Pubdate: Sat, 19 Aug 2017
Source: Globe and Mail (Canada)
Copyright: 2017 The Globe and Mail Company
Contact:  http://www.theglobeandmail.com/
Details: http://www.mapinc.org/media/168
Authors: Benedikt Fischer and Mark Tyndall
Page: S3

THE OPIOID INTERVENTIONS CANADA NEEDS NOW

Canada is in the grip of an unprecedented opioid crisis. An estimated
2,458 Canadians died of opioid-related overdose deaths in 2016 - more
than the national count of motor-vehicle accident and homicide deaths
combined. British Columbia reported 967 (mainly opioid) drug-overdose
fatalities in 2016, and is on track for 1,500 in 2017. Alberta and
Ontario have also seen substantial increases. Numerous interventions
have been discussed and initiated recently - yet, the number of deaths
continue to rise.

Part of this deadly stalemate relates to the fact that, underlying the
opioid crisis are two paradoxically linked challenges - neither of
which are adequately understood or addressed by current responses. On
the one hand, a substantial portion of the present crisis is due to
years of systemic and non-evidence based overprescribing, which put
too many people, for too long, on too high doses, of opioid drugs. To
counter this, excessive opioid prescribing levels have to be
substantially reduced in order to prevent even more Canadians being
exposed to opioid misuse, dependence and undue death. These sensible
reductions in harmful opioid prescribing at the individual and
population level are the central objective of newly tabled Canadian
prescription guidelines.

However, reductions in opioid prescribing are not occurring in a
vacuum and are generating substantial collateral damage. While
concrete numbers are lacking, it is estimated several hundred thousand
Canadians are problematic opioid users (including those with
dependence). While trauma, pain and mental illness often facilitate
substance use, most people using opioids non-medically began or
sustained their drug use with access to medically prescribed opioids.
In addition to systemic overprescribing, the supply of pharmaceutical
opioids is generated through double-doctoring, symptom feigning and
diversion through or with the help of others. However, while engaging
in "non-medical use," the supply of opioids mostly originated from
within the medical system, hence providing relatively predictable drug
potency and purity.

Yet, here is the critical dilemma: An unintended consequence of
recent, well-intentioned efforts to curtail opioid overprescribing has
resulted in marked reductions in medical opioid supply. These supply
gaps have resulted in an emerging illegal, potent and toxic drug
supply, including illegally produced fentanyl and carfentanyl and
other illegal drugs laced with toxic opioid analogs. This dynamic, at
least in British Columbia and Alberta, has fuelled the majority of
recent opioid overdose deaths. Thus, the present challenge is to
devise strategies that simultaneously address both these core fronts
of the opioid emergency in ways that minimize further unintended
consequences. While excessive opioid prescribing must be reduced, it
is equally important that those Canadians with existing problematic
opioid use - i.e. those at greatest risk for overdose deaths - are not
suddenly deprived of their (relatively) safe opioid supply.

Standard 'harm reduction' interventions - for example, naloxone
programs or supervised consumption facilities - even if greatly
expanded, are unlikely to substantially reduce the overdose toll in an
environment of a toxic drug supply. Nor can this be achieved through
sole reliance on evidence-based addiction treatment programs (e.g.,
opioid, even if these include heroin-based, pharmacotherapy
treatment), as these approaches are neither feasible to the required
scale, nor do they provide desirable options for many at-risk users.
In other words: These measures reach too few at-risk people with too
little protective impact in the current crisis scenario.

What is urgently required is creative thinking outside of the box.
Thus, we concretely propose, at least for the regional hotspots of the
present emergency, a comprehensive program to provide the at-risk
opioid user population a safer opioid drug supply for survival. For
ideal reach and impact, such a protective program would identify and
register current high-risk opioid users to - at least temporarily -
receive access to safe opioid medications through the public health
system (e.g., hospitals, community clinics, mobile distribution). This
targeted distribution program would - as an emergency measure - seek
to protect vulnerable, treatment-resistant opioid-dependent users from
acute risk of overdose, while providing links to addiction treatment
and other services where desired. The details of such an emergency
distribution program should be tailored to regional contexts, and
developed with input from key stakeholders (e.g., public health and
medical authorities, law enforc! ement, first responders).

This opioid distribution program for high-risk users would be an
emergency measure to respond to an exceptional public health crisis.
Its underlying idea resembles the "British System" of medical
narcotics prescribing in Britain (1920s to 60s). Combined with
initiated reductions in inappropriate opioid prescribing, these
measures have the potential to significantly reduce the number of
opioid overdose deaths in the short-term, while addressing the
long-term hazards of excessive opioid availability in the population.
This would be in the interest of the health and safety of all Canadians.

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Benedikt Fischer is a senior scientist at the Institute for Mental 
Health Policy Research, Centre for Addiction and Mental Health and a 
professor of psychiatry at the University of Toronto. Mark Tyndall, is 
Executive Medical Director at the BC Centre for Disease Control, and 
professor at the School of Population and Public Health, University of 
British Columbia.
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MAP posted-by: Matt