The CAMH in Toronto is asking for the review as part of its sweeping recommendations on how policy makers and physicians can address an epidemic of overdose deaths across Canada.Fred Lum/The Globe and Mail
Canada's largest mental-health and addictions hospital is calling on Ottawa to launch a review of all prescription painkillers available across the country and to pull high-dose opioid medications off the market.
The Centre for Addiction and Mental Health in Toronto is asking for the review as part of its sweeping recommendations on how policy makers and physicians can address an epidemic of overdose deaths across Canada.
"We need to better document what is contributing to the opioid load in any community," said Peter Selby, a clinician physician at CAMH. Is it large numbers of low-dose opioids, he asked, or moderate amounts of the high-dose medications? He said Health Canada should ban high-dose opioids for non-cancer care patients.
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A recent Globe and Mail investigation found that Ottawa and the provinces have failed to take adequate steps to address the overprescribing of a drug whose risks are substantial and benefits uncertain. The practice dates back two decades, when doctors began prescribing opioids to relieve moderate to severe pain as pharmaceutical companies promoted their benefits. In 2015, doctors wrote 53 opioid prescriptions for every 100 people in Canada, according to figures compiled for The Globe by IMS Brogan, which tracks pharmaceutical sales.
The CAMH policy framework, which will be released officially on Monday, says opioids are being prescribed too frequently and in overly high quantities and doses. "This excess supply of opioids has fuelled an epidemic of overdose deaths and addiction," the report says.
CAMH says Health Canada must do more than review all opioids on the market. The research hospital is also urging the federal Liberal government to approach the crisis "through a health lens, not a criminal one," and put its drug strategy back under the auspices of Health Canada.
As part of its war on drugs, the former Conservative government prosecuted low-level offenders and all but ignored harm-reduction measures, such as making an overdose antidote more widely available. The National Drug Strategy was renamed the National Anti-Drug Strategy in 2007, and moved from Health to the Justice Department.
The name change deepened the stigma for people addicted to opioids, said Dr. Selby, who helped prepare the recommendations.
"It's pretty bad when you have an anti-drug strategy," he said. "We don't have an anti-diabetes or an anti-cancer strategy."
CAMH's new policy framework is being unveiled less than two weeks before federal Health Minister Jane Philpott plays host to a national summit on opioids.
David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto, will deliver a keynote address at the gathering. Like CAMH, he will be calling on Health Canada to undertake a review of opioids, a class of painkillers that includes oxycodone, hydromorphone and fentanyl.
Dr. Juurlink suggested the federal drug regulator could start by looking at high-dose formulations, which the Ontario government has already announced it will stop paying for under its public drug plans in January.
"I think that the same move could be made by other provinces and, frankly, I think that Health Canada … should actually review whether or not these products should remain available in Canada," Dr. Juurlink said.
He pointed out that in the case of some of the high-dose formulations, a single pill or patch exceeds the equivalent of 200 milligrams of morphine per day, which the current Canadian prescribing guidelines consider a "watchful dose" – the threshold where doctors should more closely monitor patients.
The Canadian guidelines have not been revised since 2010, leaving them out of date with current research on the risks associated with taking painkillers. The maximum daily dose is four times the amount highlighted in new national guidelines for prescribing opioids in the United States.
The U.S. Guidelines, published in March by the Centers for Disease Control and Prevention, urge doctors to weigh the benefits and risks carefully when increasing a patient's dose to more than the equivalent of 50 milligrams of morphine a day and to avoid increasing dosages to more than 90 milligrams.
The Michael G. DeGroote National Pain Centre at McMaster University in Hamilton is overseeing the revision of the Canadian guidelines, which are scheduled for release in 2017. Until then, CAMH is urging doctors in Ontario to follow the CDC guidelines. Physician regulatory colleges in several other provinces have endorsed the CDC guidelines.
But medical experts cautioned that doctors must slowly wean their patients off opioids. If they lower the dose too quickly, they said, a patient could go into withdrawal and resort to using illicit fentanyl or other street drugs.
Jason Busse, an associate professor at McMaster University's Department of Anesthesia and co-lead of the group working on updating the Canadian guidelines, said the challenge in Canada is that many chronic-pain patients are on daily doses substantially higher than what the CDC guidelines recommend. Among a survey of 170 patients in long-term opioid therapy at McMaster's chronic-pain clinic, the median daily dose was 180 milligrams.
"There was a period of time where there was perhaps too free of a hand for prescribing and the pendulum's now swinging the other way," Dr. Busse said.
A spokesman for Dr. Philpott declined to say if the Health Minister would endorse a wholesale review of prescription opioids. But he pointed out that her previously released five-point plan promised some changes to opioid availability, including adding clear warnings for some of the products.
Karen Howlett
Kelly Grant