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Commentary

A safer drug supply: a pragmatic and ethical response to the overdose crisis

Mark Tyndall
CMAJ August 24, 2020 192 (34) E986-E987; DOI: https://doi.org/10.1503/cmaj.201618
Mark Tyndall
School of Population and Public Health, University of British Columbia, Vancouver, BC
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  • RE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
    Brian J Myhill-Jones [MD, CCFP]
    Posted on: 06 April 2021
  • RE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
    Andrea Ryan [MD, CCFP (AM)], Andrea Sereda [MD, CCFP] and Nadia Fairbairn [MD, MHSc, FRCPC dip ISAM]
    Posted on: 28 October 2020
  • Addressing the Dual Public Health Emergency: Supporting Physicians to Prescribe Opioid Medications
    Nilanga Aki Bandara [BSc], Vahid Mehrnoush [MD] and Jay Herath [PhD]
    Posted on: 31 August 2020
  • RE: CMAJ 2020 articles on the overdose crisis in BC and a pragmatic and ethical response
    Melodie K. Herbert [BSN, MD, CCFP]
    Posted on: 24 August 2020
  • Posted on: (6 April 2021)
    Page navigation anchor for RE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
    RE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
    • Brian J Myhill-Jones [MD, CCFP], Clinical Assistant Professor, Department of Family Practice, UBC, Physician, OAT team, Sechelt, British Columbia

    I am responding to the commentary of Tyndall(1) in the January 2021 print CMAJ on opioid addiction and safe supply. The main reason that family physicians are reluctant to prescribe narcotics is the fear of reprimand from the Colleges of Physicians and Surgeons. No amount of physician “education” on opioid prescribing for risk mitigation as suggested by Bandara et al(2) will change the status quo until this issue is addressed.

    I will not reiterate all the excellent points made in this and 2 related letters in the issue(2,3). However, the article by Crabtree et al(4), is really an important study and revelation. As Tyndall illustrates, synthetic opioids such as fentanyl were the main factors in overdose deaths, with prescription drugs associated with only 7.7% of deaths. This is confirmed very recently by the BC Coroners Report on illicit drug toxicity(5). This study also confirmed that almost all the benzodiazepines were illicit ones, not those provided by prescription. These reports both clearly demonstrate that the emphasis on prescription regulation for Opioid Agonist Therapy by Colleges across Canada is misplaced. In fact, it very possible that this prohibition, as pointed out in the letter by Ryan et al, may lead to more deaths as many physicians are reluctant to prescribe risk mitigation drugs which might help avert these tragedies. In addition, the Colleges have a virtual zero tolerance for benzodiazepines prescribed with opioids. The BC Coroners Report clear...

    Show More

    I am responding to the commentary of Tyndall(1) in the January 2021 print CMAJ on opioid addiction and safe supply. The main reason that family physicians are reluctant to prescribe narcotics is the fear of reprimand from the Colleges of Physicians and Surgeons. No amount of physician “education” on opioid prescribing for risk mitigation as suggested by Bandara et al(2) will change the status quo until this issue is addressed.

    I will not reiterate all the excellent points made in this and 2 related letters in the issue(2,3). However, the article by Crabtree et al(4), is really an important study and revelation. As Tyndall illustrates, synthetic opioids such as fentanyl were the main factors in overdose deaths, with prescription drugs associated with only 7.7% of deaths. This is confirmed very recently by the BC Coroners Report on illicit drug toxicity(5). This study also confirmed that almost all the benzodiazepines were illicit ones, not those provided by prescription. These reports both clearly demonstrate that the emphasis on prescription regulation for Opioid Agonist Therapy by Colleges across Canada is misplaced. In fact, it very possible that this prohibition, as pointed out in the letter by Ryan et al, may lead to more deaths as many physicians are reluctant to prescribe risk mitigation drugs which might help avert these tragedies. In addition, the Colleges have a virtual zero tolerance for benzodiazepines prescribed with opioids. The BC Coroners Report clearly demonstrates that prescription benzodiazepines play virtually no role in overdose deaths.

    Enlightened support from the Colleges of all of our addiction teams and family physicians on the front lines is needed. Regulatory Colleges across Canada need to urgently re-evaluate their attitudes and regulations to make a significant difference in the death rate in light of this highly toxic drug supply. Colleges quite correctly emphasize evidence based care. Now, with this new evidence regarding drugs associated with overdoses, it is important to update and make changes, quickly, in order to save lives. Physician comfort in providing narcotics prescriptions will not change until the Colleges update current guidelines. In addictions medicine, the patient population is seriously ill, emotionally and often physically. It’s not surprising then, with their severe anxiety, some will benefit from anxiolytic medication. Indeed, reducing their anxiety related to acute stress will likely reduce the need to fall into opioid cravings and abuse. Physicians should provide Trauma Informed Care, individualized for each patient, itself a tenet of College doctrine. This should not exclude small doses of benzodiazepines in stable, monitored patients.

    Above all, Colleges need to provide unequivocal reassurance that no reprimand will follow implementation of modernized, evidence based guidelines regarding safe supply. Only then will physicians feel safe in providing these risk mitigation prescriptions.

    Show Less
    Competing Interests: None declared.

    References

    • 1. Tyndall M. A Safer Supply: A Pragmatic and Ethical Response to the Overdose Crisis, CMAJ 2020 August 24;192:E986-7. doi: 10.1503/cmaj.201618
    • 2. Ryan A. Measures to Support a Safer Drug Supply, CMAJ 2020 December 7:192: E1731. doi: 10.1503/cmaj.77303
    • 3. Bandera N. Addressing a Dual Public Health Emergency: Supporting Physicians to Presribe Opioid Medications, CMAJ 2020 December 7;192: E1731. doi: 10.1503/cmaj.77303
    • 4. Crabtree A. Toxicology and prescribed medication histories among people experiencing fatal illicit drug overdose in British Columbia, Canada.CMAJ 2020 August 24;192:E967-72. doi: 10.1503/cmaj.201618
    • 5. British Columbia Coroners Service. Report on Illicit Drug Toxicity, Type of Drug Data (Data to December 31, 2020). Posting date February 11, 2021
  • Posted on: (28 October 2020)
    Page navigation anchor for RE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
    RE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
    • Andrea Ryan [MD, CCFP (AM)], International Collaborative Addiction Medicine Research Fellow and Addiction Medicine Physician, BC Centre on Substance Use
    • Other Contributors:
      • Andrea Sereda, Family Physician
      • Nadia Fairbairn, Assistant Professor, Department of Medicine

    CMAJ recently published a commentary regarding safer supply, pharmaceutical alternatives to the poisoned drug supply fueling the overdose crisis(1). Tyndall’s article describes the roots of the overdose crisis; calling for a clear strategy to scale up safer supply prescribing(1). Addressing barriers to prescribing, coupled with decriminalization of drugs, is essential to realizing success of this approach.

    Tyndall indicates physician provision of safer supply has been met with reluctance and prescribing rates are falling short to impact the overdose crisis(1). This is in part due to prescription review programs by regulatory colleges, with perceived inappropriate prescribing being grounds for reprimand. Federal Minister of Health Patty Hajdu released a letter calling on colleges to support clinicians and increase access to safer supply(2). As the Minister points out, important measures to prevent opioid over-prescribing must be weighed against the need to prescribe pharmaceutical alternatives. Supporting clinicians to prescribe without fear of reprisal may impact access to safer supply.

    Prescribing rates, however, for even evidence-based therapies for opioid use disorder are low among physicians indicating the widespread adoption of safer supply prescribing will remain challenging(3). A practitioner-led model requires engagement from more clinicians, with access to a wider array of opioid formulations. Recently British Columbia implemented a Public Health Ord...

    Show More

    CMAJ recently published a commentary regarding safer supply, pharmaceutical alternatives to the poisoned drug supply fueling the overdose crisis(1). Tyndall’s article describes the roots of the overdose crisis; calling for a clear strategy to scale up safer supply prescribing(1). Addressing barriers to prescribing, coupled with decriminalization of drugs, is essential to realizing success of this approach.

    Tyndall indicates physician provision of safer supply has been met with reluctance and prescribing rates are falling short to impact the overdose crisis(1). This is in part due to prescription review programs by regulatory colleges, with perceived inappropriate prescribing being grounds for reprimand. Federal Minister of Health Patty Hajdu released a letter calling on colleges to support clinicians and increase access to safer supply(2). As the Minister points out, important measures to prevent opioid over-prescribing must be weighed against the need to prescribe pharmaceutical alternatives. Supporting clinicians to prescribe without fear of reprisal may impact access to safer supply.

    Prescribing rates, however, for even evidence-based therapies for opioid use disorder are low among physicians indicating the widespread adoption of safer supply prescribing will remain challenging(3). A practitioner-led model requires engagement from more clinicians, with access to a wider array of opioid formulations. Recently British Columbia implemented a Public Health Order expanding access to safer supply by authorizing prescribing by registered nurses. This is a major step for increasing access to safer supply.

    In Ontario, safer supply programs have been in place for up to 5 years showing initial results of decreased overdose, decreased infections, improvements in chronic disease management and decreased illegal activities to fund illicit drug purchase(4). These programs are creating compelling evidence that many of the harms of illicit drug use are in fact related to prohibition of these substances and our societal response to their use(4). PM Justin Trudeau specifically indicated that decriminalization of drugs is not being considered and that safer supply is the government’s key priority for addressing the overdose crisis(5). However, criminalizing drugs and the people who use them disproportionately impacts poor and racialized groups, undermining efforts made to improve access to health care services, such as safer supply. Government officials should look to decriminalization as part of next steps to support expanded access to safer supply. This would require legislative change and coordination amongst government agencies, as has been done in response COVID-19.

    Swift and decisive action has been crucial to Canada’s success limiting COVID-19. The same emphatic response is needed now combat the overdose crisis. Clinicians must be supported by regulatory colleges to prescribe in tandem with decriminalization of drugs and people who use them.

    Show Less
    Competing Interests: None declared.

    References

    • Tyndall M. A safer drug supply: a pragmatic and ethical response to the overdose crisis. CMAJ 2020 192 (34) E986-E987.
    • Hajdu P. Letter from the Minister of Health regarding treatment and safer supply. 2020.
    • Guan Q, Khuu W, Spithoff S, Kiran T, Kahan M, Tadrous M, et al. Patterns of physician prescribing for opioid maintenance treatment in Ontario, Canada in 2014. Drug Alcohol Depend. 2017;177:315-21.
    • Bonn M, Felicella G, Johnson C, Sereda A. COVID-19, substance use, and safer supply: Clinical guidance to reduce risk of infection and overdose. 2020.
    • Woo A. Trudeau says focus is on safe supply, not decriminalization as overdose deaths spike. The Globe and Mail. 2020.
  • Posted on: (31 August 2020)
    Page navigation anchor for Addressing the Dual Public Health Emergency: Supporting Physicians to Prescribe Opioid Medications
    Addressing the Dual Public Health Emergency: Supporting Physicians to Prescribe Opioid Medications
    • Nilanga Aki Bandara [BSc], Teaching Assistant, University of British Columbia
    • Other Contributors:
      • Vahid Mehrnoush, Post-doctoral Research Fellow
      • Jay Herath, Instructor

    Tyndall’s article (1) provides timely insight regarding the overdose epidemic. The COVID-19 pandemic poses unprecedented risk to Canadians with opioid use disorder, who- already marginalized -are quite dependent on in-person health care delivery. In regard to COVID-19 prevention, the Canadian Government defines clinically vulnerable people as those with “mild to moderate respiratory disease” or with a “weakened immune system as the result of certain conditions or medicines they are taking” and are advised to take extra care. Thus, patients with chronic opioid dependence should be included in the clinically vulnerable high-risk group, this means we need to create healthcare policies supporting them.

    Due to COVID-19, there is a severe shortage of clean opioids for these patients. Hence, rapid action on the part of the healthcare community is needed to mitigate the risks of disrupted care for these patients. The COVID-19 pandemic has reversed system-level gains in expanding access to medication for opioid use disorder and halted critical opioid research on prevention and care. Resultantly, rises in opioid overdose-related problems have been seen due to multiple factors (1).

    A key point in this article is that physicians in BC have been cautious prescribing opioid medications despite clinical guidance provided during the COVID-19 pandemic (1). The cautious approach to prescribing opioid medications may be the result of messages physicians have seen (2). These m...

    Show More

    Tyndall’s article (1) provides timely insight regarding the overdose epidemic. The COVID-19 pandemic poses unprecedented risk to Canadians with opioid use disorder, who- already marginalized -are quite dependent on in-person health care delivery. In regard to COVID-19 prevention, the Canadian Government defines clinically vulnerable people as those with “mild to moderate respiratory disease” or with a “weakened immune system as the result of certain conditions or medicines they are taking” and are advised to take extra care. Thus, patients with chronic opioid dependence should be included in the clinically vulnerable high-risk group, this means we need to create healthcare policies supporting them.

    Due to COVID-19, there is a severe shortage of clean opioids for these patients. Hence, rapid action on the part of the healthcare community is needed to mitigate the risks of disrupted care for these patients. The COVID-19 pandemic has reversed system-level gains in expanding access to medication for opioid use disorder and halted critical opioid research on prevention and care. Resultantly, rises in opioid overdose-related problems have been seen due to multiple factors (1).

    A key point in this article is that physicians in BC have been cautious prescribing opioid medications despite clinical guidance provided during the COVID-19 pandemic (1). The cautious approach to prescribing opioid medications may be the result of messages physicians have seen (2). These messages stigmatize opioids and create fear amongst physicians, as they worry their patients may become addicted and succumb to their addiction (2). It is important to address the discomforts physicians have in regard to prescribing opioids. Moreover, additional factors exist around opioid medications have to be considered including socioeconomic status, mental health and substance use problems (3). These factors create a situation where it is less likely physicians prescribe opioid medications.

    We suggest further resources be created to support physicians become more comfortable prescribing opioid medications, as most physicians lack training to optimally prescribe opioids (4). The current guidelines in BC- addressing both the overdose and COVID-19 crises -provide a great deal of clinical support for prescribing healthcare professionals including valuable case studies (5). However, these guidelines would benefit from additional resources to support healthcare professionals reflect on their positionality in regard to prescribing opioids and to develop additional confidence in their ability to manage patients with opioid use disorder. Specifically, programs similar to the BC project ECHO on substance use disorder- it supports care providers assist patients with opioid use -are valuable resources that should be included in clinical guidelines. Resources that support health care professionals better understand how to use opioids empowers us to make evidence-based decisions confidently.

    Show Less
    Competing Interests: None declared.

    References

    • Mark Tyndall. A safer drug supply: a pragmatic and ethical response to the overdose crisis. CMAJ 2020;192:E986-E987.
    • von Gunten C. The Pendulum Swings for Opioid Prescribing. Journal of Palliative Medicine. 2016;19(4):348-348.
    • Webster F, Rice K, Katz J, Bhattacharyya O, Dale C, Upshur R. An ethnography of chronic pain management in primary care: The social organization of physicians’ work in the midst of the opioid crisis. PLOS ONE. 2019;14(6):e0215148.
    • Comerci G, Katzman J, Duhigg D. Controlling the Swing of the Opioid Pendulum. New England Journal of Medicine. 2018;378(8):691-693.
    • Ahamad K, Bach P, Brar R. Risk mitigation: in the context of dual public health emergencies. [Internet]. Bccsu.ca. 2020 [cited 28 August 2020]. Available from: https://www.bccsu.ca/wp-content/uploads/2020/04/Risk-Mitigation-in-the-Context-of-Dual-Public-H
  • Posted on: (24 August 2020)
    Page navigation anchor for RE: CMAJ 2020 articles on the overdose crisis in BC and a pragmatic and ethical response
    RE: CMAJ 2020 articles on the overdose crisis in BC and a pragmatic and ethical response
    • Melodie K. Herbert [BSN, MD, CCFP], retired family doctor, worked at the Fraser Valley Cancer Centre, and at Peace Arch District Hospital

    Thank you for the study, showing that prescribed opioids are rarely implicated in overdose deaths, and for M. Tyndall's response, which acknowledges that opioid addiction and overdose deaths are most commonly in people who have experienced trauma, mental health problems, etc. Physician prescriptions for opioids are not the driving force of this fatal overdose crisis. As a retired GP I am happy to see the promotion of harm reduction strategies and decriminalization of illicit substance use.

    Competing Interests: None declared.

    References

    • Mark Tyndall. A safer drug supply: a pragmatic and ethical response to the overdose crisis. CMAJ 2020;192:E986-E987.
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Mark Tyndall
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