Jocelyn Downie and Stefanie Green argue that secobarbital, a self-administered medication for medical assistance in dying, will increase patient access and autonomy.
Under the Canadian medical assistance in dying (MAiD) legislation, both provider-administered lethal injection and self-administered ingestion of lethal medication are legally permissible. However, until very recently, the gold-standard drug for self-administered MAiD was not available. That changed in November 2017 with the announcement of the renewed availability of secobarbital.
Secobarbital was developed in the 1930’s and was primarily used in Canada to treat insomnia and epilepsy but was also used for pre-operative anesthesia. It was often misused recreationally, especially through the 1960’s and 70’s, and was associated with accidental overdose. As newer, safer drugs came along, secobarbital use was discontinued in Canada and its Health Canada approval lapsed.
However, a new need for secobarbital emerged when self-administered MAiD became legal in Canada. Secobarbital is the preferred drug for self-administered MAiD for several reasons. First, it is especially soluble in both water and alcohol and so it allows for a more palatable solution than is possible with the alternatives. Second, because of its solubility it is possible to use a higher dose in a smaller volume, reducing the risk that patients will not finish the full dosage (without vomiting or falling asleep). Perhaps most importantly, secobarbital has a faster onset of action than most alternatives. This means that the extended dying periods associated with alternative medications are far less likely to occur. With increased palatability, smaller volumes, and quicker onset of action, patients may be more likely to choose a self-administered MAiD option and it may also be a better experience for family and friends who are attending. Providers may be more willing to participate in self-administered MAiD (especially in those jurisdictions in which they are required to remain with the patient throughout the dying process) and health authorities may be more likely to develop protocols for self-administered MAiD.
Typically, drugs require approval from Health Canada before they are made available to consumers. When MAiD became legal, a drug manufacturer could have sought approval to once again market secobarbital in Canada. However, drug approval is a time-consuming and expensive process and MAiD creates only a relatively small market for secobarbital. To date, no pharmaceutical company has sought Health Canada’s approval for secobarbital.
An alternative path for making drugs available to consumers is called compounding. For this, a compounding pharmacy or compounding pharmacist purchases the necessary active pharmaceutical ingredients from a distributor. When presented with a prescription from a physician or nurse practitioner, the pharmacist compounds the final product and it can then be made available to the patient. This does not require Health Canada approval. While nothing prevented any active pharmaceutical ingredients distributor from making secobarbital available in this manner, no company was doing so until one Canadian company took the necessary steps to source the active pharmaceutical ingredients.
The active pharmaceutical ingredients for secobarbital are now available from a compounding distributor.* If a patient meets all of the eligibility criteria and the procedural safeguards for MAiD, a physician or nurse practitioner can write a prescription that can be sent to a compounding pharmacy in either the community or hospital. The compounding pharmacy can order the active pharmaceutical ingredients from the distributor and can then compound the prescribed final product. The secobarbital can then be provided to the patient for ingestion following any relevant provincial or territorial protocols.
The availability of secobarbital is a step forward for MAiD in Canada. It should increase access to self-administered MAiD because some providers, for the reasons outlined above, may now be willing to prescribe secobarbital where they would not have been willing to prescribe the alternatives. Also, some providers may be willing to write a prescription but not to administer the medication themselves. Having self-administered MAiD as a viable option may therefore expand the number of willing providers. This is particularly significant in rural and remote areas with few healthcare providers.
The availability of secobarbital should also increase patient autonomy as it means that patients may have more control over the timing and circumstances of their death. They can choose whether to have either provider-administered or self-administered MAiD. Where authorities do not require the presence of a provider for self-administered MAiD, patients will not need to cater to the sometimes limited schedule of a medical or nurse practitioner.
In sum, the availability of secobarbital allows for increased access and autonomy, without compromising in any way the robust system of eligibility criteria and procedural safeguards for MAiD.
Stefanie Green is the co-founder and President of the Canadian Association of MAiD Assessors and Providers (CAMAP) and clinical faculty at the University of British Columbia and University of Victoria.
* The list of compounding pharmacies with an established association with the active pharmaceutical ingredients distributor is available from the Canadian Association of MAiD Assessors and Providers (CAMAP). Any compounding pharmacy wishing to join this list may also contact CAMAP to facilitate the process with the API distributor. The name of the distributor is available to healthcare providers from CAMAP.