The two Western provinces hardest hit by Canada's overdose crisis are introducing new rules for prescribing opioids and other psychoactive drugs in efforts to curtail the use of legal medications behind an epidemic of painkiller abuse.
A recent regulatory case also highlights the need for explicit prescribing standards in Ontario, where illicit fentanyl is rapidly spreading to many communities, medical experts say.
Beginning April 1, physicians in Alberta will be required to first check a patient's medication history in either the province's Pharmaceutical Information Network (PIN) or an alternative, independent source before initiating or renewing a prescription for drugs such as opioids, benzodiazepines, sedatives and stimulants. This is to flag issues such as overprescribing and doctor-shopping.
Meanwhile, British Columbia is working on a similar guideline to require physicians to check patient history in the province's PharmaNet database before prescribing drugs with potential for misuse or diversion.
It is currently mandated for all physicians in transient-care settings, such as walk-in and methadone clinics; this will expand in phases to include other physicians who prescribe these drugs, likely starting next year, said College of Physicians and Surgeons of BC registrar Ailve McNestry.
As of January, less than one-third of the province's 11,574 physicians had access to the database.
Canada's epidemic of addiction and overdose deaths is rooted in the overprescribing of opioids, whose risks are substantial and benefits uncertain. In 2015, doctors wrote one opioid prescription for every two Canadians, according to figures compiled for The Globe and Mail by IMS Brogan, which tracks pharmaceutical sales. Canada ranks as the world's second-biggest consumer of prescription opioids.
Alberta's college began working on its new standard last year, spokeswoman Kelly Eby said: "We knew opioid prescribing was an issue and we needed to have more checks and balances in place to help address the problem."
In Alberta, 343 people died from apparent overdoses linked to fentanyl last year, according to the province. Of those, 24 per cent had filled a prescription for an opioid in the 30 days prior. Almost 40 per cent were prescribed opioids from three or more health-care providers.
Alberta's PIN database automatically flags for the college potential problem situations, such as when a patient sees more than one physician. However, it can take days or weeks for this alert to reach physicians; requiring physicians to check the PIN themselves closes this window. Approximately 70 per cent of physicians currently have access to the database.
"The college has a long-term plan in place that by 2020, all physicians will have access to PIN and be using it on a regular basis," Ms. Eby said.
Both colleges favour remedial approaches over disciplinary action for physicians who are flagged. In B.C., no physician has ever been disciplined for prescribing practices, but between 200 and 300 physicians are referred to educational programs each year, Dr. McNestry said.
In Alberta, one physician had a disciplinary hearing for prescribing, while between 15 and 20 have had prescribing restrictions placed on their practice, which is outside of the disciplinary process, Ms. Eby said.
A record 922 people died of illicit drug overdoses in B.C. last year, and fentanyl was detected in about 60 per cent of those deaths.
Meanwhile, a recent regulatory case also highlights the need for explicit prescribing standards in Ontario.
The case involves a doctor who put a patient's life in "serious jeopardy" by failing to act on her "long and destructive opioid dependency over the course of seven years," a provincial disciplinary panel has ruled.
The mother of the unidentified patient complained to the College of Physicians and Surgeons of Ontario in August, 2014, a year after her daughter attempted to take her own life. The doctor, identified only by the initials PAH, continued prescribing opioids rather than tapering her off, leaving her on four different painkillers, including OxyContin, at the time of the complaint. She died of an overdose on Nov. 19, 2014.
The suicide attempt should have raised a "red flag" for the doctor, "who did nothing to follow up after this incident and continued to prescribe the same medication," the college said in expressing "extreme concern" about the doctor's care. The college recommended that the doctor complete an education program and be clinically supervised for a few months. The patient's mother asked Ontario's Health Professions Appeal and Review Board to launch a review into the college's decision. In a decision released on Friday, the review board upheld the college's decision.
Meldon Kahan, medical director of the substance-use service program at Women's College Hospital in Toronto, said the unnamed doctor is far from alone in failing to manage a patient's addiction properly or in overprescribing opioids.
"He just didn't know what he was doing," Dr. Kahan said in an interview. "Unfortunately, so many doctors don't know what they're doing with respect to opiates."
The college did not launch disciplinary proceedings against the doctor. He initially prescribed opioids to the patient in 2007 to treat chronic pain from a back injury.
The review board notes in its decision that the college has expressed alarm that the doctor recently had been licensed to prescribe methadone, another opioid used to treat patients addicted to painkillers. Once again, however, there is nothing on the public record identifying the doctor.