Prescription painkiller OxyContin, which will be delisted from Ontario's drug benefit program, at the in-patient pharmacy at Sunnybrook Health Sciences Centre in Toronto on Monday, Feb. 20, 2012.Michelle Siu for The Globe and Mail
A Northern Ontario coroner says the province's doctors and pharmacists need to take extra care in switching patients from OxyContin to other opioids, following the death of a man whose doctor changed his prescription and gave him an incorrect dose.
Purdue Pharmaceutical is discontinuing its popular painkiller OxyContin in favour of OxyNEO, which is harder to crush and, in theory, tougher to snort and inject. Several jurisdictions are going further to stem the problem: Starting this month, seven provinces and the federal government's health benefits program will pay for OxyNEO only in exceptional circumstances. This means a sudden shift in treatment for patients across the country.
Michael Wilson, regional supervising coroner for Northwestern Ontario, says the man who died lived in the Kenora-Rainy River-Thunder Bay area, and had been prescribed OxyContin for years to treat his chronic pain. He was covered by a federal government program for first nations and Inuit that ended its previous coverage of OxyContin on Feb. 15.
The man's doctor switched him to a different opioid, and he died of an apparent overdose shortly thereafter. It isn't yet clear how he took the drugs or what other factors were involved.
"It was clear on review there was an error," Dr. Wilson said. "An incorrect strength was prescribed, and dispensed."
Dr. Wilson sent an advisory to the Ontario Pharmacists' Association and the College of Physicians and Surgeons warning them to "work closely in determining the appropriate dosage for medications prescribed to replace the discontinued OxyContin."
"I'm not trying to establish responsibility or blame," he told The Globe and Mail, "but hoping to make recommendations that will prevent deaths in the future." He said he couldn't reveal the man's identity because of privacy concerns.
After more than a decade of misinformation around the addiction potential of opioids, experts say some family physicians remain in the dark about proper courses of treatment.
Mel Kahan, an addiction expert with the University of Toronto's family medicine department, says the death is "a strong argument in favour of stricter regulations and more training." Common substitutes for oxycodone – the active ingredient in OxyContin – include hydromorphone, fentanyl and morphine. Oxycodone is more potent than morphine, but less potent than hydromorphone and fentanyl.
While there are hundreds of opioid overdose deaths in Ontario every year, a tiny fraction of them – fewer than 1 per cent – are due to medical error, Dr. Kahan said.
Canada came out with lengthy opioid-prescription guidelines two years ago, but the guidelines aren't binding.
"Imagine you're a doctor in a busy office and you're seeing 60 to 70 patients a day and someone sends you a multi-page guideline. You're simply not going to have time to read it," said David Juurlink, a drug-safety specialist at Sunnybrook Health Sciences Centre in Toronto. "A substantial amount of re-education of physicians needs to take place. And that is no easy task."
But some worry "re-educating" doctors would just make them squeamish about prescribing painkillers altogether.
Several Colleges of Physicians and Surgeons across Canada say they have no intention of imposing more mandatory rules, or restricting when a doctor can prescribe these drugs, or in what doses.
"This is a very controversial area of medical practice. There are experts to defend liberal prescribing," Galt Wilson, deputy registrar of B.C.'s College of Physicians and Surgeons, said in an e-mail. "In that context, 'penalties' are almost impossible to impose."
Ultimately, Dr. Kahan argues, the question comes down to changing the behaviour of prescribing physicians. And without mandatory rules and penalties for breaking them, he says, that's not easy.
"Doctors have developed this habit, this response to chronic pain … that has caused a crisis. So how do you deal with that?" he reasons. "It's a rising epidemic, and it seems completely preventable. There is a sense of social responsibility to do this."