A Changing Landscape
Beth Sproule, RPh, BScPhm, PharmD 1,2
Maria Zhang, RPh, BScPhm, PharmD, MSc 1,2
1 Centre for Addiction and Mental Health, Toronto, Ontario
2 Leslie Dan Faculty of Pharmacy, University of Toronto
Opioid-related mortality continues to increase significantly in Ontario. In 2020 alone, there were 2,426 opioid-related deaths in our province, representing a 60% rise from 2019.1 The illicit fentanyl supply is a key driver of the current opioid crisis as it directly contributed to 87% of the deaths in 2020.1 The COVID-19 pandemic has only worsened this public health crisis, likely related to changes in the illegal drug supply due to supply disruptions, less access to services and harm reduction supports, and greater use of substances to cope with stress.2
SO HOW CAN PHARMACISTS HELP?
The roots of the crisis lie, in part, in the rise of prescription opioid availability over the last two decades and those risks are still present.3-5 Continuing to advance and improve our opioid stewardship activities is critical in helping to prevent our patients from developing opioid use disorder and other iatrogenic opioid-related sequelae. Also, our take-home naloxone kit distribution efforts are vital in preventing overdose-related deaths. Between July 1, 2017 and June 30, 2018, Ontario pharmacies dispensed 91,456 take-home naloxone kits, accounting for 62% of all kits distributed in the province.6 Unfortunately, the impact may be dampened as many deaths occur without anyone else present to intervene.1 Knowing this, pharmacists can ensure that their patients who use drugs know of local resources such as safe consumption/injection sites, and other harm reduction practices such as using drugs with a trusted family member or friend, in a space where they could be found quickly, and/or utilizing supports available, such as the National Overdose Response Service hotline (nors.ca) or technology such as Brave App or Lifeguard App.
For individuals living with opioid use disorder, there is an additional evidence-based effective method to saving lives where pharmacists play a central role – treating opioid use disorder. Pharmacotherapy is the most effective treatment for opioid use disorder, and we know that opioid agonist therapy (OAT) saves lives. The mortality risk is significantly reduced for people with opioid use disorder while in OAT treatment compared to out of OAT treatment – even in the era of illicit fentanyl.7
At the same time, the approach to providing OAT services is evolving as the opioid crisis advances, and we are experiencing fundamental change in Ontario. The most significant shift is the change in the role of the College of Physicians and Surgeons of Ontario (CPSO) in setting the standards of practice for methadone treatment. The CPSO Methadone Maintenance Treatment Program Standards and Clinical Guidelines from 2011 were rescinded in March 2021.8 This decision was taken because it was perceived that the exceptional status of methadone, and the high degree of oversight, disincentivized physicians in offering the service, thus limiting access for patients.8 This is similar to the rationale for Health Canada’s 2018 decision to remove the Section 56 exemption requirement for methadone prescribers – to improve access to treatment.9 Other recent practice changes include the adoption of non-traditional techniques for initiating buprenorphine (e.g., microdosing and/or home inductions)10, the availability of new long-acting buprenorphine formulations (i.e., extended release injection and subdermal implant)10, modified approaches for methadone treatment for people using fentanyl11, increasing acceptance of slow-release oral morphine (SROM) for opioid use disorder12, injectable OAT treatment options (i.e., hydromorphone, diacetylmorphine)13 and the growing availability of safer supply programs.14,15 The goal of this article is to help pharmacists navigate these changes by highlighting the current guidance available and key messages.
KEY RESOURCES FOR PHARMACISTS
Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder
Release date: May 2021
Developed by: Centre for Addiction and Mental Health with medical regulatory authorities across Canada including the College of Physicians and Surgeons of Ontario
Place in practice: Detailed national guideline on opioid agonist therapy synthesized from provincial standards and guidelines with updates and additional expert opinion
OAT discussed: Buprenorphine, methadone, slow-release oral morphine, and injectable OAT
Topics covered: Broad ranging (e.g., engaging patients, building relationships, expectations of prescribers, how to choose treatments, best practice summaries)
Take note: Updated guidance on the value of urine drug testing and ECGs, non-traditional buprenorphine induction strategies, when to use SROM
Methadone treatment for people who use fentanyl: Recommendations
Release date: June 30, 2021
Developed by: Mentoring, Education, and Clinical Tools for Addiction: Partners in Health Integration (META:PHI), a provincial initiative based at Women’s College Hospital
Place in practice: For experienced prescribers who are able to apply clinical judgment when using these methadone treatment recommendations for people who use fentanyl as they have uniquely high opioid tolerance
OAT discussed: Methadone only, specifically for people who use fentanyl
Topics covered: How to initiate, titrate, and stabilize methadone treatment, balancing the risks of methadone toxicity with the significant dangers associated with illicit fentanyl use if OAT is not available or if treatment needs to be restarted
Take note: Recommendations around when and how to use the upper end of the dose ranges, add slow-release oral morphine to prioritize engagement and retention in treatment. Likewise, alternative management of missed doses is suggested to avoid treatment drop-out. A webinar recording and a plain language summary are also available through META:PHI.
COVID-19 Opioid Agonist Treatment Guidance
Release date: March 2020; last updated December 2020
Developed by: Collaborators from CAMH, META:PHI, Ontario Medical Association (OMA)
Place in practice: Helps clinicians navigate buprenorphine and methadone treatment as it relates to the COVID-19 pandemic restrictions specifically.
OAT discussed: Buprenorphine and methadone
Topics covered: Modified buprenorphine and methadone take-home doses, frequency of visits
Take note: Focuses on increasing the number of take-home doses for patients to reduce the need for pharmacy visits. The changes during the pandemic are being evaluated to help determine whether the take-home dose strategies should go back to usual after the pandemic or not. An accompanying guide for pharmacists was developed by CAMH.
OTHER EMERGING PRACTICES
Injectable forms of OAT (i.e., injectable hydromorphone and diacetylmorphine) have a well-developed evidence base over many years supporting their use for people who have not responded to oral OAT options.16 iOAT programs function similarly to other OAT programs, however, patients visit the clinic multiple times per day to inject prescribed pharmaceutical diacetylmorphine or hydromorphone. The clinics are staffed by trained healthcare professionals and peer support workers who can intervene quickly in cases of overdose. These programs have limited availability in Ontario, however, there is ongoing work to develop resources, raise awareness, provide support and identify and address barriers to this evidence-based treatment.17 A significant hindrance is the limited availability of funding support. Clinical and operational guidance are available for clinicians and health administrators through the Canadian Research Initiative in Substance Misuse.
Safer Supply Programs function as an additional response to the overdose crisis, with the goal to reduce the risk of overdose and overdose deaths by providing pharmaceutical opioids as an alternative to the toxic illicit supply. This harm reduction approach is intended to support those who continue to meet criteria for opioid use disorder despite being in OAT programs and/or individuals who face barriers in accessing OAT. Safer supply programs are generally offered through primary care settings (Community Health Centres or primary care clinics) allowing engagement in other health and social supports. A common model utilized is to provide a supply of SROM (daily observed dosing) in combination with take-home hydromorphone immediate-release tablets. Health Canada is supporting safer supply programs in Ontario allowing expansion of current programs and the development of new programs.14,18,19 These include programs that provide scheduled dispensing through machines accessed using biometrics (MySafe Project).20 Evaluation of these programs is underway to help guide the way forward. It will be helpful to have more information on the benefits of these programs (reduced harms related to opioid use, improved health and social outcomes), as well as how to mitigate potential unintended consequences (e.g., health complications from injecting tablets, tablet diversion to new users). A guidance document is available at Safer Opioid Supply Programs (SOS): A Harm Reduction Informed Guiding Document for Primary Care Teams. More information is available through the Safer Opioid Supply Ontario Community of Practice.
Other resources that may be useful for pharmacists, particularly those who are looking for a primer into opioid use disorder include the CRISM National Guideline for the Clinical Management of Opioid Use Disorder which provides high-level guidance on selecting between various opioid agonist treatments, without detailing exactly how to prescribe them.
Additionally, the Health Quality Ontario Opioid Use Disorder Quality Standard includes a strong statement confirming OAT as first-line treatment, and clear guidance for what people with opioid use disorder should expect from Ontario treatment providers. Lastly, for pharmacists working with older adults, the Canadian Guidelines on Opioid Use Disorder Among Older Adults make recommendations tailored to this population including prevention measures and treatment approaches.
These guidance documents all speak to the importance to improving access to OAT for people with opioid use disorder, as well as ensuring quality of care to meet their needs. The focus on engaging and retaining people in treatment is a direct response to the current, still worsening opioid crisis. Understanding the patient, their situation and treatment goals is key to informing clinical decisions. This is facilitated by effective communication between pharmacists and prescribers. Good clinical documentation also assists pharmacists within practice settings. The CAMH guidance specifically for pharmacists (Opioid Agonist Maintenance Treatment: A Pharmacist’s Guide to Methadone and Buprenorphine for Opioid Use Disorder21) is being revised to continue to support practice. Many of the same tenets still apply, but clinical judgement and decisions tailored to the patient situation are essential. During this time of changing guidance, the significance of effective communication and collaboration cannot be overstated. Patient safety and their retention in treatment depend on it.
- Gomes T, Murray R, Kolla G, Leece P, Bansal S, Besharah J, Cahill T, Campbell T, Fritz A, Munro C, Toner L, Watford J on behalf of the Ontario Drug Policy Research Network, Office of the Chief Coroner for Ontario and Ontario Agency for Health Protection and Promotion (Public Health Ontario). Changing circumstances surrounding opioid-related deaths in Ontario during the COVID-19 pandemic. Toronto, ON: Ontario Drug Policy Research Network; 2021. https://odprn.ca/research/publications/opioid-related-deaths-in-ontario-during-covid/
- Modelling opioid overdose deaths during the COVID-19 outbreak. Canada. https://www.canada.ca/en/health-canada/services/opioids/data-surveillance-research/modelling-opioid-overdose-deaths-covid-19.html
- Canadian Centre on Substance Use and Addiction. (n.d.). Opioids . Retrieved June 9, 2021, from https://www.ccsa.ca/opioids
- Government of Canada. (2019). Canada’s Opioid Crisis. https://www.canada.ca/en/health-canada/services/publications/healthy-living/canada-opioid-crisis-fact-sheet.html
- Canadian Centre on Substance Use and Addiction. (2013). First Do No Harm: Responding to Canada’s Prescription Drug Crisis. https://www.ccsa.ca/first-do-no-harm-responding-canadas-prescription-drug-crisis-report
- Tadrous M, Shearer D, Martins D, Campbell T, Gomes T. Naloxone Distribution Across Ontario. Toronto: Ontario Drug Policy Research Network; June 2019. DOI: 10.31027/ ODPRN.2019.01. https://odprn.ca/wp-content/uploads/2019/05/Naloxone-Distribution-Report-Final.pdf
- Pearce LA, Min JE, Piske M, Zhou H, Homayra F, Slaunwhite A, Irvine M, McGowan G, and Nosyk B. “Opioid Agonist Treatment and Risk of Mortality during Opioid Overdose Public Health Emergency: Population Based Retrospective Cohort Study.” BMJ, March 31, 2020, m772. https://doi.org/10.1136/bmj.m772
- CPSO eDialogue. “Methadone Maintenance Treatment Policy Rescinded.” https://dialogue.cpso.on.ca/2021/03/methadone-maintenance-treatment-policy-rescinded/.
- Canada, Health. “Methadone Program.” https://www.canada.ca/en/health-canada/services/health-concerns/controlled-substances-precursor-chemicals/exemptions/methadone-program.html.
- Ng K, Kim J, Veljovic S, Zhang M. Buprenorphine for opioid use disorder treatment: Focus on new formulations and alternative induction protocols. OCP Pharmacy Connection July 29, 2020. https://pharmacyconnection.ca/opioid-use-disorder-treatment-spring-summer-2020/
- Bromley L, Kahan M, Regenstreif L, Srivastava A, Wyman J. Methadone treatment for people who use fentanyl: Recommendations. Toronto, ON: META:PHI; 2021. www.metaphi.ca
- Centre for Addiction and Mental Health. Opioid Agonist Therapy: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder. Published May 2021. https://www.camh.ca/en/professionals/treating-conditions-and-disorders/canadian-opioid-use-disorder-guideline
- Canadian Research Initiative in Substance Misuse (CRISM). National Injectable Opioid Agonist Treatment for Opioid Use Disorder Clinical Guideline. Published September 23, 2019. https://crism.ca/projects/ioat-guideline/
- Health Canada. Interactive map: Canada’s response to the opioid crisis. https://health.canada.ca/en/health-canada/services/drugs-medication/opioids/responding-canada-opioid-crisis/map.html. Accessed June 20, 2021. (Filter for “Substance Use and Addictions Program (SUAP) – safer supply projects” to see list of funded programs across Canada).
- Health Canada. Letter from the Minister of Health regarding treatment and safer supply. https://www.canada.ca/en/health-canada/services/substance-use/minister-letter-treatment-safer-supply.html
- Effectiveness of supervised injectable opioid agonist treatment (siOAT) for opioid use disorder. Public Health Ontario December 2017 https://www.publichealthontario.ca/-/media/documents/E/2017/eb-effectiveness-sioat.pdf?la=en
- Addictions & Mental Health Ontario. Injectable Opioid Agonist Treatment (iOAT) Resources. http://amho.ca/our-work/iOAT/
- Government of Canada highlights support for safer drug supply project in Ontario. Health Canada News Release Sept 18, 2020. https://www.canada.ca/en/health-canada/news/2020/09/government-of-canada-highlights-support-for-safer-drug-supply-projects-in-ontario.html
- Government of Canada supports safer supply project for people with opioid use disorder in Guelph. Health Canada News Release May 20, 2021. https://www.canada.ca/en/health-canada/news/2021/05/government-of-canada-supports-safer-supply-project-for-people-with-opioid-use-disorder-in-guelph.html
- Government of Canada supports expansion of innovative safer supply project to operate in four cities across Canada https://www.canada.ca/en/health-canada/news/2021/03/government-of-canada-supports-expansion-of-innovative-safer-supply-project-to-operate-in-four-cities-across-canada.html
- Isaac, P., Janecek, E., Kalvik, A., & Zhang, M. (2015). Opioid Agonist Maintenance Treatment: A Pharmacist’s Guide to Methadone and Buprenorphine for Opioid Use Disorders. Centre for Addiction and Mental Health. https://store-camh.myshopify.com/products/p6500