CBC Q&A: Windsor doctor concerned over two recent opioid overdoses

Opioids are supposed to be used on a short-term basis for moderate to severe pain. But Dr. Tony Hammer in Windsor, Ont. believes they are being used increasingly for chronic pain including back pain and headaches. 

The addictions specialist says manufacturers and physicians "have rather been taken in to prescribing larger and larger quantities both in terms of the total dose and in terms of formulation. The pills have gotten bigger and bigger." 

And for Dr. Hammer that's a problem because he says they are gateway drugs to addiction.

Starting in January, Ontario will stop paying for higher-strength opioid medications through its Ontario Drug Benefit (ODB) program. The goal is to crack down on the increasing problem of addiction to the painkillers.

Here are edited excerpts from the interview:

The province's Ministry of Health and Long-Term Care has set caps for morphine at 200 mg tablets, hydromorphone at 24 mg and 30 mg capsules and fentanyl at 75 mcg/hr and 100 mcg/hr patches. What do you think about this? 

That alone is not nearly enough and it's quite vague. There needs to be far more detail, accommodating cancer care for example, and making sure that although we can't prescribe a 200 mg tablet of morphine - that it involves other drugs and prevents us from getting around it by prescribing multiple 100 mg tablets for example. The sooner there is either legislation or standards by the College (of Physicians and Surgeons of Ontario), the better. What is going on now is dangerous and this is reflected in the current problem with the mortality of patients from accidental overdose who are on these high doses and mixing them with sedatives.

How often do you see that in your practice? 

In my practice, we've had two deaths in the last month of accidental overdose. Often the patients don't reveal to other physicians they're also getting these drugs from other sources and from the street and these physicians simply don't have the skills to evaluate these patients and ensure they're complying with the prescriptions they're providing.

So these patients started in your care?

One was under my care and unbeknownst to us started seeing other physicians who I think carelessly and without precautions prescribed similar drugs without an evaluation. A urine drug screen would have revealed that they were on methadone. The other one left our care and then complained to a walk-in clinic that they were in pain. (The doctor) started treating the pain with narcotics without checking that the patient was using street drugs already and the primary problem was addiction, not pain. You have to be careful when these patients who are addicted say they are in pain, they have learned over the years that to say that they have reliably, in the past, have been prescribed narcotics. They lose the capacity to take enlightened decisions on whether they need these drugs. All they know is this drug solves their problems. They feel better, they can avoid withdrawal and if they do have pain, it goes away. 

Could anything be done to have better communication among physicians?

There is a very big need to have a central clearing house so that every doctor, before prescribing a hypnotic or a narcotic, can go to a database and find out if that patient has been prescribed similar drugs in the past. In the States, in 49 of the 50 states, that is there and my American colleagues say this is one of the most valuable tools. We can do this to a certain extent at the moment in Ontario but it is not 100% reliable. So it's difficult to say to these other doctors prescribing these drugs, 'Don't prescribe anything until you have verified whether they are getting drugs from an alternative source.' But a central database so that we can find out whether they are being prescribed by other physicians is absolutely essential and badly needed.