SSM|And on The Topic of PATCH4PATCH: What Will it Accomplish?

Editor’s Note: Last week the Sault Ste. Marie and Area Drug Misuse Strategy Committee issued a press release announcing the launch of a Fentanyl Patch4Patch exchange program for Sault Ste. Marie. The Committee is comprised of area physicians, pharmacists and agencies inclusive of Sault Ste. Marie Police, Algoma Public Health, Group Health Centre, Sault Area Hospital, North East LHIN, A New Link and Dr. Alan McLean and the Superior Family Health Team. The program requires patients to return used fentanyl patches to the pharmacy before new fentanyl patches are dispensed.

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What difference, if any at all, will a Patch4Patch program have in the use and the misuse of fentanyl[1] in the community?

I normally approach my writing of an article by only playing the devil’s advocate. This time I thought I would take it a step further by providing the positive impact that the Patch4patch program is intended to have, along with a dose of that skepticism I’ve become known for.

For those who have been prescribed fentanyl, I would say that yes, the program, in theory at least, will have a positive impact. Awareness of it’s ‘addictive’ potentials and education around ‘using as prescribed’ and ‘cautioning’ against the risks of improper use are key to keeping those who are using fentanyl for chronic pain from accidently overdosing.

Optimistically, the Patch4Patch program will provide the opportunity for a closer and more transparent relationship in the patient/doctor/pharmacist dynamic. Limited prescribing, a one-month supply rather than three, allows each to observe and watch for signs of dependency and misuse, as well as, under or over prescribing and miss prescribing.

I believe most patients will abide by the practice of returning their used patches and that other than it perhaps being a bit of a nuisance, they will be happy to do it. However, I also believe that these are, save a few, the same people who have never abused their prescription in the first place. They are not dependent on either the drug itself or having to sell off pieces of their script in order to supplement their income.

Now let’s look at substance use realistically.

We divide substance use into two groups, licit and illicit. If you are prescribed an opioid, such as fentanyl, it’s okay with society and we can accept it and even have empathy for the pain you are in. On the other hand, in the minds of many, those who are using illicitly, have got to stop it and if they don’t they deserve whatever they get. This disconnected way of thinking has only exacerbated addiction to substances dramatically.

If we were to look at substance use from both the illicit and licit substance users perspective, there is actually no difference at all. The simplistic analogy for both demographics is that ‘it feels good’. The pain caused by the disease or the dis-ease subsides, even if just briefly, and it feels good.

We accept that it feels good for the prescribed user to be out of chronic pain. No one wants another to suffer and it would be immoral to let the terminal suffer with chronic pain only to die in the end. However, we do not consider, nor do we accept, the pain or dis-ease of an illicit user. We perceive that they are not suffering solely on the basis that their pain may not have been diagnosed, visual to us or labeled by anyone with anything other than that of degradation. We fail to see beyond the protective façade they have built and do not give merit to it. Most significantly, we do not appreciate that other mechanisms to treat their pain, are very often not easily at hand for illicit users for a variety of reasons.

There is nothing in the Patch4Patch program that works to the benefit of illicit fentanyl users. The question remains, however, will it hinder in any way, those who use fentanyl illicitly? My answer to that is a blatant no. Not even for a moment!

Is the Patch4Patch initiative designed to curb diversion of fentanyl patches?

There is a short and a long answer to this question. The short answer is yes. To some degree it will have the desired result of less diversion of the patch. However, as stated above, I do believe that those who seek to supplement their income in this fashion will find a way, at least initially, to do just that. Similarly, those who use their patches to get high will not be detoured by implementing this practice.

The long answer is something quite different. Intended or not, preventing a patch from being diverted is more of a side affect than it is the main focus. By creating an environment where you are first educating the patient on the benefits and harms associated with using such a powerful drug[2], you are affectively creating a co-relationship between patient/doctor/pharmacist and making each accountable for their part of the healthcare paradigm. In monitoring that accountability and the responsibility of each, you allow for everyone to hold a respectful position in that patient’s wellbeing. Responsible disposal of the patch prevents unintended harm to children and pets and keeps it out of our waterways.

Many who become addicted to the opioids (fentanyl is an opioid derivative) first began using it under a doctor’s advice. When you have a situation where the patient is seeing the physician once per month, and the pharmacist perhaps more often, the occurrence of cross-over from use for pain to addiction or dependency is more likely to be recognized immediately and steps can be taken sooner. Three sets of eyes looking out for the best possible result for the patient.

Here come my ‘Buts’

By restricting access to fentanyl patches, or anything for that matter, you are creating a demand and an imagined urgency for that very thing. In doing so, you make it a lucrative product for black market and underground enterprise to thrive on.

Those seeking fentanyl are going to continue to seek it and will get it from whatever source is easiest and the least expensive. Unfortunately, that may very well mean a surge in break-ins, pharmacy holdups and incidents of nursing home patients having the patches taken from their bodies as they lie in their beds.

With fentanyl patches going for $400 to $500 for new and used at $150, as recently reported, I can guarantee you there are some out there who are supplementing their income and that it’s not just done by those who are diverting their own prescription.

Has anyone thought to question what measures are taken in hospital, care giving, and nursing home settings to ensure that staff are not diverting new or used patches? How many hands will each patch go through before its destruction and can we assume each hand is an honest one? Is there zero tolerance on not having a patch to exchange for a patch when it is changed for a patient? Who is going to be in charge of the picking up and destruction of collected patches and will anyone know if every patch is accounted for? What is the consequence of not having a patch to exchange for a new one?

In Response to my ‘Buts’

Ms. Sandra Byrne, manager of Community Alcohol and Drug Program for Algoma Public Health, took my call and responded effortlessly and knowledgably, addressing many of these buts.

Long prior to the implementation of the Patch4Patch program for the Algoma community, a practice of accountability for each fentanyl patch was established within nursing home settings and with in-home care providers and has been working well in each of these circumstances.

For someone who is in control of administering their own patch, it is recommended that no more than 10 patches be dispensed to them at one time. In the event that a patient does not return all patches the pharmacist is expected to notify the patients physician. In order to continue the patient on pain management, the pharmacist will dispense only one patch at that time. When that patch is returned they will be given two, until they reach five patches. Provided there are no further incidents, at this point the patient can go back to receiving their full prescription at one time.

Patients applying their own patches are asked to return used patches when the full prescription has been used. Patches are to be returned to the patch disposal sheet, attached to a paper with date and time of each use and signed by the patient. The Pharmacist is expected to check everything prior to filling the next script.

From there, used patches are collected and incinerated and if all goes as expected, it is intended that few patches will be used in any unintended way.

The Algoma community is as advanced as any, and better than most, in providing assistance in all situations of substance use whether it be illicit or licit. We can all agree that there is only so much you are able to do under the constraints funding and government legislation or lack thereof. Among various resources available to citizens is the ASH[3] and New Link[4] programs. The Neighbourhood Resource Centre[5], is a facility where a number of community resources are brought right to those who need it and may not seek it otherwise. Support is provided one to one and is based on that individuals specific needs.

All are wellness based foundations rather than punitive, putting the client into the discussion of how they can best be served.

My Biggest ‘But’ of All!

When asked, “what will happen to those who are now dependent on diverted fentanyl to support their substance use?” Ms Byrne listened while I explained my many concerns for this demographic.

When oxycontin became unavailable, many oxy users immediately turned to using street heroin. It was cheap, as potent but much more dangerous to use. The intent of impeding oxycontin misuse instead became responsible for a spike of death and disease amongst substance users and did nothing combat illicit substance use.

Reports from various provinces and territories have filled the front page of the news over the last year (and there has been a flood just recently[6]), telling us of the sharp increase in overdose deaths attributed to ‘homemade’ fentanyl[7],[8],[9],[10],[11] (also described as: greenies, green beans, green monsters). The dosage of fentanyl in each pill is inconsistent and toxic binding agents are used in the manufacturing. In many cases, this home cooked fentanyl is being passed off as heroin or oxy and the user overdoses without an unawareness of what it was that they actually took. Even with assuming we can get to a place of zero diversion of patches, these reports verify that a very dangerous and deadly way around the patch4patch regulation is already in existence. So what has actually been accomplished? We’ve forced them from ‘clean’ and ‘safer’ substance use into the unknown once again.

Already knowing the answer, I still questioned Ms. Byrne as to how it is that we can implement all of these guidelines around the use of fentanyl patches, an opioid that can easily cause death even when used as directed, and yet we still have not found a way to implement easy availability and distribution of Naloxone[12], the opioid reversal drug? The answer is that Federal and Provincial policy makers, as well as a plethora of other regulatory bodies, do not want to take on the cost or the responsibility. Ms. Byrne is supportive of having Naloxone in the community to respond to the risks of opioid overdose. My frustration is the myriad of obstacles in the way of accomplishing this.

I also had the fortune of connecting with Mike O’Shea, Ontario Mental Health at North East Local Health Integration Network (North East LHIN), to seek his views on the Patch4Patch program within his district of the LHIN and we found ourselves headed down another avenue altogether.

“It’s not about judgment, blame or punishment of a substance user; it’s about connecting with that person. Without that connection, you have nothing. They need to know your present for them and for their benefit” O’Shea explained. “And that you’re not going anywhere”.

“We are moving to a model of health first and that does not include a practice of shaming, segregating or stigmatizing.” He went on.

I quite agree with this methodology. Re-humanizing the De-humanized. Is that not what I’ve really been getting at? Empathy and compassion v. prosecution and persecution.

[1] http://en.wikipedia.org/wiki/Fentanyl

[2] http://www.nugget.ca/2013/12/06/fentanyl-patch-exchange-policy-launched

[3] http://www.drugandalcoholhelpline.ca/Directory/Program/15892

[4] http://www.yellowpages.ca/bus/Ontario/Sault-Ste-Marie/A-New-Link/15680.html

[5] https://www.facebook.com/neighbourhoodresourcecentressm

[6] http://www.ccsa.ca/Resource%20Library/CCSA-CCENDU-Oxycontin-Fentanyl-Alert-2014-en.pdf

[7] http://calgaryherald.com/news/crime/deadly-painkiller-linked-to-rising-number-of-alberta-deaths

[8] http://vancouver.24hrs.ca/2015/01/05/fentanyl-related-deaths-rise-bc-cdc

[9] http://panow.com/article/495030/saskatoon-police-link-another-overdose-death-fake-oxycontin

[10] http://www.cbc.ca/news/canada/british-columbia/oxycontin-lookalike-pills-prompt-warning-in-surrey-b-c-1.2785953

[11] http://www.thestarphoenix.com/Family+mourns+latest+victim+fentanyl+overdose/10716562/story.html#__federated=1

[12] http://en.wikipedia.org/wiki/Naloxone