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Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 

 

 

 

 

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Thursday
May252017

Facing our Opioid Crisis and What Comes Next

 

May 25, 2017 - The latest news reports confirm our greatest fears: the opioid crisis has been escalating for years and the provincial government and health care officials are caught flatfooted dealing with this issue.

Fentanyl is Ottawa’s deadliest drug, a dangerous drug which is 30 – 50 times more powerful than heroin. It has been available on Ottawa streets for years and there is a growing bootleg market for the tablets. In 2015, 17 of 45 (38%) opioid-related drug overdoses had fentanyl in the victims’ bloodstream. The latest figures show there has been 319 emergency department visits to Ottawa hospitals in the first three months of 2017!

So, it is good news that Ottawa's fifteen hundred firefighters will begin carrying Naloxone kits by the end of June. They will carry the easily administered nasal spray version of the opioid antidote naloxone saving time to first response and possibly saving lives. But our leadership in this community – and at Queen’s Park and the Ministry of Health – cannot be complacent with this band aid approach.

Addressing opioid use and abuse will require new resolve as naloxone-resistant fentanyl compounds emerge and move across boarders often in tiny but deadly amounts. Here are some important things to consider.

New types of fentanyl compounds resistant to the antidote are being manufactured off shore. One such compound is Acrylfentanyl. It has surfaced in the U.S. and there are concerns that it may be making its way to Canada as experts in B.C. are warning. Acrylfentanyl requires more naloxone to reverse and it lingers longer in the body. This means that not only may multiple doses of naloxone be needed but that they may also be ineffective.

Naloxone kits are not the end solution. They are simply a tool to be used for now. Our health officials must ask themselves why Canadians are the second highest consumers of prescription opioids on a per capita basis in the world. Our government must to do a better job of anticipating “what next?”.

 

On physicians, prescriptions and our health care realities

It has been easy to blame Canada’s physicians for over-prescribing. Efforts to reduce and control opioid prescribing have been ongoing in Ontario for over twenty years. Despite this, according to a recent Health Quality Ontario report, 1 in 7 people filled a prescription for opioids in 2015/16 and more than 9 million opioid prescriptions were filled—the highest rate ever in Ontario. Why is this?

It is simplistic to blame physicians for over-treating pain although in some cases this may contribute. This is not to absolve physicians from responsible and safe prescribing of opioids but to suggest that there are many other factors involved in opioid use in Ontario.

Conditions in Ontario’s health care system are contributing to this increase through long wait times for care. Patients waiting for definitive treatment for months or years with painful conditions seek relief. Physicians can attempt to provide it through a variety of means starting with non-opioid interventions including physio, acupuncture, exercise therapy as well as psychological support to name just a few. However, severe pain for degenerative conditions requires more robust pain relief efforts. The risks of addiction and dependence must always be weighed with benefit in the judicious use of opioid prescribing.

Of note, the rate of opioid prescriptions filled is higher in rural parts of Ontario and there is a shift toward more potent opioids such as hydromorphone. Prescriptions for hydromorphone increased by 29 per cent in Ontario while codeine prescriptions dropped by 7 per cent.

Lack of timely access to care in rural areas can result in unintended negative consequences and solutions should address this aspect of our health care system.

The drop in prescriptions of codeine, a traditionally acceptable pain reliever, may be in part explained by increased awareness over the past several years that standard doses of codeine may be toxic for people with the CYP2D6 genotype. With more point of care testing it may be possible to more safely prescribe codeine when it is a better option based on a patient’s unique genetic profile.

Difficulties with timely access to care in Ontario also have an impact on prescribing patterns. The overcrowding in emergency rooms across Ontario can result in more opioid pills being prescribed per prescription to prevent patients from having to return to the ER for additional pain relief. Difficulties accessing primary care may result in patients seeking stronger pain relief and more of it “just in case” they need it. While it is easy to comment on these prescribing practices as having negative consequences, the reality is that the environment in which we live has an impact on behaviour.

Prescribing by dentists and dental surgeons should also be considered in efforts to address excessive opioid availability in our communities especially for our youth. Wisdom teeth extractions should not result in every young patient receiving 25 opioid pills when smaller quantities would be sufficient in many cases and when even a less potent medication may suffice.

Health officials must consider the human behaviour contributing to opioid prescribing patterns but also reflect on systemic and social factors that may be contributing to the high rates. Even if opioid prescribing patterns by physicians were ideal all the time, the reality is that illicit fentanyl has changed the landscape of opioid abuse across Canada. As non-prescription fentanyl and its analogues from thousands of illegal drug labs that operate without government oversight or regulation in foreign countries seep into Ontario, efforts to curb inappropriate opioid use must take a more comprehensive approach beyond physician prescribing patterns.

 

Seniors and prescription drugs

The aging of the population with associated rise in cancer cases and other diseases requiring palliation results in more need for severe pain control especially for pain related to tumour metastases. As more patients seek palliative care for comfort from diseases at the end of life, effective pain control is a necessity. It is not unusual to see cancer patients taking large doses of opioids since their tolerance to the drug increases over time and more of it is required to alleviate their suffering.

Robust palliative care includes use of potent opioid drugs but how “left-over” prescription opioid medications are handled will make a difference to the circulation of opioids in our communities. Ottawa Public Health’s “Secure Your Meds” campaign is an effort to encourage patients and their families to lock up medications and to return expired and unused drugs. It is reported that 13 per cent of Ottawa high school students used prescription drugs non-medically and two-thirds of students got them from a family member or from someone they lived with.

 

We must do better

There are no easy answers to this opioid crisis.  However, the government and public health officials need to redouble their efforts to address the issues surrounding the deadly trends of opioid abuse and drug overdoses. These trends cannot be tolerated. They are unacceptable. We must do better. There needs to be new urgency and a comprehensive approach to address this crisis.

 

Reader Comments (60)

There is so much that is wrong with the deal that its hard to know where to begin..
I start with pointing out that one of the negotiators on the OMA side is Danielle Martin's husband. Hard to believe that this kind of conflict of interest would be overlooked.
June 5, 2017 | Unregistered CommenterMerrilee Fullerton
The EMS thing is a political pre-election joke...it is amazing how we, as citizens, just buy this stuff...if will have ZERO impact. EMS already has the ability to agree to not taking someons to the ER. Other than the most miniscule problem, they dont have the skills or legal comfort to differentiate most complaints. Most WICs near me dont seem to be able to do it! Are they really going to sort out influenza symptoms? Or are they more comfortable bringing them to the ER and then sit on their laptops for 3 hours (Not that they want to, but i work ER; there are few shifts where i dont arrive to 10 paramedics doing that-if only the public knew there are, at any time, millions of dollars in salaries sitting on their laptops for hours at a time across the GTA). And any process that significantly reduces ER visits by EMS will expose a surplus of paramedics who are being paid, literally, for 2 on 1 care to a patient on a monitored EMS gurney. The house of cards will fall. EVERYONE who works the ER knows minor visits have NO impact. It is always the elderly unwell, and their compatriots blocking the under capacity floors, who are killing the ER system. And , once again, rather than making the users (=voters) held accountable for inappropriate use of the ER , most of whom walk in anyway and dont use EMS, we will now try and download care onto the latest cheaper non-doctors: paramedics. And linking this to the essay topic (opiates), many inappropriate ER visitors are the result of chronic pain issues, who cant get proper pain management, physical therapy, dental care, mental health care ( all outside of ths "universal" coverage), and they either have no GP, or cant get an appointment for 2 weeks (i hear that many times a shift). They also use it for convenience (the ER has its lowest volumes during things like the Super Bowl). But to hold users of the system accountable is to lose votes. So blame the docs, and get EMS to miraculously save the system, we promise, to start the year after the election...
June 5, 2017 | Unregistered CommenterKsy11
BA

The intent is to round up all the cats under a BA contract, get a single contract, and then squeeze a group bound by contract, but not unionized.

The majority will support it, not wishing to see the future.
June 6, 2017 | Unregistered CommenterMovingforwardOntario
KYS11

Thanks.

You can't pay EMS enough to make these kinds of decisions as a first responder. The first inquest for an untoward outcome by the ambulance EMS not taking appropriate action will pull the veil off this. You must EMS immune to the consequences of such decision before EMS will cooperate.
June 6, 2017 | Unregistered Commentereklimek
Thanks Realist for that piece of intel which says it all. I'm surprised Hoskin's wife is not negotiating for the OMA as well.

Time to vote NO.
regarding EMS

CUPE which represents the majority of paramedics – about 6,000 paramedics and dispatch/communication officers province-wide – complained that Premier Kathleen Wynne made the “partisan” announcement at the annual meeting of Ontario’s firefighters union.

CUPE is encouraging the province to hold meaningful consultations with paramedics about expanding cost-effective ambulance based emergency medical care, and not advancing on the profound changes to EMS proposed Monday.

http://www.nugget.ca/2017/06/06/municipalities-will-pay-price-for-risky-dangerous-changes-proposed-for-ems--cupe
June 6, 2017 | Unregistered Commentereklimek
SS
not registered to the site. what's it about?
June 7, 2017 | Unregistered Commentereklimek
So, it now appears that the OMA negotiators including Mr Barrett would like to deliver deliver Ontario doctors to the Liberals on a silver platter before the next election which could be this July, August or September. No wonder this is such a rush.

The deal is a bad deal. I will be voting NO.

A yes vote will be a problem in "perpetuity".....

I'm pressed for time right now but plan to post more soon.
June 7, 2017 | Unregistered CommenterMerrilee Fullerton
A ‘no’ vote for binding interest arbitration

Written by Dr. Douglas Mark on June 6, 2017 for CanadianHealthcareNetwork.ca
Email Print Text size Comment

Dr. Douglas Mark
Hard though it may be to believe, Ontario’s doctors have been without a contract for 38 months and counting. Small wonder the Ontario Medical Association and the Ministry of Health and Long-Term Care are feeling the heat to “get a deal done” as soon as possible. While I’m not a defender of the status quo—certainly not when it comes to healthcare and how it’s funded or administered—an argument could be made that sometimes it’s better to deal with the world as we know it rather than taking a chance on something risky and unproven.
Take, for instance, binding interest arbitration . . .
My colleagues and I overwhelmingly rejected the tentative Physician Services Agreement (tPSA) that was hastily foisted upon the medical profession last summer by the previous leadership of the OMA. Not surprisingly, after the tPSA went down rather spectacularly in flames, grassroots physician leaders made it clear that heads needed to roll—including those at the very top. The eventual resignation of the entire executive committee and subsequent board elections have gone a long way toward breathing new life into the Ontario Medical Association.
That said, DoctorsOntario does have serious misgivings about the tentative binding interest arbitration (tBIA) agreement that the new OMA Board has placed in front of its members for consideration. For one thing, why the rush to get this ratified? We’ve been clamouring for our representative association to negotiate some form of binding arbitration on our behalf for more than two decades. Is there some reason why we can’t have more than a couple of weeks to make up our minds on such an important piece of the puzzle?
Then there is the question of whose “interests” are being looked after here—ours or the government’s. Let’s face it, Ontario premier Kathleen Wynne and health minister Dr. Eric Hoskins need this agreement a lot worse than the province’s doctors do. In fact, I’d be willing to wager that the ink will barely be dry on this agreement should we ratify the tBIA on July 17 before the two sides hunker down somewhere and begin negotiating a new physician services agreement. I mean, why not? We are only 12 months away from the next provincial election. The clock is ticking for the premier and our health minister.
They need to “kiss and make up” with the province’s 30,000-plus doctors pronto. Ontario’s doctors need no such thing. What we do require—ever so badly—is an outside, independent analysis of what’s in the tentative binding interest arbitration agreement and what it all means. That’s why DoctorsOntario, along with others, asked a leading labour lawyer, Richard Charney, to take a look at the document and give us his thoughts via a legal opinion.
Here, briefly, is a summary of Mr. Charney’s concerns:
1. The Framework Appendix does not provide for the recovery of clawbacks nor does it prohibit it. The OMA may hope to achieve this result through a Charter challenge, but this is at best speculative.
2. The Appendix appears to be enforceable through the Arbitration Act. It would always be possible for the legislature to repeal and override the Appendix, although that can be subject to another Charter challenge.
3 The Appendix provides for a duty to bargain in good faith, although the enforcement mechanism, while present, is not as expeditious as may be preferred by the OMA and its members.
4. The scope of interest arbitration is broad but is subject to exceptions and ambiguous criteria.
5. Under the Appendix, physicians are at risk that starting in 2024, payments to subsidize physicians for a portion of their fees to the CMPA may be curtailed.
6. Section 23 of the Appendix excludes from interest arbitration certain matters, such as decisions to add or de-list fee codes and pensions.
7. The interest arbitration provisions contain criteria. Some of the criteria are open to different interpretations. Clauses (a) and (d) together may invite a cap on the Physician Services Budget.
8. The Appendix contains a broad prohibition on strikes. Furthermore, the total ban on job action applies even to matters not subject to arbitration, a troublesome situation.
9. With respect to rights arbitration through a Referee, access to such a process is granted to the “Parties,” but there is ambiguity as to what that entails.
10. The Appendix indefinitely entrenches the role of the OMA as the sole legal representative and bargaining agent for all physicians in Ontario.
11. The Appendix ousts the right of appeal from a decision of an interest or rights arbitrator.
12. The Appendix deprives an arbitrator of the power to order legal cost or interest.
13. The perpetual nature of the Appendix is a concern. Even physicians who see a benefit to the Appendix should consider the fact that things are bound to change in the long run, yet the OMA appears to be committing itself indefinitely.
Sobering thoughts, indeed.
Bottom line, no matter how we try, we just can’t trust a government that has unilaterally clawed back $3 billion from Ontario’s doctors over the past three years to do what they say they’ll do. Which is why DoctorsOntario is recommending our colleagues all across the province reject the tBIA. We’re frankly tired of playing Charlie Brown to Kathleen Wynne’s Lucy. Let’s not give the premier yet another opportunity to yank the football away from us just as we’re about to kick it.
Dr. Douglas Mark is the Interim President of DoctorsOntario. Follow him on Twitter @DocsOntario.
June 7, 2017 | Unregistered CommenterStephen Skyvington

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