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Doctors’ reckless prescribing of fentanyl largely to blame for deadly overdoses: expert

Sharon Kirkey 04.06.2016

Canada’s doctors have been “mind-boggingly cavalier” in prescribing fentanyl — the most potent narcotic painkiller used outside operating rooms — and much of the responsibility for the country’s
opioid overdose crisis lies with the medical profession, a leading drug safety researcher is charging.
Dr. David Juurlink says a new study showing half of all prescriptions for fentanyl patches are unsafe reflects dangerous prescribing habits and a serious lack of appreciation for the drug’s toxicity.
Fentanyl has a strength 100 times that of morphine. Guidelines say no one should be put on the drug without doctors first trying a less-potent opioid.

But a study published this week of all patients in Manitoba prescribed fentanyl patches over 12 years found while prescribing has improved, half of new prescriptions are still being written for first-time users with no exposure to opioids.

“It’s very difficult for even a seasoned pain physician to justify the de novo initiation of fentanyl,” said Juurlink, head of clinical pharmacology and toxicology at Toronto’s Sunnybrook Health Sciences Centre.

“The idea that we’re just starting people on fentanyl is mind-boggling.”

He and others say the study is the latest evidence of a public health catastrophe the profession, and the public, still hasn’t fully grasped.

More people are dying from opioid overdoses than from car accidents. The medical profession has to take some ownership of this menace.

“This is a massive social problem and it is heartbreaking to me the extent of the lack of awareness … that is at least in part a function of some willful blindness,” said Dr. Gus Grant, president of the Federation of Medical Regulatory Authorities of Canada.

He said regulators are seeing loose prescribing, as well as a few malignant doctors “who have somehow fallen into the sway of the criminal element.”

One Nova Scotia doctor is alleged to have prescribed more than 50,000 oxycodone pills to a patient who never received them. On Wednesday, a Toronto family doctor was arrested in a fentanyl trafficking ring.

Grant stressed such doctors are outliers. But he also said opioid prescribing isn’t following the guidelines and, as a result, “we see the ills associated with these drugs.”

Few people should ever be escalated to taking fentanyl, he maintains, “because by the time they get to that stage, it’s more likely than not that they have declared themselves unresponsive to opioids.”
“It’s time to confront the reality of pain management in 2016,” he said. “Opioids don’t work well for a great many patients.”

According to the federal government’s own projections, Canadian sales of opioids could exceed $600 million a year by 2019, up from $484 million a decade ago.

Fentanyl is making up a growing share of that market, as provinces tighten access to oxycodone — originally known as OxyContin and one of the most abused drugs in history. OxyContin was replaced in 2012 with a “tamper-resistant” version that becomes a gummy gel when turned into liquid, making it harder to inject.

However, generic versions of the original formulation have entered the market. This week, Ottawa announced the government won’t force the generics to make their versions of oxy harder to snort or inject, prompting criticism Canada’s drug-abuse “carnage” will only worsen.

But while the tamper-resistant formulations are an modest improvement over the older drug, most abuse happens through the ingestion of intact pills, Juurlink said.

With fentanyl, it’s through patches — they come in doses of 25 to 100 micrograms.

The most common form provides three-day continuous drug delivery and has become a “popular choice” for chronic pain, researchers report this week in the Canadian Medical Association Journal.
It is also the most potent opioid prescribed outside hospital. According to Juurlink, people not only die from exposure to excess levels of fentanyl, but the combination with many other drugs that are routinely prescribed can increase its level to lethal ranges.

In 2009-14, there were at least 655 deaths in Canada involving fentanyl, and more than 1,000 lethal drug poisonings where post-mortem drug testing detected the presence of fentanyl, says the Canadian Centre on Substance Abuse.

In Alberta alone, more than 270 people died from fentanyl overdoses last year, double the 2014 toll.
People are dying not just from illicit street drugs and lethal bootleg fentanyl from China and other underground markets, but also from legitimate prescriptions.

Juurlink has treated patients who arrive in hospital with multiple fentanyl patches, adding up to 400 micrograms or more. “And it’s almost always the case that they are being made worse rather than better by the drug,” he said.

Calgary emergency physician and toxicologist Scott Lucyk frequently sees unintentional overdoses
from fentanyl.

“It’s one of the big players right now,” he said. “They come in with respiratory depression — they’re not breathing as well. They have drowsiness and altered level of consciousness.”

“We have physicians who are prescribing these drugs who are not totally familiar with the delivery system,” he said, “and so the chance for patients coming with opioid toxicity, or potentially dying, is definitely there.”

Grant said opioids are important for pain and that doctors need to know how to use them judiciously.
“I do believe physicians are becoming more rigorous in their prescribing and I do see that there is an enhanced social awareness of it,” he said.

“But we’re nowhere near where we need to be.”