"It is critical to understand that people who are at-risk of an accidental overdose include individuals who are taking opioids as prescribed, in addition to people using opioids non-medically. Effective opioid overdose prevention targets all opioid-using populations." - Prescription for Life, Summary Report
The MDSCNO's list details 4 important actions, that if implemented, can help to significantly reduce the devastating problem of opioid related injuries and death. They are as follows:
1. Add Naloxone to Provincial, Federal and Veterans Affairs Formularies
It's frightening to think that there are over 150 opioid medications listed in the Ontario Drug Formulary (ODB, General Benefits), yet suspiciously absent from that list is the lifesaving medication used to reverse overdoses caused by the slew of opioid medications. That's right - Naloxone isn't on the list, even though it is a post-patent, WHO Recommended Essential Medicine. The MDSCNO considers Naloxone's absence from the Formulary "a barrier to patient safety and for prescribers (currently physicians only) who wish to prescribe naloxone or co-prescribe naloxone with opioids for at-risk patients." I couldn't agree with them more. Adding Naloxone to the Provincial, Federal and Veterans Affairs Formularies helps to reduce the barrier of price, and ensure that those in need of access to this lifesaving medication are able to obtain it.
2. Increase On-site Naloxone Access
This might seem like a bit of a given, yet within the Province of Ontario, on-site Naloxone access is limited to a small group of HIV and HCV programs. First, the MDSCNO recommends expanding on-site Naloxone programs beyond these few public health units and HCV programs. For this medication to be accessible, it needs to be made available to those at risk! Second, to provide a Naloxone kit to all patients receiving Opioid Substitution Therapy (Methadone, Suboxone). Third, to ensure that Naloxone is provided at Ontario hospitals. Fourth, to provide Naloxone to all inmates discharged from Ontario correctional institutions who are at risk of overdose. Lastly, to provide Naloxone upon request to all Aboriginal, Inuit and Metis nations. Simply put, Naloxone needs to be placed in the hands of the at risk populations, and the second recommendation by the MDSCNO helps to ensure that happens.
3. Ensure Health Professionals and Others Can Be Lifesavers
The MDSCNO calls for two important steps to be taken in order to ensure that our health professionals are able to effectively help reduce the skyrocketing rate of opioid overdoses. Adding Naloxone to the list of medicines that Pharmacists and Nurses in Ontario can prescribe is the first step listed by the MDSCNO. The report itself makes it abundantly clear that both Pharmacists in Ontario have a very key role to play when it comes to preventing overdose deaths. Their 'expertise, access to records, frequent interactions with patients as well as the high level of patient trust' makes them an ideal point of access for distributing Naloxone to at risk populations. One particular study done in Ontario "revealed that 56.1% of fatal opioid overdose victims had filled a prescription for opioids in the month (66.4% had seen a physician)," yet our Pharmacists and are unable to provide the lifesaving medication Naloxone to their patients, despite the fact that the Pharmacists' Scope of Practice does technically allow for this to be implemented.
Secondly, the report calls for on-site Naloxone and training to be provided to "select jail, correctional centre, detention center and policing staff," and the MDSCNO aren't alone in that recommendation. The College of Physicians and Surgeons of Ontario (CPSO) also recommends that the Province's correctional facilities have Naloxone on-site. Considering that "federally, 80% of incarcerated males have an identified ‘substance abuse disorder," and officials from Public Safety, the Correctional Service and the Parole Board of Canada conclude drug-free prisons are “an aspirational goal, just as is achieving drug-free societies," it isn't hard to understand why the MDSCNO included this vital step in their report.
4. Develop Overdose Policies
Having a solid plan and policy in place regarding overdose prevention is essential, yet the Province of Ontario is seriously lacking in this area.The first recommendation made by the MDSCNO regarding overdose policy is to develop and implement a real-time prescription monitoring and surveillance system. In order to effectively combat opioid overdose, we need to be able to fully understand and effectively evaluate the full scope of the problem. Yet as it stands currently, "Health Canada cannot provide a national snapshot of drug-related deaths for any year; data from the Office of the Chief Coroner for Ontario is at least a year behind; the Ontario Ministry of Community Safety & Correctional Services does not track overdoses occurring in its correctional facilities; the Ontario Health Minister’s promise of 2012 to implement “real-time surveillance of opiate overdose and withdrawal in 73 emergency departments” has yet to be realized; the MOHLTC’s Public Health Division has recently ceased its ineffective short-lived monitoring and surveillance activity; and the Ontario Narcotics Monitoring System has been described as non-functional."
Second, the MDSCNO calls for concise and clear third-party liability guidelines to be provided, as well as the elimination of any potential concerns and barriers identified. "Potential third party liability concerns could arise when Naloxone i) is administered by a bystander/Good Samaritan when the victim does not have a prescription, and/or ii) is prescribed to a person not using opioids (e.g. concerned parent)." These barriers prevent both the prescribing and the use of Naloxone, but they can be minimized through the implementation of clear guidelines.
The third recommendation regarding overdose policies is for the Province of Ontario to develop specific Overdose Prevention Plans. Here in Canada, no provincial or federal plan exists. Ontario needs to take the lead in developing a strategic plan in order to help combat this growing public health crisis.
The fourth recommendation made by the MDSCNO is an important one; for the Government of Canada to create and implement Good Samaritan Legislation. "In an Ontario study of barriers to calling 911 during an (illicit) overdose emergency, respondents reported that 911 was called just 46% of the time at the last witnessed overdose, the primary barrier cited being fear of police presence and the potential for criminal charges." By providing witnesses of an overdose limited immunity from prosecution, we remove the primary barrier cited for failing to seek medical attention.
The final recommendations regarding policy made by the MDSCNO are for Health Canada to reschedule Naloxone to ensure Pharmacists can provide it without a prescription, and encourage additional formulations of the drug (such as intranasal and auto-injectors, which are not currently available in Canada).
Being a former intravenous drug user living in Ontario, I can personally attest to how desperately needed the changes recommended by the MDSCNO are. Here's a stark fact: over the course of the several years in which I was actively using opiates, not once was I ever made aware of the lifesaver that is Naloxone. It's not as though I was banging my drugs under a rock during this time, either. In the beginning, it was a secret that I worked endlessly to conceal, but when my life began to crumble around me, the truth was no longer so easy to hide. I was prescribed my drugs via my physician majority of the time, eventually needed to access social services, needle exchange services on a regular basis and eventually chose to start Methadone Maintenance Treatment. Yet not once during that course of time did I ever encounter any information about Naloxone. None. It wasn't until I was well over a year into my Methadone Treatment, when I started writing and researching on the subject of opiate addiction, that Naloxone crossed my path.
Ontario can no longer continue to sit idle on such a deadly issue. Immediate action towards reducing the record setting levels of opioid overdose fatalities must be taken, and the MDSCNO has provided an effective plan to help curb the problem. The medical and non-medical opioid-using population will continue to be put at risk each day that continues to pass without accessible Naloxone
The lives of opiate using Ontarian's matter, be it medical or non-medical. Increasing access to Naloxone has the potential to save the lives of many. What are we waiting for?