialomiteanu A, Rehm J. Recent Developments in Prescription Opioid-related Dispensing and Harm Indicators in Ontario, Canada. Pain Physician. 2015 Jan 4;18(4):E659-62.

7. Dhalla IA, Mamdani MM, Gomes T, Juurlink DN. Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Can Fam Physician. 2011 Mar 2;57(3):e92-6.

Conflict of Interest:

None declared