A naloxone kit is kept on hand to treat someone overdosing on an opioid such as fentanyl. It ought not to contain an opioid such a fentanyl, but that’s just what happened with a couple of such kits obtained at the Shoppers Drug Mart in Elmira.
The occurrence is being investigated by Health Canada and the Ontario College of Pharmacists.
An area resident, who requested anonymity, found fentanyl in place of naloxone in a kit acquired at the Elmira store. They compared the new kit to one obtained from another pharmacy to confirm the discrepancy, later confirming with another party that a similar mix-up had occurred.
In both cases, the owner-pharmacist came out to pick up the kits.
The information was shared briefly on social media after the February 5 incident before being taken down by the area resident.
The Toronto Star reported last week of the discovery, though stating only that the incident had occurred in Ontario. It noted the ongoing investigation.
Health Canada told The Observer it is working with the provincial Ministry of Health and Long-term Care, local health officials and the Ontario College of Pharmacists to gather information on what happened at the pharmacy.
“Health Canada received a report that the wrong drug was included in two naloxone kits obtained from a pharmacy in the Kitchener-Waterloo area. Based on information to date, this appears to be an isolated incident,” said spokesperson Anna Maddison.
The Elmira Shoppers Drug Mart referred questions to the Loblaw head office, where spokesperson Catherine Thomas said the company is moving quickly to deal with what is seen as an isolated incident.
“We share the view that this is a considerable error, and one that absolutely should not have happened. Our local pharmacist-owner took immediate action to ensure consumer safety, visiting the customers to secure the product and provide the correct medication, and to offer a detailed apology,” she said in an email to The Observer.
“This was a case of human error. We are taking appropriate steps to reinforce professional and operational expectations and procedures to help prevent this type of unfortunate situation from reoccurring.
“It is important that customers understand that this isolated event should not reduce their confidence in Naloxone kits as an effective response for accidental opioid overdose.”
The province plans to spend an additional $222 million over the next three years to fight the opioid crisis, including making naloxone kits more readily available. That strategy sees kits made available to emergency responders, at hospitals and directly to the public.
The move came in response to a large spike in opioid-related deaths in the province last years. There were 336 opioid-related deaths in Ontario from May to July 2017, compared with 201 during the same time period in 2016. From July to September 2017, there were 2,449 emergency department visits related to opioid overdoses, compared with 1,896 in the three months prior, a 29 per cent increase, according to provincial figures.
Health Canada’s Maddison said the kits remain a key component in bringing down those numbers.
“Naloxone kits containing either the injectable form of naloxone or naloxone nasal spray are still the best way to temporarily reverse an opioid overdose. Given the importance of naloxone in helping to save lives, we encourage Canadians who have a naloxone kit to check the contents before the kit is needed,” she said.