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- Page navigation anchor for RE: A safer drug supply: a pragmatic and ethical response to the overdose crisisRE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
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 MoreCompeting 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
- Page navigation anchor for RE: A safer drug supply: a pragmatic and ethical response to the overdose crisisRE: A safer drug supply: a pragmatic and ethical response to the overdose crisis
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 MoreCompeting 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.
- Page navigation anchor for Addressing the Dual Public Health Emergency: Supporting Physicians to Prescribe Opioid MedicationsAddressing the Dual Public Health Emergency: Supporting Physicians to Prescribe Opioid Medications
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 MoreCompeting 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
- Page navigation anchor for RE: CMAJ 2020 articles on the overdose crisis in BC and a pragmatic and ethical responseRE: CMAJ 2020 articles on the overdose crisis in BC and a pragmatic and ethical response
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.