Opioids in the Community: Chronic pain, Palliative Care, and Addiction. Dr Ahmed Jakda September 2017

Transcription

1 Opioids in the Community: Chronic pain, Palliative Care, and Addiction Dr Ahmed Jakda September 2017

2 Outline Context Background Action Delisting Highstrength Long- Acting Opioids Opioid use and prescribing in Ontario Addressing patient needs 2

3 Context: De-listing High-Strength Long-Acting Opioids 3

4 Context: Recognizing the Need for Change Changes were prompted as a result of the Ministry s commitment to review the entire opioid drug class for pain management in response to OxyNEO changes and the Brockville Inquest (2011 coroner s inquest). These changes were informed by recommendations from a subcommittee of clinical experts, referred to as the Pain Medication Formulary Review Subcommittee, which included representation from experts in pain, addiction, palliative care, clinical pharmacology, internal medicine, family practice, and pharmacy. 4

5 Context: Delisting High-Strength Long-Acting Opioids In July of 2016, the Ministry of Health and Long-Term Care announced that the Ontario Drug Benefit (ODB) Formulary/Comparative Drug Index would be updated in January Rationale: to raise awareness and encourage appropriate prescribing in accordance with clinical practice guidelines. The changes, which came into effect January 31, 2017, included delisting the following higher strengths of long-acting opioids: Morphine 200 mg tablets; Hydromorphone 24 mg and 30 mg capsules; and Fentanyl 75 mcg/hr and 100 mcg/hr patches. To note: Lower-strength, long-acting opioids continue to be funded under the ODB program. 5

6 Background: Opioid use in Ontario 6

7 Analyzing the Impact The Ontario Drug Policy Research Network conducted a rapid analysis of how the changes to the availability of high strength formulations of long acting hydromorphone, morphine and fentanyl would impact patients The analysis reports prescribing trends in the ODB program between April 2014 and March

8 Prevalence of High-Strength Long- Acting Opioids Reimbursed by ODB 8

9 Prevalence of High-Strength Long- Acting Opioids Reimbursed by ODB 9

10 Opioid Utilization in Palliative Care Number of patients receiving palliative care in Ontario % of those patients who receive opioid prescriptions reimbursed by the ODB % of those patients who receive high-strength longacting opioid prescriptions reimbursed by the ODB ODB-eligible individuals dispensed high-strength long-acting opioids* DO NOT require these medications for palliative purposes 10

11 Duration of Treatment in Palliative Care 35,960 people started palliative care in Ontario (April 2013 to March 2014) and died by March 31, 2015 Median duration of palliative care 24 days 1,070 (3%) used a high strength opioid during palliative care: Median duration of palliative care: 148 days Median duration of high strength opioid use: 56 days 93% had received another opioid through ODB in the 1 year prior to starting a high strength formulation. 11

12 Action: Addressing Patient Needs 12

13 Principles to Address Patient Needs Regardless of changes coming, the system must evolve to work together to care for patients. It is important that changes are person-centred, and are accompanied by adequate education for both primary care clinicians and specialists A person-centred approach that enhances quality care and reduces potential for harm is necessary. 13

14 Efforts to Ensure Ongoing Access Recognizing these changes would impact access to high-strength long acting opioids for patients who may require them for palliative purposes, a number of steps were taken: Regular meetings with the Ontario Public Drug Program Branch of the Ministry of Health and Long Term Care Formation of a clinical advisory subgroup Development and implementation of recommendations Ongoing meetings to monitor implementation 14

15 Changes to Ensure Ongoing Access To ensure ongoing access to patients who may require medications for palliative purposes, high strength long acting opioids were moved to the Palliative Care Facilitated Access (PCFA) list Concurrently, to expand access to key medications required for primary level palliative care, non-opioids were transitioned to the general formulary Physicians who do not qualify for PCFA can access these drugs through the ODB Program s Exceptional Access Telephone Request Service (TRS). 15

16 Revised PCFA & Changes to the General Formulary Currently on PCFA Fentanyl Transdermal System Hydromorphone (24mg/30mg) Hyoscine Butylbromide (tablet) Methadone (1mg/ml, 10mg/ml, 1mg, 5mg, 10mg, 25 mg) Morphine Sulfate* Oxycodone HCL Pamidronate Disodium Phenobarbital* Transitioned to General Formulary (As of July 31st, 2017) Diazepam Dimenhydrinate Glycopyrrolate Hyoscine Butylbromide (injection) Furosemide Lorazepam Metoclopramide Phenytoin Midazolam Injection Scopolamine Hydrobromide * Work is underway to try and transition these to general formulary 16

17 PCFA Prescription Process Physician with PCFA designation Permitted to prescribe drugs on PCFA list (including highstrength opioids) Supports non-pcfa prescribers with initial consultation and follow up if needed Prescription for high-strength opioid indicating PCFA on prescription Physician granted registration as PCFA prescriber by OMA and OPCN Yes Meets PCFA program criteria Submits PCFA declaration/ application form to OMA Physician without PCFA designation Qualified to obtain PCFA designation? While awaiting PCFA registration No If requesting a high-strength long-acting opioid Consult with PCFA registered physician Obtain CPSO number of the PCFA consultant Telephone Request Service (TRS) #: or Prescription for high-strength opioid indicating TRS on prescription Approved by TRS Call or fax EAP s TRS to obtain authorization for reimbursement of the high-strength opioid. May also request reimbursement for other drug products on the PCFA list. If approved, funding is granted for up to 12 months 17 Renewals require a new PCFA consult for non-pcfa prescribers.

18 Appendix

19 The Ontario Palliative Care Network Our Mandate: Be a principal advisor to government for quality, coordinated, palliative care in Ontario Be accountable for quality improvement, data and performance measurement and system level coordination of palliative care in Ontario Support regional implementation of high-quality, high-value palliative care 3

20 The Ontario Drug Policy Research Network Network of clinical researchers from across Ontario interested in drug policy research Launched in 2008: Funded through research grants from MOHLTC and Ontario SPOR Support Unit (CIHR) Primary Objective: Provide high quality, relevant drug research to Ontario s policy-makers in a timely manner on an asneeded basis 20