The Prescription Review Committee has noted that some physicians, when asked to rationalize their prescribing of large quantities of opioids and benzodiazepines to elderly patients, respond by saying that these medications are intended for “snowbirds” who spend three to six months a year in Florida or California.
The committee does not condone the dispensing of hundreds of narcotic and sedative medications to elderly patients who should be reassessed regularly.
In reviewing several cases recently, the committee concluded that prescribing these medications for more than two months at a single dispense is not medically appropriate. Patients should be encouraged to arrange a medical follow-up at intervals when they return to Canada (i.e. Christmas or other family holidays). Elderly patients who do not return to Canada should be encouraged to find a treating physician in their destination community.
Become familiar with the Take Home Naloxone Program
Opioid overdose is a public health issue in BC. In 2009, more than 200 deaths were identified as illicit drug deaths; opioids were found in 60%, and an additional 74 deaths were in patients prescribed opioid medication (http://www.bcmj.org/bc-centre-disease-control/increasing-access-naloxone-bc-reduce-opioid-overdose-deaths). The risk of overdose from opioid substitution therapy is highest during the initiation, titration, and tapering of doses. Changes to methadone formulation came into effect in February of this year, and dispensing a solution that is 10 times more concentrated may increase the potential for overdose. Other subpopulations at higher risk for overdose include people who use opioids who have:
- a history of previous overdose
- been discharged from prison or drug treatment recently
- a high-dose opioid prescription
- co-morbidities (e.g., respiratory/hepatic/renal disease)
- concurrent treatment involving antidepressants or benzodiazepines
Physicians should be aware of these risks and know how to minimize the risk of overdose. Unintentional death from opioid overdose is preventable with education and timely administration of naloxone, an opioid antagonist.
Naloxone reverses respiratory depression due to prescribed and illicit opioids such as methadone, morphine, heroin, fentanyl, hydromorphone, or oxycodone. Naloxone has been approved for the reversal of opioid respiratory depression in Canada for over 40 years and is on the World Health Organziation (WHO) Model List of Essential Medicines. Naloxone cannot be abused, and in the absence of narcotics, exhibits no pharmacological activity. Furthermore, naloxone may be of particular benefit to individuals who are reluctant to access emergency care or where emergency services are not readily available.
The BC Take Home Naloxone (THN) Program trains people to prevent, recognize and respond to opioid overdose by administering naloxone. Since it began in August 2012, the program has expanded to 35 sites across BC and nearly a thousand people have been trained to recognize the signs of, and respond to, an opioid overdose. Over 650 kits have been dispensed to eligible clients, and over 55 overdose reversals have been reported (likely an underestimation).
Research has shown that having naloxone available does not increase risk-taking behaviour. Rather, many people feel empowered by the training and may alter drug-using behaviours, as reported in this CMAJ article.
Physicians should discuss the Take Home Naloxone Program with patients at risk of opioid overdose, as well as with the patient’s friends and family members who may witness an overdose. Simply providing or prescribing Naloxone is not sufficient. People can be trained to recognize the signs of overdose and respond to an overdose. Calling 911 for medical support is the first and most critical step of overdose response.
Naloxone is currently not covered by PharmaCare, and the cost may present a barrier to many patients. Naloxone kits and training materials are available through the BC Centre for Disease Control’s Harm Reduction program at no cost to participating sites.
Patients who are interested in receiving training and a naloxone kit can be referred to one of these Take Home Naloxone sites; however, physicians can enroll their clinic to be a participating site by reviewing the program implementation guide (or watch the video) and then completing a new site registration form.
For more information on the Take Home Naloxone Program, please visit the website towardtheheart.com, and specifically http://towardtheheart.com/assets/naloxone/medicalethical-concerns-final_97.pdf.