Ontario government takes steps to combat opioid addiction

[Ontario’s drug plan will no longer cover high-dose opioids/Canadian Press]

De-listing high-dose opioids from Ontario’s drug plan can help reduce the harms of addiction, as long as access is maintained for those who need the narcotics the most, one medical expert says.

“It’s a very consistent policy decision,” says Dr. Norm Buckley, who is on the executive council of the Canadian Centre on Substance Abuse’s First Do No Harm strategy. “The Ministry of Health in Ontario has been trying to recognize the problems that arise from high-dose prescribing.”

Earlier today, the province announced that Ontario’s drug plan will no longer cover high-dose opioids in order to help curb prescription painkiller abuse.

According to a notice posted on the Ontario Ministry of Health’s website, the decision means that all opioids that exceed the equivalent of 200 milligrams per day will no longer be covered by the provincial drug plan.

“The inappropriate use, abuse and diversion of prescription narcotics has emerged as a significant public health and safety issue in Canada and other jurisdictions around the world,” the notice reads.

This decision makes Ontario the first province to make such a move amidst a growing number of opioid-related deaths across Canada.

In June, British Columbia’s college of physicians released Canada’s first mandatory standards for prescribing opioids. Modeled on American guidelines, those standards include only prescribing the drugs a few days at a time and starting patients on lower doses.

But the Ontario decision does not - and should not - mean that the province is no longer funding opioid prescriptions at all, says Buckley.

“Nobody is advising physicians to withdraw care,” Buckley says. “Making [opioids] available even in a multi-tablet preparation, as long as it’s available I think you’re less likely to drive [patients] to the black market.”

What drives patients to the black market, he says, is a feeling of desperation and abandonment by their care providers; or the withdrawal of care altogether.

Expanding care for chronic pain beyond opioids is another part of reducing the harms that come with the narcotics, Buckley says. Until recently, that hasn’t been the case in most provinces.

Last year, Ontario announced funding for university-affiliated pain clinics, such as the one Buckley works with at McMaster University in Hamilton. These institutions have helped to expand the spectrum of care options available to those managing chronic pain, he says.

For those who require opioids, it would be dangerous to simply remove access, Buckley says.

Instead, he recommends providing higher doses in smaller chunks - for example, five 6-milligram pills versus one 30-milligram pill - can give patients the relief they need while reducing some of the risks of opioid use.

“The fact is that you can still deliver care without using large-dose preparations because you can simply give more smaller pills,” Buckley says. “For the patient who requires higher doses, we’ll still be able to do that.”

Ontario’s move may inspire similar changes in other parts of Canada depending on their particular needs and resources, Buckley says. In other provinces and territories, high-dose opioids are still listed on drug formularies as either general benefits or restricted access.

Ontario’s move mirrors the approach taken in the United States, which is managing its own increase in opioid overdoses and deaths.

Other solutions will require a national approach, something advocated for through CCSA’s First Do No Harm strategy.

For example, patients who pay for opioids out of pocket or have them covered through private insurance will still be able to access large-dose formulations in Ontario. Changing that may require action like federal changes to approved dosage formulations of individual medications, Buckley says.

"We’ve set up a false battle between treating pain and avoiding addiction,” Buckley says. “You want to be sure that you’re prescribing appropriate medications for people who require them, but also that you’re taking the appropriate approach to treating whatever problem people have.”