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Ontario plans to stop funding high dose opioids

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4300 (Published 03 August 2016) Cite this as: BMJ 2016;354:i4300
  1. Owen Dyer
  1. Montreal

The public health insurance programme in Canada’s most populous province, Ontario, will stop paying for high dose opioids in an effort to improve clinical outcomes and reduce the growing burden of opioid addiction.

The drugs due to be delisted are morphine 200 mg tablets; hydromorphone 24 mg and 30 mg capsules, sold under the brand name Hydromorph Contin; fentanyl 75 microgram/hr and 100 microgram/hr patches; and meperidine (Demerol) 50 mg tablets.

From January 2017 these will not be funded, even under the Exceptional Access Program or the Compassionate Review Policy. Physicians are being warned to begin tapering opioid doses where necessary.

Canada trails only the United States in opioid prescriptions, and Ontario has seen a growing death rate from opioid use, rising to over 500 a year and continuing to grow after the province’s drug formulary stopped covering OxyContin (oxycodone) in 2012 and replaced it with tamperproof OxyNEO. That change did not produce the intended reduction in deaths because many patients switched to other prescription opioids, including Hydromorph Contin, which, like OxyContin, is made by Purdue Pharma.

Fentanyl patches have also been implicated in numerous deaths, and a study this April in the Canadian Medical Association Journal found that they were often inappropriately prescribed.1 Overall, opioid overdoses account for about one in eight deaths in Ontario adults aged 25-34.2

A June study published in JAMA that compared opioids with other types of painkiller in chronic non-cancer pain found that they were associated with a heavy burden of mortality, especially early in treatment, that went beyond the risk of overdose alone.3

The committee that recommended removing high dose opioids from formulary coverage explained its rationale, writing that treatment beyond the equivalent of morphine 200 mg/day shows “little evidence to demonstrate improved pain management while being strongly associated with adverse events, addiction and opioid-related mortality.”

It added, “Since many patients on high doses may be considered ‘opioid failures,’ tapering or withdrawing opioid treatment may result in improved mood, pain and function, with less sedation, fatigue, constipation, etc.”

In the case of meperidine (Demerol), the committee “concluded that there is no therapeutic role” owing to its addiction potential and “significant neurotoxicities (metabolized to normeperidine which is a neurotoxin), especially in patients with reduced renal function.”

Removing the drugs from formulary coverage does not completely remove them from circulation, as patients may still pay for their own opioids. BuTrans (buprenorphine) and Targin (oxycodone/naloxone) are not covered by any provincial formulary and account for a small fraction of Canadian opioid prescriptions, but their use is growing extremely quickly.

References

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