What is happening with the opioid crisis in Canada? What should I know to use opioids safely with palliative care patients?

Medications

Background on the Opioid Crisis

The opioid overdose crisis refers to the rise in opioid overdose deaths. The crisis has resulted in prominent media coverage and has become a major Canadian health concern. Unfortunately, for many health care providers, patients and families, this has impacted perceptions regarding the usefulness of opioids in symptom management for palliative care patients.

The issues in the current opioid crisis are primarily a result of illegally obtained fentanyl or carfentanil being used for non-medical reasons. Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine. Carfentanil is chemically similar to fentanyl; 10,000 times more potent than morphine; and is not prescribed in humans due to its extreme toxicity. Fentanyl and carfentanil are added to illicit drugs and taken by users who believe they are taking another product such as oxycodone or heroin. ^[1]Drug dealers do this to boost profit margins because they are less expensive and easier to make.

Current street drugs can contain a variety of drugs with unknown potencies mixed together, which is resulting in significant overdoses and causing an increase in opioid-related deaths. This increase was first noticed in British Columbia and Alberta, with the crisis then spreading across Canada.

In 2016, the government acknowledged that the opioid crisis is a multifaceted issue with devastating effects on many communities. Health Canada recognized the need to have a national strategy, and three documents were developed to initiate change.

1) Health Canada's Action on Opioid Misuse, which includes the following 5 actions:

Better informing Canadians about the risks of opioids.
Supporting better prescribing practices.
Reducing easy access to unnecessary opioids.
Supporting better treatment options for patients.
Improving the evidence base. ^[2]

2) Joint Statement of Action to Address the Opioid Crisis, which represents the commitment of the health ministers and other organizations to take action on this complex health and social issue. ^[3]

3) Canadian drugs and substances strategy: A comprehensive, collaborative, compassionate and evidence-based approach to drug policy. This document calls for:

Prevention - Preventing problematic drug and substance use.
Treatment - Supporting innovative approaches to treatment and rehabilitation.
Harm reduction - Supporting measures that reduce the negative consequences of drug and substance use.
Enforcement - Addressing illicit drug production, supply and distribution.
The above strategies to be supported by a strong evidence base. ^[4]

Addressing Concerns of Patients and Families

Patients and families may have concerns about considering fentanyl to manage symptoms at end of life based on the information they hear from the media. Note that fentanyl used properly in palliative care patients is not leading to the fentanyl overdose crisis. Opioid-related overdose or death is uncommon when opioids are:

Prescribed appropriately.
Used for legitimate pain or dyspnea control.
Monitored closely for efficacy.

It is crucial that patients and families understand this as well as the difference between opioid tolerance, opioid dependence and opioid addiction.

Opioid tolerance – Addiction is uncommon when opioids are prescribed and used properly for pain control. The body does develop opioid tolerance as it becomes used to the medication, and the dose may need to be increased.

Opioid physical dependence – refers to the likelihood that the symptoms of withdrawal will occur should an opioid be stopped suddenly. Because of this susceptibility to physical withdrawal, opioid doses are weaned when they’re no longer being used. Patients will continue to require opioid medications to manage their pain or dyspnea unless the underlying cause of the symptom goes away.

Addiction – occurs when there is an overwhelming preoccupation with obtaining more medication, without any medical need for it.

According to the Centre for Addictions and Mental Health, a simple way to describe addiction “is the presence of the 4 Cs:

Craving
Loss of control of amount or frequency of use
Compulsion to use
Use despite consequences.”

It’s very uncommon for people to develop addiction when they use opioids in palliative care as prescribed by their health care provider to manage symptoms.

Safety Considerations with Opioids

Guidelines and Standards

Guidelines and standards have been developed to address opioid-related issues in health care. These documents are usually written to provide guidance in managing chronic pain, addiction or diversion issues and may not fully apply to palliative care pain situations. However, the suggestions for safe opioid prescribing, handling and disposal need to be recognized and adhered to by all health care providers.

Suggestions for safe opioid use in the palliative care population include the following:

Thoroughly and frequently assess pain and other symptoms.
Determine a clinical diagnosis and objective evidence when prescribing and re-evaluating medications with a patient.
Consider the use of an opioid risk assessment tool when initiating opioid medications.
Carefully evaluate concurrent medical conditions when prescribing opioids.
Perform regular reviews of patient prescriptions and medication usage through the provincial/territorial medication database.
Have one prescriber for a patient’s pain medications.
Utilize one pharmacy for the dispensing of all medication prescriptions.
When a patient is discharged from an acute care setting, prescribe only the quantity of opioids that will be required prior to community follow-up being resumed.
In cases of long term opioid use, do not exceed a three-month supply and consider specific instructions on refill information within this time frame.
Consider random pill counts and/or random urine drug testing for patients on opioids.
When patient assessment or reassessment reveals a diagnosis of a substance use disorder, strongly consider consultation with addiction medicine specialists.
When patient assessment or reassessment reveals a history of a mental health diagnosis, consider consultation with a psychiatrist or other mental health services.
Consider consultation with a palliative care specialist/team if pain management is complex, or when suggestions for managing pain are desired.
Educate patients and families on the safe storage of medications. Advise that prescription medications, especially opioids, should be securely stored and preferably locked. This will decrease the potential for other household members (especially children) deliberately or accidentally taking these medications.
Ensure medications that are not being used are returned to the pharmacy. This would include: when a patient is prescribed a new medication or dose, and upon the death of a patient.

In Conclusion

Diversion, misuse and abuse are potential patient safety issues that can be reduced when health care providers are vigilant with implementing safe opioid prescribing, initiation, titration and monitoring. As health care providers taking care of palliative care patients, we need to educate patients and families about the safe use, handling and storage of opioids, which includes ensuring there is a plan for safe removal of opioids from a home following the patient’s death.