The Ontario Public Drug Programs has recently announced its decision to de-list funding of higher strengths long acting opioids as of Jan 2017. These include:
- Morphone 200mg tablets (MS Contin 200mg SR tab, Novo-morphine SR 200mg, M0Eslon 200mg ER cap)
- Hydromorphone 24mg and 30mg capsules (Hydromorph Contin 24mg, Hydromorph Contin 30mg)
- Fentanyl 75mcg/hr and 100mcg/hr patches (generic brands of Fentanyl patches 75mcg/hr and 100mcg/hr)
This change is a result of an attempt to address the ongoing and escalating concerns of opioid misuse, abuse and diversion across Canada as well as many parts of the world.
According to 2010 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-cancer Pain, high-dose opioid prescribing is defined as any dose exceeding the equivalent of morphine 200mg/day. It is thought that there is little evidence to demonstrate any additional benefits when opioids are consumed above this limit of morphine 200mg/day or equivalent. This is how the Ontario Drug Benefit Program has arrived at the decision to de-list the above opioids.
We now have less than 6 months to address this funding decision with our prescribers and patients. So what are our options?
From reviewing the above guideline, here are some takeaway points from my perspective:
- Switch or stop the opioid. If the patient is experiencing adverse effects or not responding to the current opioid, one should consider switching to another opioid, or discontinue. Depending on the current dose, tapering may be needed. There is no universal tapering strategy and it ranges from 10-15% of dose reduction daily to every 2- 3 weeks. For the elderly population, this must be done very slowly. Also for patients with psychiatric conditions, it is important to monitor how changes in the pain regimen may trigger or worsen their mood or psychiatric symptoms.
- Revisit Opioid Trial Steps. Some patients who have been on opioids chronically may not have had the opportunity to follow through on the opioid trial steps. Perhaps this is an opportunity to review these steps again to ensure they have been addressed and documented.
1) Pain condition & diagnosis
2) Risk screening
3) Goal setting
4) Informed consent
5) Appropriateness of opioid selected and dose, and
6) Opioid effectiveness.
- Collaborate. It may be worthwhile to consult pain specialist or other health care providers as appropriate. This may lead to other recommendations or potential solutions to be explored or considered.
- Addiction Treatment. If tapering the opioid is not an option or unsuccessful, we may need to consider addiction treatment options. These include:
- Methadone or buprenorphine treatment
- Structured Opioid Therapy
- Abstinence-based treatment.
The Centres of Disease Control and Prevention (CDC) in United States has also recently released a guideline for prescribing opioids for chronic pain. I find that they also have some interesting recommendations that is worth reviewing. Check out my post on this guideline.
Finally, there is always the option to pay for the opioid that is not covered by Ontario Drug Benefits Program, or to dispense the larger quantity of the lower strength opioids that is reimbursed by the program. However, the latter approach can be considered cheating so I doubt many pharmacies will openingly agree to do so.