Improve opioid prescribing rules, training to curb fentanyl deaths, say advocates

Advocates are calling for more training and rules around prescribing after Alberta Health report revealed 60 per cent of those who overdosed on fentanyl had received an opioid prescription within a year of their death.

Most Albertans who overdosed on fentanyl in 2016 had been prescribed an opioid within a year of their death

Amy Graves, whose brother died of an opioid overdose, said prescribing physicians should be required to check a patient's drug treatment history. (CBC)

Six years after Amy Graves of St. Albert lost her younger brother to an accidental opioid overdose at a party, special occasions emphasize his absence.

"Every holiday, every birthday, every cause of celebration is a reminder that there's somebody missing from that equation who can't share that moment with me," said Graves, who launched the Get Prescription Drugs Off the Street Society after Josh's death.

Since then, Graves has advocated for tighter controls around prescribing opiates, which is why she was so frustrated by numbers in the latest Alberta Health report.

They revealed 60 per cent of the 343 Albertans who overdosed on fentanyl in 2016 had received a prescription for an opioid within a year of their death.

"It makes someone like me feel helpless," said Graves, insisting action to curb opioid abuse should have been taken long before it evolved into a market supplemented by organized crime in which fentanyl deaths have skyrocketed.

Currently, Alberta physicians are not required to check a patient's prescription history before prescribing an opioid. The latest numbers suggest addicts might use that to their advantage.

Almost 40 per cent of Albertans prescribed an opiate in the year prior to their death visited three or more different health care providers, according to the report.
Josh Graves, pictured here with his niece, died in 2011 from an opioid overdose.

Graves is pleased the College of Physicians and Surgeons of Alberta is in the process of updating its standards around prescribing opiates.

A draft will be considered by the college's executive next month.

Among the requirements, the physician would have to look into a patient's drug treatment history prior to writing a prescription. Most doctors currently have access to the system which allows them to check if they wish.

The college also tracks opioid prescribing through the triplicate prescription program which flags potential misuse and abuse.

Wildrose health critic Tany Yao suggested improved physician care at the end of treatment would also help prevent addictions that begin through legitimate prescriptions.

"Physicians have to do some follow up therapy with their patients if they're prescribing these opioids and work with them as they wean them off these drugs," said Yao, who is also a paramedic.

Opportunity to start treatment

Dr. Hakique Virani, an addiction medicine and public health specialist at the University of Alberta, says patients' access of the healthcare system in the lead-up to an overdose also reveals a way forward.

"That means that there was a touch point where we could have recognized a problem and prevented this fatal occurrence," he said, noting 13 per cent of those who died last year were in the emergency room within 30 days of their fatal overdose.

"That was a remarkable opportunity for us to start treatment if they presented with an addiction problem in addition to their overdose. We need to seize those opportunities."
Dr. Hakique Virani said fentanyl users seeking prescriptions offers an opportunity to intervene. (CBC)

That this was not the case could have occurred for a variety of reasons, among them a lack of training, time or resources, Virani explained.

To that end, Virani is among a group of doctors in Edmonton and Calgary working to create direct avenues to treatment for opioid addicted patients who end up in the emergency room.

"We're trying to develop an abridged training for (emergency department doctors) to start treatment right in the department," said Virani, who is also medical director at Metro City Medical Clinic.

Virani said he's seen countless patients who were prescribed an opioid after an acute injury at work or playing sports, but when they showed signs of addiction, the physician hit the breaks too quickly.

"And the patient may find themselves on illicit opioids like fentanyl.

"I think it's fair to say that our prescribing in general has contributed to or might even be the genesis of this whole opioid epidemic that we're in," he added while emphasizing the focus should now be on demand reduction and implementing safety measures.

Improve training to prescribe opioids

Dr. Matt Rose said medical students and residents who come through the inner-city Boyle McCauley Health Clinic are not adequately trained on how to set up a carefully managed and monitored pain-management plan.

"We're talking about what to us is extremely basic," said Rose, explaining it involves asking people if they have problems with alcohol or drugs, and understanding the nature of their pain as well as underlying mental health issues.

"And to the med students and the residents this is all new stuff, unless they've spent time at a chronic pain clinic."

The College of Family Physicians of Canada and medical school at the University of Calgary were asked to respond to the criticism but did not provide comment.

In a statement, Alberta Health said it is is expanding Albertans' access to opioid replacement therapy. Among the initiatives, the province is training more family physicians and offering treatment at more primary health care clinics.

Last year, 8,200 physicians prescribing opioids were provided with a list of patients exceeding guidelines, the statement added.

"Physicians have been advised to reassess patients on dosages that exceed recommendations and cautioned not to abruptly withdraw or taper medications."

andrea.huncar@cbc.ca                      @andreahuncar