Improved Access to Naloxone in Ontario’s Fight against Opioid Overdoses:

by

LEGAL + AVAILABLE ≠ ACCESSIBLE

Naloxone

Over the past decade Ontario has seen a steady rise in the number of opioid related deaths and narcotic misuse across all socioeconomic groups in the province. Of particular concern is that despite ongoing provincial initiatives little has been accomplished to prevent the rampant abuse and misuse of narcotic pain medications. The opioid epidemic is a public health crisis of epic proportions. Recently it has been estimated that 1 in 8 deaths in Ontario is related to opioid abuse.

The government has rolled out a variety of initiatives to combat the problem. They have stopped paying for higher-strength narcotic pain medications through the provincial drug benefit payment plan in an effort to reduce the abuse of these agents. The provincial government has also increased funding for addiction services, and set out new guidelines for opioid use in chronic pain. (http://nationalpaincentre.mcmaster.ca/guidelines.html)

These recent policy initiatives from the provincial government to combat the provinces growing opioid crisis are welcome news. The problem represents a complex health issue with potentially devastating consequences for individuals, families and the communities they live in. Unfortunately the crisis continues to grow and these efforts do not go far enough to help prevent the senseless deaths that are occurring every day on the streets of our cities from accidental overdoses.

blog graph.jpg

Ontario opioid toxicity deaths, by drug – 2002-13. Data from Ontario Coroner.

Historically the use of the lifesaving antidote for an opioid overdose, Naloxone was only available to a select group of healthcare providers like physicians and paramedics. Most recently this past year the provincial government reduced the restrictions on this lifesaving medication making it available in local pharmacies to consumers without requiring a prescription.

This is a welcome policy change that will save lives….unless you live in Grassy Narrows, Attawapiskat, Pikangikum, White Dog, or any of the other remote Northern Ontario First Nation reserves where there are no pharmacies or publicly available free Naloxone kits. You may not find these communities listed on the provincial government website ‘Where to get a free naloxone kit’ but deaths from overdoses are happening here at alarming rates.first nation grassy

While there is strong support for this new policy change, simply removing the legal barriers and improving the availability of this life saving intervention may not equal improved accessibility for some residents of Ontario.

LEGAL + AVAILABLE ≠ ACCESSIBLE

Major health disparities exist amongst remote First Nations communities living in Northern Ontario. These populations are socially marginalized and medically underserviced. Access to healthcare for these populations is limited as is the quality, equity and timeliness of the healthcare they do receive. This results in disproportionately high burdens of disease and poor health outcomes. First Nations youth have higher rates of suicide and an increase prevalence of risk taking behaviours which can all lead to higher rates of alcohol and drug abuse and ultimately death from overdose.

Attawapiskat

The government’s expansion of initiatives and services which take aim at combating the opioid epidemic in Canada need to target all Canadians and not just those living in urban centers. If the government is serious about broadening access to initiatives like free Naloxone it needs to couple that with initiatives to ensure these initiatives reach the most vulnerable and disadvantaged members of society like the remote First Nation reserves of Northern Ontario. There needs to be a global expansion of healthcare funding for Aboriginal populations that aims to reduce the health disparities that currently exist in these populations.  Otherwise available does not equal accessible.

 

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7 Responses to “Improved Access to Naloxone in Ontario’s Fight against Opioid Overdoses:”

  1. childhealthandpolicy Says:

    Fascinating to see that Ontario has legalized access to naloxone but not made it easily accessible to the people, especially the remote First Nation communities.

    We have had varying success with access in New England. Massachusetts has pushed for widespread naloxone availability through standing orders at most pharmacies and it is covered by MassHealth,our state Medicaid program. http://www.mass.gov/eohhs/gov/departments/dph/programs/substance-abuse/prevention/naloxoneaccess/information-for-community-members-about-how-to-get-nalo.html

    Naloxone is also covered by Medicaid in CT but there has been less of a public education campaign to notify community members that pharmacists are also trained to prescribe.Colleagues in CT complain about the access.

    In total agreement that we need to make treatment legal,accessible, and inexpensive, especially for the most vulnerable. Great eye-opening blog!

  2. naohiisse Says:

    It is amazing that Ontario decided legislation of pharmacy to distribute free naloxone to people there without prescription. It would not be feasible in Japan even if the same problems happen because pharmacy in towns has never been given authority to distribute any medicine under strict laws historically. Nowadays some kinds of medicine have been permitted to be sold as over-the-counter drug but they are only limited cases. I wonder how our politicians might overcome such problems in our country. Environmental factors are different among nations.
    Local health centers may be the next place to distribute free naloxone in remote areas without pharmacy but it seems sufferers may feel more psychological barrier to local health centers than local pharmacy.
    Thank you for sharing interesting cases in your blog!

  3. childhealthandpolicy Says:

    At least in the US, these are not over the counter medications. The pharmacists must go for training in their prescription. We also have pharmacists who are trained to give immunizations! All of these are still very closely scrutinized, however.

    Another big push is for student health centers at colleges to increase access to naloxone.

  4. etjuhn Says:

    Thank you Canadan 33 for the post.

    The cessation of payments for higher dose narcotics, and the increase in funding for drug rehabilitation services, appears to be a step in the right direction in Canada’s fight against the opioid epidemic. However, I agree with your blog post that increased Naloxone access in the more remote communities should be addressed in their health policy.

    Interestingly, due to the higher risk burden for these marginalized communities, I wonder if a new or amended policy could be enacted. Perhaps if various international organizations or programs such as the WHO or the G8 committee were able to get behind the opioid impact in the remote communities, policy makers could be influenced to make this a priority item. Moreover, if these policy makers were able to understand the benefits of funding the needed clinics (or mobile clinics on wheels) or pharmacies in the remote areas of need, a prioritization of this issue might take place. Also, if this new policy were indeed to take place, I suspect the program managers would be a critical part of the process as they would need to execute on the allocation of day-to-day resources to ensure the most effective distribution of the free naloxone kits.

    I also wonder if the single payer system in Canada impacts the country’s ability to form effective policy webs, and if the information and knowledge being shared from various influential channels is able to traverse appropriately through the power dynamics. Or, if the political context in Canada could influence such decisions. For example, in the US, various stakeholders with lobbing power can often impact policy decisions; I wonder if either edgy or hot tactics (such as protests or sit-ins) might be effective in ensuring the remote communities receive the opioid treatments they deserve.

  5. sabiha17 Says:

    Thank you so much for your post. Naloxone access is a very important topic when discussing the opioid epidemic. This is true in Canada as well as the United States. I deal with patients with opioid overdoses very frequently and many do not like the antidote. They hate the way Naloxone gets them out of their “high.” I would love to think that the solution to the opioid epidemic could be as easy as making Naloxone more readily available. However; the epidemic is much deeper, it is the result of deep rooted problems in society that few have the will or resources to even begin to tackle.

  6. kazumisakashita Says:

    Dear Canadan33,

    Thank you very much for your post. It is great to know the policy change Canadian government made to reduce opioid-related negative health outcome.

    Thinking an effective delivery method to underserved community, I recall Japanese traditional way of medication delivery which is called “Oki-gusuri = Home medicine box delivery”. This has been a common delivery system especially in rural areas. (Recently there are pharmacies everywhere, so this system is not very popular.) A private pharmacy distributes a kit (box) of various OTC medications to houses for free. Every 2-3 months the pharmacy staffs directly visit each house who keep a kit, and check which medication was used how much. Customers need to pay only for medications they used. The staffs also check the expiration date of each drug, and exchange to new one as needed. This method was adopted into Mongolia initially by a NGO in 2004 and now by the Mongolian central government in order to deliver medications to nomadic families who lives in remote grasslands. Currently this method is adopted in several Asian countries. The downside of this system is that it requires community agreement and trained delivery staffs, as well as secure environments where delivery staffs visit directly. Still it may be a possible way to distribute Naloxone kits in First Nation.

    Needless to say, primary prevention for opioid dependence including education is essential.

    Kazumi Sakashita

  7. stephendsander Says:

    Canadan33, I really appreciate your blog that sheds light on a growing crisis that affects even the most remote, but no less important communities in Canada. Before I read your blog, I did not consider the impact geographic locale would have on access to much needed addition treatments.

    While I appreciate your contributions to increase the access to life saving emergency treatments such as naloxone, I take issue with the promotion of policies that restrict access of prescription opioids from those that potentially need them the most.

    Few treatment options exist for people that live with chronic, severe pain. The nation needs non-opioid medicines that are effective at relieving severe pain, but that are safe and not potentially abusive. Until then, people in pain require opioids to maintain a healthy life.

    Perhaps the single most important nuance to understand when managing pain and deciding on policy that impacts people with pain is the distinction between physical dependence and addiction. Chronic pain, by definition, does not go away, but the opioid receptors in the brain develop a tolerance, eventually diminishing the pain-relieving effects of opioids at their current dose. This is dependence, and it is normal. Doses need to be incrementally increased over time to provide the same level of relief. And inadequate pain management impacts not only quality of life, but deteriorates activities of daily living and leads to depression, anxiety, and “self-medication” with more harmful substances such as alcohol.

    The point is….those with very longstanding pain may require very high doses. Policy that is focused on restricting access to high doses seems to not take this into consideration.

    Thank you for considering this in your fight against the growing and crisis that is taking the lives of so many.

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