Sunday, October 23, 2016

Opioids in Canada

  1. Public health emergencies must be declared more liberally. 
  2. Ongoing, coordinated surveillance. 
  3. Naloxone – freely available
  4. Supervised drug consumption services
  5. Medications for opioid addiction
  6. We must address overprescribing of opioids.
  7. Drug use should be considered a public health issue, not a criminal one.

Fentanyl front lines: Fentanyl-linked deaths triple this year

There have been 555 deaths as a result of illicit-drug overdoses from January through September, eclipsing the 508 drug-related deaths in B.C. in 2015.
The total number of illicit-drug overdoses in September was 56, up from 49 in August, according to the latest statistics released Thursday by the B.C. Coroners Service.
The powerful opioid fentanyl was detected in 302 deaths — 61 per cent of all drug deaths from January through August this year —more than triple the number of fentanyl-related deaths compared with the same period last year.

A summary of ODPRN research on prescription opioid use in Ontario
Click through our Interactive Map on opioid prescribing and
opioid-related hospital visits in Ontario
From 2008 – 2015, the ODPRN conducted several population-based studies to investigate the use of opioids in Ontario. The key objective of these studies was to provide evidence to inform discussion regarding the safe and appropriate use of opioids.
This report summarizes these findings as well as policy and practice implications into four key themes of our research:
  1. Overall trends in opioid use are increasing in Ontario, particularly at doses that exceed guideline recommendations
  2. Safety of opioid use, particularly at high doses, is related to serious adverse events, including risk of overdose death and road trauma
  3. Geographic variation in opioid prescribing, use and safety is apparent and should be considered when designing public health and policy initiatives
  4. The impact of policy and education interventions is varied and will need to involve a combination of regulatory/legislative changes, as well as patient and clinician education to respond to this ever-shifting prescribing environment
View a copy of the ODPRN’s new public report.

Canada is the world’s second-largest per capita consumer of opioids and the fallout is being felt across the country. Last week, a report found that from 2009 to 2014, at least 655 Canadians died as a result of fentanyl, a powerful opioid that is available by prescription and is also manufactured in clandestine labs and sold on the street. Opioid overdose deaths continue to rise across Canada, forcing federal and provincial authorities to respond to this growing epidemic. In Ontario alone, these drugs have killed nearly 2,500 people between 2011 and 2014.

Thursday, October 20, 2016

Patient Engagement for Quality Improvement


Quality standards are a go-to resource for quality care. They are concise sets of easy-to-understand statements based on the best evidence.
Quality standards will:
  • Help patients, residents, families, and caregivers know what to ask for in their care (patient reference guides)
  • Help health care professionals know what care to offer, based on evidence and expert consensus (clinical guides)
  • Help health care organizations measure, assess, and improve the quality of care they provide
  • Help ensure consistent, high quality care across the province so that all Ontarians receive the best possible care.

Wednesday, October 12, 2016

Opiod overdoses: Ontario Strategy

Conclusion: This study suggests opportunities for improving OD outcomes. Those who receive higher quantities of prescription opioids concurrent with other psychotropic medicines may need closer monitoring to avoid death, repeated OD events, higher service use, and higher service costs. Other opportunities for improving OD outcomes include the use of electronic health records to notify physicians of high-risk patients and updating of guidelines/operation manuals focused on the distribution of naloxone to those in highest need.

The measures include expanding access to Suboxone, which helps treat opioid addiction by stopping cravings and preventing withdrawal symptoms. The drug is considered safer than methadone, with "significantly less" risk of fatal overdose, according to information from the Ministry of Health and Long-Term Care.
The province has just added the drug to its Drug Benefit Formulary. Adocument from the Ministry of Health and Long-Term Care shows that Suboxone in 2 mg and 8 mg strengths has been changed from "limited use" to "general benefit" on the formulary.

Thursday, September 29, 2016

Reports on Aging; treatment plans

This is a bit simplistic, however, they are good questions to ask both your doctor, or perhaps your pharmacist.

I prefer that patients ask more overarching questions, such as the overall treatment plan.
This list is appropriate for all patients. 
  1. Write down symptoms, use an agenda, notebook or planner, filling extra notes. 
  2. Save the list from the pharmacy, which lists all of your prior medications. Tape it into your agenda.
  3. Write down all over-the-counter medications. They may be important, including vitamins and other supplements, e.g., creams, herbs, lotions.
  4. Create questions for your doctor. They may include: 

  • What might be causing my signs and symptoms? 
  • Are tests needed to confirm the diagnosis? 
  • What treatment approach do you recommend? 
  • What are the side effects from this treatment?
  • What are the alternatives to the primary treatment approach that you're suggesting? 
  • What health routines do you recommend to improve my symptoms?
Click images to access the resources on 5 Questions to Ask your Doctor 
Medication Questions

WHO Report on Aging and Health

Further Reading

Wednesday, September 28, 2016

Stop funding Catholic hospitals who refuse medical assistance in dying

It is now legal, in Canada, to provide medical assistance in dying (MAID). Sadly, it is a medical procedure difficult to access. The news media is full of such stories. Firstly, the Catholic hospital are refusing. Secondly, some of our Ontario LHIN healthcare staff are refusing, claiming protocols are not in place. This is wrong. This is against the law.

The Catholic hospitals are agreeing to send palliative patients to another hospital for MAID assessment, but that is a painful process, since dying patients need pain medication to transfer in an ambulance and they want them coherent in order to provide consent.

Catholic hospitals MUST, at least, provide palliative sedation to those in pain. There is a risk this promotes dying, but it is unconscionable to permit a dying patient to be in pain.

If you want help, please visit Dying With Dignity Canada.

Story image for medical assistance in dying catholic hospital canada from Ottawa Citizen

Patients must be transferred out of Catholic hospitals to discuss ...

Ottawa Citizen-16 hours ago
Catholic hospitals and health institutions have said they will not ... It's a policy that is being called “unconscionable” by the head of Dying with Dignity Canada. ...Medical assistance in dying is legal and accepted health care.
Story image for medical assistance in dying catholic hospital canada from Edmonton Sun

Demand for medically assisted dying in Alberta significantly higher ...

Edmonton Sun-4 hours ago
Relatively few have been completed in a hospital. ... Covenant Health, the Catholic-based health provider that opposes medical aid in dying, ... Brad Peter, co-chairman of the Edmonton chapter of Dying with Dignity Canada, ... The Process — Five stages of Alberta's Medical Assistance in Dying program:.
Story image for medical assistance in dying catholic hospital canada from Niagara Falls Review

CLOSEUP: Niagara man asks to die

Niagara Falls Review-Sep 1, 2016
He has been in hospital, currently at Hotel Dieu Shaver, for the past six weeks. ...Medical assistance in dying received royal assent in Canada in June ... a Catholichealth-care organization, Shaver does not provide medical ...
Story image for medical assistance in dying catholic hospital canada from Ottawa Citizen

Today's letters: Readers' recount family experiences with palliative ...

Ottawa Citizen-Sep 23, 2016
It does not matter that the Bruy√®re is a Catholic hospital; it is the choice of the patient. ... Any discussion of the role of medical assistance in dying in our ... the “superbug” to save lives, not only in Canada but around the world.
Story image for medical assistance in dying catholic hospital canada from The Kingston Whig-Standard

'Another form of care'

The Kingston Whig-Standard-Sep 2, 2016
... Court of Canada struck down the ban on the procedure effective June 6. ...Catholic faith-based hospitals oppose assisted death and consider it a ... theassistance from doctors if they are suffering intolerable pain and if the end of ... draft policy on assisted dying that will go to the hospital's internal medical ...
Story image for medical assistance in dying catholic hospital canada from National Post

Catholic hospital, the biggest palliative care centre in Ottawa, says it ...

National Post-Mar 1, 2016
But Dying With Dignity Canada, which has fought for physician assisted ... funded health care institutions provide medical assistance in dying.”.
Story image for medical assistance in dying catholic hospital canada from The Globe and Mail

What you should know about the Liberals' assisted-dying bill

The Globe and Mail-Apr 14, 2016
Did the government say whether it would require Catholic hospitals to provide ... Archdiocese of Toronto and the Catholic Health Alliance of Canada, ... both of which have legalized medical assistance in dying, according to ...

Story image for medical assistance in dying catholic hospital canada from Vancouver Sun

Catholic hospitals wrestle with assisted death

Vancouver Sun-Feb 25, 2016
St. Paul's Hospital and nine other Metro Vancouver medical facilities overseen by ... said medical assistance in dying should be made available with few ... the approach by Catholic health care providers throughout Canada.”.

Tuesday, August 23, 2016

Palliative Patients in Hospital made to co-pay

Our South East LHIN (Local Health Integration Network)  is demanding that vulnerable patients in hospitals, as well as the dying patients in palliative care rooms who are being told to take their loved ones home or pay a co-pay. This is criminal. They are forced to sign contracts to co-pay, on top of OHIP payments.

On top of this, many Ontarians have been told to take their palliative family members home, or to long-term care, WHILE THEY ARE IN A DESIGNATED PALLIATIVE CARE ROOM.

 Ontario hospital staff continues to pressure patients (This I wrote in May.)

Do these staff members not understand when patients are dying?
What pressure is administration putting on family members?
What is wrong with doing a Palliative Performance Scale (PPS) assessment, to determine the patient's situation?
What are the qualifications to be in a palliative bed in a hospital?

Staff tell the spouse the patient has to be removed and sent to long-term care. There isn't a place. They tell the spouse the patient is turning the corner, improving, and moves her to a room down the hall. The oxygen tube falls off the patient's face and it's up to the spouse to replace it.
'Here she is dyin' on you, and they move her to another room.'
There should be a PPS test done on a regular basis by staff. This doesn't seem to happen. She's at 30% when I visited her last at home, no better (20%) when I visited two weeks later in hospital.

dying patients deserve to be in hospital
their families have earned this right
There is a difference between Complex Continuing Care (CCC) requirements and palliative patients who need proper nursing, and pain and symptom management. Many have bedsores, catheters and infections. Family members are often unable to change soiled adult incontinence products, empty a catheter bag, or help a palliative patients navigate their way to the bathroom.

ACE Publications

In 2012, the Advocacy Centre for the Elderly (ACE) had over 250 requests for assistance relating to discharge from hospital. In the first six months of 2013, this number skyrocketed to 200 such requests! Patients requiring admission to other care settings or requiring additional care in the home are often told that they must comply with hospital or Community Care Access Centre (CCAC) policies. These policies may “require” the patient or substitute decision-maker (SDM) to select possible LTC homes from a “short list” where a bed is or will soon be available. If they do not comply with the policy, the hospital threatens to charge the uninsured daily rate which ranges anywhere from $500.00 to $1,500.00 or more per day. Hospitals may also require the patient/SDM to sign a “contract” indicating that they “agree” with this policy. In fact, no one is required to sign such a contract. More and more frequently, hospitals are blocking LTC home applications and CCAC workers are refusing to take applications from hospital patients, based on their interpretation of hospital policies or Home First/Wait at Home Program requirements. 

ACE dealt with this in Toronto in 2008:

Many people should be in hospital as they die, since family members are unable to change adult incontinence products, empty catheter bags, or have a CADD pump, which is only available in hospital, and provides morphine pain management on a regular basis. Families have a hard time keeping medications straight, let alone doing the nursing needed.


Friday, August 12, 2016

The Burden of Premature Opioid-Related Mortality

Key findings demonstrate:

  •  The overall rate of opioid-related mortality increased by 242% between 1991 and 2010 
  • The annual YLL due to premature opioid related death increased 3-fold 
  • The proportion of deaths attributable to opioids increased significantly over time among all ages 
  • By 2010, nearly 1 of every 8 deaths among individuals aged 25 to 34 years was opioid-related 
  • The majority of opioid-related deaths occurred in men, involved a single opioid, and were deemed as accidental. 
  • The opioids most commonly involved in opioid-related deaths were morphine and or heroin (or the two combined), followed by oxycodone, methadone and codeine. Oxycodone was the opioid most commonly involved in overdose deaths involving a single opioid 
  • For overdose deaths where multiple opioids were involved, the most commonly involved opioids were codeine, morphine or heroin (or both)

Comfort for family of palliative patients

Once our most intensive interventions end, we are left with this — a choice of tuna fish or chicken salad, or maybe some Oreos, brought up from the hospital basement.

Ontario Drug Policy Research Network - Citizen's Panel

Attached to St. Mike's hospital, we were in the ODPRN building, very interesting work. Hubby took a trip around downtown Toronto while I was in the meetings.
The ODPRN is funded by Ontario SPOR Support Unit (OSSU) and the Ministry of Health and Long-term Care (MHLTC), as well as The Keenan Research Centre of St. Michael's Hospital, and the Institute for Clinical Evaluative Sciences (ICES).

The Ontario Drug Benefit Formulary has 12 large prescription classes.  The Ontario MHLTC pays for some drug classes, for some patients (Ontario Drug Benefit Program). Seniors have subsidies, as do people on ODSP (disability), residents of LTC, receive social assistance, are enrolled in a home care program, or in hospital. Administrative Claims Data is an historical archive of all submitted medical claims for specific services by patients in Ontario.

Research on the data allows the MHLTC to answer questions, ensure the efficacy of drugs prescribed, and track the effect of changes to drug policy.
For example, through good research, the government has saved money by changing the number of diabetes test strips available to patients, making the testing process more effective. They have also changed the high-strength opioid formula making it less susceptible to being abused by those using it for recreation.

Which drugs do the programs pay for?

Here are some groups who are covered...