Canada is in the midst of a “man-made epidemic” of opioid addiction – this spring, BC even declared a state of emergency after a surge in drug-related deaths. Provinces across the country are working on the issue, as spiking addiction rates and deaths raise alarms.
Sherry Stephenson is one of the people who got caught up in opioid addiction. “I struggled my whole life with addictions, but nothing got the better of me than these opioids,” she says. She was first prescribed them after a car accident in the summer of 2003 – just months after she’d graduated from college. She’d been a single mom since 16 and had overcome an abusive relationship, using cocaine and alcohol, and the death of her father from a heroin overdose. Her family doctor prescribed OxyContin and Percocet to deal with the pain from that car accident, and she was on them for the next six years, slowly increasing the doses. “They numbed every ounce of pain I had in my body and my life – emotional too. It just made everything okay, until it wore off, and I needed to fix that pain again,” she explains.
The drugs, which she chewed and snorted near the end of those years, would lead to kidney damage and make her so dependent that she had to take a pill before she got out of bed in the morning. She explains that her doctor didn’t seem to notice any of the signs that she was addicted or ask too many questions at her monthly appointments to refill her prescriptions. “This guy was basically the best drug dealer I ever had,” she says.
The problem of overprescribing opioids in Canada began in the mid-90s, when they shifted from being used primarily in palliative care and for cancer pain – which they’re still recommended for – to much greater use in chronic pain. By the early 2000s, the opioid crisis had become obvious, with opioid addiction and overdose doubling between 1991 and 2004 in Ontario. And while the drugs being prescribed have changed – shifting from OxyContin, one of the first long-lasting opioids, to OxyNEO, a similar drug that’s harder to abuse, as well as fentanyl and Hydromorph Contin – the overall amount of opioids prescribed has is still rising. In 2012, Canadians filled 18 million opioid prescriptions. Last year, there were 22 million. That makes us the second-largest consumers of opioids in the world, after the U.S.
Not all opioids are coming from physicians’ prescription pads – many of those addictions start from recreational drug use. But there is also no debate that many people became addicted after using these drugs as prescribed, then abusing their prescription drugs by crushing, snorting or injecting them, or turning to drugs like heroin or made-in-China fentanyl bought on the streets. “There is a huge push by the media to think of this as a fentanyl disaster, and certainly the spike in deaths is related to fentanyl. But the underlying issue [of opioid addiction] is not new,” says Mark Tyndall, executive medical director of the BC Centre for Disease Control and professor at the UBC School of Population and Public Health.
For this article, however, we’re leaving aside the issue of street drugs to focus on the many issues around the prescription of opioids for chronic, non-cancer pain. Here are five ideas on how the health care system can better manage the opioid crisis.
1. Change our guidelines around prescribing opioids
There was a strong push towards prescribing opioids in the late ’90s and early 2000s, when “the companies that make these drugs spent hundreds of millions educating doctors on the use of opioids for chronic pain, telling us that these drugs worked well over the long term, and that the risk of addiction was less than 1%. But in hindsight when you look at the literature they used to support those claims, it’s incredible that we bought that message,” says David Juurlink, a physician at Sunnybrook Health Sciences Centre and Head of the Division of Clinical Pharmacology and Toxicology at the University of Toronto.
That oft-repeated 1% stat had minimal scientific backup, and the real rates of addiction are much higher. A 2015 systematic review found addiction rates may be as high as 8% to 12%. And Purdue Pharma, makers of OxyContin, was recently found guilty in the US of misleading doctors about the addictiveness of the drugs during that time – they even used fake scientific charts.
Now, “we need to reset the practising habits of physicians,” says Gordon Wallace, managing director of safe medical care with the Canadian Medical Protective Association. One way to do that is for Canada to revise its opioid prescribing guidelines, which haven’t been updated since 2010. A new version of the Canadian guidelines is set to be released next summer.
Meanwhile, the provinces are working on their own guidelines. Health Quality Ontario is creating a quality standard for opioid prescribing for pain. In Alberta, the College of Physicians and Surgeons is circulating a draft proposal around prescribing guidelines that would require doctors to prescribe the lowest effective dose, to track the drug use history of their patients, and to discuss potential side-effects with them.
And the College of Physicians and Surgeons of B.C. recently endorsed the stricter American guidelines from the Centres for Disease Control and Prevention, which were updated in 2016. They are significantly more conservative than Canada’s current guidelines, with recommendations that physicians should consider non-drug therapies (like cognitive behavioural therapy and exercise) before opioids. If they do prescribe opioids, they should be reassessed within a month, and at least every three months after that. Indeed, it’s not clear if opioids are effective for long-term pain. Most studies on opioids’ effectiveness are short-term (less than eight weeks long), with no placebo-controlled randomized clinical trials looking at the effect on pain of using opioids for over a year.
2. Rein in high-dose prescribing
After taking opioids for some time, people usually become tolerant and need more to achieve the same pain-management effects. But this can be dangerous, because it increases the risks of side effects like sedation, death and addiction. People who are on low doses of opioids are three times more likely to be dependent on or addicted to opioids; those who are on high doses are 122 times more likely. There’s even a phenomenon where taking opioids can increase people’s pain.
“The majority of people who are on long-term opioid therapy, particularly at higher doses, are actually being harmed more than helped by it,” says Juurlink. “Especially for people who are on high doses, it’s incumbent upon their doctors to have the difficult conversation with them, to say I know you think these drugs are helping you, but a slow taper will often leave people feeling better, more alert, more able to function.”
The new CDC guidelines address this issue directly, stating that doctors should reassess after increasing doses above 50 morphine milligram equivalents (MME) a day, and avoid increasing or “carefully justify” increasing doses to above 90 MME a day.
In a similar move, Ontario recently announced that it would stop covering high-dose opioids (higher than 200 MME a day) on its public drug plan (the dose above which physicians should carefully reassess the patient’s needs, according to the current Canadian guidelines). Above that level, “there is little evidence to demonstrate improved pain management, while [it’s] strongly associated with adverse events, addiction and opioid-related mortality,” reads a Q&A about the change.
3. Introduce better monitoring systems
Another crucial component is to create prescription monitoring systems that both physicians and pharmacists can access. The current Narcotic Monitoring System in Ontario issues an alert to pharmacists if abuse is suspected, but doctors don’t have a way of seeing if their patient has seen a different prescriber the day before, for example. “To me one of the big shortfalls of this system is that it’s down to the pharmacist to be the gatekeeper,” says Tara Gomes, a Principal Investigator of the Ontario Drug Policy Research Network. “If prescribers knew the history when they saw a patient, it would avoid those prescriptions being written in the first place.”
That’s already happening in BC, where the PharmaNet systems allows physicians and nurse practitioners access to the drug records of their patients online.
She’d also like to see systems to help the regulatory colleges across the country identify outlier prescribers, and help them refine their prescribing habits. One example of that is Alberta’s Triplicate Prescription Program, which gathers dispensing data in the province for select drugs. As a result, it allows the College of Physicians and Surgeons of Alberta (CPSA) to identify doctors who may be over-prescribing opioids and offer them education, as well as having doctors who are experts in chronic pain management or addiction work directly with them to provide advice on how to manage their patients. This system has been shown to be effective in the short term, says Trevor Theman, registrar for the College of Physicians and Surgeons of Alberta, but they’re just starting to collect data on whether it effects long-term prescribing habits.
“People aren’t very good at looking at themselves,” says Theman. “This is true in chronic disease management too – physicians say I’m sure I manage my diabetes patients well, [but if you look at the data], some things are getting missed.”
The program offers insights into the extent of the issue in Alberta. Theman estimates that a quarter of the province’s 10,000 doctors have one or more patients exceeding the college’s standards in terms of dose or duration. About 15* doctors have patients on over 4,000 MME a day. “It’s an enormous problem,” he says.
4. Taper existing opioid users and help those who have developed addictions
Some patients who are dependent on opioids will respond well to a slow taper, gradually lowering their physical need for the drug. But for others who have become addicted, they may need a set of more intense interventions, like access to better mental health services, abstinence programs, and methadone or Suboxone to stabilize their cravings.
That’s important because cutting off high-dose prescribing can force regular users to the streets, to avoid the excruciating effects of withdrawal. “People who are already addicted, to say that we have tighter rules, and in the next month we’re going to have to wean you off, many of those people will be going to the streets,” says Tyndall, which has happened in some places in the U.S. after tighter restrictions.
“People who are currently on opioids need better access to proper chronic pain management, addiction treatment and detoxification,” says Theman. “For that group, it’s not just a matter of turning off the tap.”
5. Focus on alternative ways of managing pain
Experts agree that it’s time to place more importance on methods of treating pain that don’t include opioids.
Fiona Campbell, a physician and the president elect of the Canadian Pain Society, says that we should be using what she calls the 3 ‘P’s approach to managing pain: looking at combinations of not only pharmacological, but also physical and psychological strategies. She also says that better prevention and treatment of acute pain can also make chronic pain less likely to develop. “However, if conservative strategies fail for the treatment of chronic pain, we should consider using opioids safely and effectively.”
Cognitive behavioural therapy, exercise, mindfulness and physiotherapy are all proven ways to reduce pain without medication, and acetaminophen and NSAIDs like aspirin and ibuprofen are also effective for most pain. For more complex pain, neuropathic medications can be another good option, says Campbell.
Publicly funding physiotherapy and psychotherapy for the treatment of chronic pain is also necessary, she says. “I think a real barrier here is that expert professional help like physiotherapy isn’t publicly funded,” she says. “So the easiest intervention is for primary care providers to provide prescriptions.”
*This article has been updated from the original version to correct an inaccuracy in the number of Alberta doctors prescribing over 4000 MME.
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Interesting article. It’s hard to disagree with any of the suggestions for improvement. At a a very fundamental level, I would like to know how you define addiction, a term no longer used in the DSM, and one which is often conflated with physical and/or psychological dependence. Substance Use Disorder, as defined in the DSM 5, is a spectrum disorder, but only the highest scoring (6+) are classified as having a severe disorder, which, I assume, equates with what used to be called addiction. In my experience, the ratio of non-addicted opioid misusers (those using in a manner or dosage not recommended for legitimate usage) outnumber truly addicted opioid users by a ratio of about 10:1. Treatment of each of these groups can be very different. Nevertheless, productive discussion requires a common understanding of the terms of reference.
Not sure what mini-pain NSAIDS and aspirin work for. They don’t touch any pain I ever had including severe migraines. Now I’m allergic to both after years of non-migraine care besides the psycho-babble for my “fake” headaches before Glaxo and sumatriptan came on the scene. My guess is the physio, talk therapy, CBT pushing crowd have no concept of what real pain is. I have osteoarthritis to look forward to, no cure, no way to stop the progression, no medication. Just get used to it because Buddha and Jesus say pain is good. I’ve never been prescribed pain meds ever, not for anything and doubt I ever will. Dignitas says one of the big problems they have now are untreated pain patients who can’t take it anymore flocking to end it. Give your heads a shake. The pendulum needs to swing back to the middle. The WHO says pain treatment is a human right but you would never know it.
Vera, as a Chronic Migraineur, I completely agree with you. You never know until it happens to you. I take 2 Percocet as a rescue drug if my Triptan and NSAIDS do not provide relief. This is about 1/3 to 1/2 of my Migraines. I average about 12 Migraines a month. So I need about 10-12 Percocet a month. Because I use them only as a last resort, they work. I only take 2 and this has been for 5 years. I have not needed to increase the dose, I haven’t become tolerant because I don’t take it everyday. Besides the pain relief, the second biggest reason for using Percocet for me is that it allows me to avoid EVER going back to the ER for treatment. I am judged the moment I walk through the door and treated like a piece of garbage. What are we doing to fix THAT problem?
No one should have to live a life of untreated Chronic pain. Chronic Pain patients are the ones who will suffer the most. The illegal fentanyl and laced fentanyl that is being sold by dealers is the main problem. You are just pushing more patients to use whatever means are needed to live some resemblance of a life. For some, this will be obtaining illegal drugs, drugs that could be laced with who knows what and untraceable by pharmacists and physicians. The second issue is that some patients, will choose suicide. That is a fact. You will see an increase in illegal drug use and fentanyl overdoses. Let’s re-evaluate what the statistics are 6 months and 12 months from now. The only thing that is guaranteed is that drug dealers and their suppliers will be making more money, have increased demand for their product, which will in turn lead to these pills being made with greater frequency and even more dangerous ingredients. I guarantee that in 6 months to a year you will see an increase in fentanyl overdoses. At that time, the medical community will come up with some new way to blame Chronic Pain patients, most likely by cutting off access to any opioids at all. And then the cycle continues.
Hi Kristine;
I don’t know if I’m allowed to repost my comment from one of the other topics but I will try anyway. You pretty much nailed it. My approach is quite a bit more confrontational. Please note the comments from and about Roy Green who is fearlessly critical of the Colleges especially of BC. Here is an episode of his show a couple months ago:
https://omny.fm/shows/roy-green-show/hour-3-segments-1-and-2-kate-nicholson
Here are my comments from the other discussion:
“Instead they could be spending their time learning acceptance while creating and cherishing many moments of connection, love, joy and fun with loved ones.”
Thanks to the all knowing uncaring College of Physicians and Surgeons and their senseless war on pain patients this can’t happen for patients. Roy Green is right when he said on the air a month ago “If you live in BC I feel sorry for you because of the College of Physicians and surgeons interfering in the doctor patient relationship by threatening to sue GP’s if they don’t cut back or curtail their prescribing of opiates”.
I recall that when the College first sent these threatening letters to every GP in BC, a month later the news was full of the stories of increasing overdoses. This is SO simple to make the connection. In my opinion the Prescription Review Board of CPSBC is responsible for thousands of patients having to now go to the unfamiliar streets seeking pain killers. So I challenge any of the medical professionals who read this to prove I’m wrong on this. Pain patients not only have to fight for their lives but now have to fight the medical system in Canada. This is total madness.
I am one of the pain patients in BC who has had their lives ruined by these clowns at the College. Ask Roy, he knows me. Here is a note he sent me yesterday:
“What is happening to chronic pain patients is outrageous Rand. And that’s putting it mildly. Human Rights Watch in the U.S. is reviewing what patients are forced to endure. That’s a positive. It’s absolutely cruel that you must suffer as you are.
Roy”
Roy Green
The Roy Green Show
http://www.roygreenshow.com
Syndicated on the Corus Radio network
Corus Entertainment Inc. | corusent.com
_________________________
A note to the College: Roy mentioned that he has heard that the College is going to be sued. Yes he said that on the air. I would like to see a class action suit against the College for ethics violations because I personally don’t believe they have any legal, ethical or moral right to threaten GP’s into not caring for their patients the way they see fit. I don’t see the College publicly challenging doctors who give out benzos like candy and then can’t get their patients off of them. No, pain patients are easy targets for the corrupt College and their politically motivated agendas.
These are my opinions.
Absolutely need public funding for those who are happy to use physiotherapy, biofeedback, IMS, and guided exercise for ameliorating the pain issue.
Having just studied for the pharmacy qualifying exams I was shocked by the number of therapeutic guidelines which included opiates as a last resort for the management of several different types of pain, even without evidence to support their use. Having worked as a pharmacist in the UK for many years, I only really saw opiates routinely used in palliative care and as a last resort in chronic pain but only when managed by a chronic pain specialist. Family doctors would not routinely initiate opiates. I also worked as a prescribing advisor for family doctors and analyzed all their opiate prescribing. We would target outliers and investigate individual prescriptions for high quantities. We would also query any family doctor initiating opiates. As a hospital pharmacist we would always query discharge prescriptions for opiates if they were initiated in hospital, especially if used post operatively. My neighbour here in Canada broke is leg and was given 50 hydromorphone capsules post-op. I could not be believe this. A friend’s son who broke his arm was given morphine tablets for 2 weeks post discharge, he was 11. I felt this was unusal too. There needs to be a big cultural shift. There needs to be more monitoring and education for sure.
Public funding for physiotherapy would be a great step forward for patients managing chronic pain from injury and disease; an important therapy that supports patients on their road to wellness and recovery, as well as prevention of future problems. Patients also need better access to chronic pain programs, which could provide other treatments such as CBT, and faster referrals for diagnostic testing. Throwing pills to mask symptoms is not the solution to chronic pain. For patients struggling with opioid addiction, there also needs to be better access to methadone treatment programs in the community.
“Life is suffering”. This sentiment is commonly attributed to Buddha but that is likely a mistranslation of a more complex idea. That said the reality is that almost every major religion and philosophical tradition has something to that general effect somewhere in its teachings. For the majority of human history, we just accepted this as reality. Emotional pain, physical pain, psychological pain. You endured…or you took something to escape. Coca leaves, opium, betlenuts, marijuana, alcohol, nicotine. The list is long and varied and almost every culture has had its escape. It was usually a bit fringe but at times it was quite socially accepted and even seen as fashionable. A sort of balance was usually found and society went on about its merry way. Sometimes this balance got shifted. The Royal Navy keeping a subduded fleet of sailors with liberal rations of grog. Various colonial powers subduing an Asian workforce by addicting them to opium. Sometimes the balance is skewed because there is more need for the masses to escape but this seems harder to find. So why have we defined a problem in our current reality? I think the basic premise that “life is suffering” has been abandoned. The media, presumably well meaning alternative health providers, corporate entities like “Big Pharma” bombard us with ads and stories about how we have a “right” to a suffering free existence. So we go to our doctors and “demand our rights”. Doctors are problem fixers. This person has a “problem”, it needs to be fixed so I “fix” it. Now I know it’s actually a really complex problem and that I’m really not “fixing” it but the bandaid makes me a bit happier and for a while, it makes my patient a lot happier. Everyone wins…until they lose. The patient is an addict, I’m an evil drug pusher. We blame the patient for being weak, we blame the medical establishment for being weak and nothing really happens. We suggest expensive fancy neuropathic pain meds (which don’t have much more evidence supporting them than the evil narcotics), we consider legalized or medicalized marijuana. We give lip service to complex multi disciplinary pain programs that are very expensive and hard to access where they exist at all. If you’re lucky you have a trusted family doc or nurse practitioner that says “I’m really sorry you have pain but that is what your life now is. You need to learn to live with that new reality” but really what chance does that one little relationship have against everything that we have systematically stacked against it. So blame docs, blame patients, even blame “Big Pharma” but until we accept that we have all created the world where this problem exists, it is not going away any time soon!
I agree with the above points. In particular, I still remember learning about pain management in school that there is no ceiling dose, so keep going up the dose as needed…. The new CDC guidelines have some great suggestions…. really limiting the use of opioids and perhaps changing the thinking that they should be used as absolutely last resort and have more funding for non-drug interventions such as physio and support groups.
In Ontario, we seem to be responding the crisis by delisting high dose opioids and introducing the mandatory Fentanyl patch to patch program, in addition to the narcotic monitoring system that has been in place for years now. I have written several posts around this topic in my blog:
https://drugopinions.wordpress.com/2016/05/20/the-opioid-crisis-what-a-pain/
https://drugopinions.wordpress.com/2016/04/27/fentanyl-patch-our-friend-or-foe/
https://drugopinions.wordpress.com/2016/08/12/de-listing-high-dose-opioids/
https://drugopinions.wordpress.com/2016/09/12/resources-for-tapering-opioids/
I hope that we will be successful in addressing the opioid crisis both nationally and internationally
In what world do you believe that CBT can be used by the majority of patients? Our healthcare system for psychological/ psychiatric help is a complete mess unable to take care of patients with real mental illness.
When will MD’s stop listening to, and believing, what pharmaceutical reps. tell them. These companies are only interested in making money and do not care if patients become addicted. In fact that adds to their bottom line.
Tylenol is not a good drug for pain relief and can, over the long-term cause severe liver damage. More money has to be put into pain research by the healthcare system to find drugs that work and are not dangerous.
BC’s way of tracking drug use should be implemented in all provinces as one way of stopping the abuse by patients of going to different physicians for prescriptions of the same drug. Patients should be given strict warnings when given these drugs and should be monitored. It should not end up that people in real need of these medications are denied them because of abuse by some patients.
I’m really excited that this topic has come up. The need for better montitoring systems, access to addiction treatment like buprenorphine, access to non-pharm approaches are so important. There are a few key points that really need to be added or mentioned.
First, the Canadian opioid guidelines are actually really, really good. There’s an opioid manager tool and if these guidelines were being followed, prescribed opioids would not be as much of a problem. They are in the process of updating them. This is also an area where it’s more of an attitude shift than a knowledge shift that’s needed. We need to see the assessment and treatment of pain and chemical dependency as a part of core competencies as a physician.
Second, there is not proper training for addiction physicians in the management of pain or pain physicians in the management of addiction. To treat these condition as separate and treated in separate silos has contributed to this. Pain and chemical dependency go hand in hand. There is a need not just for guidelines, but also tools, community of practice to help people build capacity in assessing and treating these conditions. Things like ECHO projects and the MMAP which are mohltc funded initiatives will also help with that. This will eventually have to involve the training of non-addiction specialists in when and how to use Buprenorphine and how to do a pain and chemical dependency assessment.
Here at St Mike’s, we are offering free training in buprenorphine. (In person and via webcast). Other programs like the ECHO and MMAP are making a huge difference here in Ontario.
Obama has put 1.1 billion towards the treatment of these disorders, And it looks like Canada is following suit.
And I’m excited to see what HQO, leadership groups in Canada, hospital and professional organizations do to help their patients who have struggled with opiates.
This is not just the problem for pain physicians and addiction physicians. One of the core principles of addiction is that “there is no wrong door to treatment”. Only when everyone in the health care system (emergency, inpatients, surgeons, nurses, community workers and hospital leadership) see it as soemthing we can help with. Will we start moving towards a sustainable solution.
The epidemic is so rampant now that even with the above measures consumers who have become addicted would be able to obtain the opioids whenever they want from other places than pharmacies. Educating the consumers should be the number one strategy. Money, energy and capacity need to be spent to educate every consumer on a one to one basis by explaining the benefits versus risk and providing the alternatives , monitoring the actions and following up! This needs to start with the pharmacists who are first line and most accessible to consumers. Money should be spent on educating the users, even a small fee for the pharmacist for every prescription not dispensed and instead counselled on alternatives such as Gabapentin, NSAIDs, non-drug measures, etc… This action would have a positive long term benefit! As it is right now, pharmacists would spend hours of their time calling prescribers to switch the prescribed opioid and to educate the patient but all that comes with loss of income and eventually jaded behaviour where we all become complacent.
I have an elderly relative suffering in agony from degenerative disc disease and afraid to use more than 2 percocets per day because a) she is reading all these dire articles about the opioid crisis and is afraid she’ll become addicted and b) she is afraid her doctor won’t repeat her prescription.
Ontario withdrew coverage for physiotherapy, which might help, for seniors. The medical system would rather throw cheap and possibly dangerous drugs at people than take the time to work on things that might actually help and prevent future flare-ups. It’s incredibly frustrating.
That’ sad.
Excellent article thank you. For those of us not in the industry it might be useful to include an overview of the different categories of pain relievers and the total addicted to all but opioids.
Thanks.
Aligned with these suggestions I could add less exuberant prescription of pain killers given to patients after various common surgeries and procedures. In my extended family alone I can count three instances of persons being given a huge number of pain killers pills in a single prescription for pain that was not-so-very intense and was expected to be short-lived (eg extraction of wisdom teeth; thyroidectomy; meniscus knee repair). The leftovers in our case appear to have been flushed down the toilet, left languishing on the shelf, and in one case returned to the pharmacy to dispose of – but in other situations I can imagine where they might end up.
That is a very important point, Joan. A study published this past week in Annals of Surgery found that wide variations in the numbers and dosage of opioids prescribed after common surgical procedures. The study also found few postoperative patients disposed of excess opioids correctly (9%).
A link to the paper is here http://mobile.journals.lww.com/annalsofsurgery/_layouts/15/oaks.journals.mobile/articleviewer.aspx?year=9000&issue=00000&article=96398