Source: The Medical Post
We have a dual tragedy: a large segment of the population who could benefit from opioids - and an epidemic of over-prescribing and abuse.
On a hot July morning, Dr. Alan Russell's patients amble in and out of his small, green office in Brampton, Ont., pouring out their histories of pain. Just before lunch, a petite blond woman turns up to see the physician because—after failed attempts to fix her T12—she finally has an appointment for another back surgery (facet denervation). "I am hopeful," she said, with a furrowed brow twisted by 18 years of chronic pain following a car accident. "I have to be."
Prior to becoming a patient of Dr. Russell's, a physician whose practice focuses on pain, she said other doctors told her to take Tylenol to alleviate the constant burning sensation in her back, which was exacerbated by movement. "It was a joke," she explained, describing how limited her life had become since the accident, how playing with her children and gardening were impossible feats. "It's almost like there's a taboo against people like us, like (doctors) think we're lying, making it up.
Doctors divided over opioids
"I always felt like I was ignored and disregarded." Now, under Dr. Russell's guidance, she's taking oxycodone (OxyContin), paracetamol/ acetaminophen (Percocet) and pregabalin (Lyrica). "These pills have allowed me a bit of interaction," she explained, noting that she can now garden for short periods of time. "Without my medication, I could do nothing at all." Her comments are echoed by the others who come to this Bramptom clinic to see Dr. Russell, a former Londoner who moved to Canada to practise medicine in 1970. Before meeting him, they say their chronic pain was undertreated, and tell of the difficulty accessing doctors who would listen to their complex cases, or give them drugs that were strong enough to manage their particular brand of agony. "I'm getting older but more and more people want to see me because no one (else) wants to see them," said Dr. Russell, now 74 years old. "A lot of people don't believe in chronic pain but it certainly exists, and the best treatment is pain relief with medication." Indeed, there are chronic non-cancer pain sufferers who, like his patient today, benefit from the well-managed use of prescription opioids. But in the face of Canada's "opioid epidemic," some of these people say getting adequate treatment is next to impossible. Theirs are the stories of chronic pain and opioids that we don't hear enough about, Dr. Russell said in an interview. Or as Dr. Angela Mailis- Gagnon, a pain specialist and professor of medicine at the University of Toronto, put it, "North America today faces a dual tragedy. On one hand, there is over-prescribing and inappropriate prescribing. On the other hand, there is serious under-treatment of many patients who can benefit from small or modest doses of opioids, with many physicians reluctant to prescribe even for the most worthy and legitimate cases." Per capita, Canada is the world's third largest consumer of opioids (after the U.S. and Belgium), and provinces across the country, such as Ontario and Alberta, have recorded particularly acute problems. Between 1999 and 2006, oxycodone-related deaths increased nine-fold in Ontario. A recent coroner's report in the province also revealed that in 2008, almost three deaths each week were caused by oxycodone toxicity—levels that remain about the same today. At the national level, a 2011 report for the federal department of justice on prescription opioid misuse, harms and control, said non-medical prescription opioid use is estimated to be the fourth most prevalent form of substance use after alcohol, tobacco and cannabis. But this wasn't always the case. Dr. Mailis-Gagnon explained that in late 1980s, the drugs gained wider use when well-known cancer doctors suggested that opioids were not only effective in cancer patients, but could treat some chronic non-cancer pain patients as well. Around that time, pharmaceutical companies began to heavily advertise the benefits of prescription opioids. "Education regarding opioids was almost exclusively left in the hands of industry and physicians versed in pain who felt very comfortable prescribing and advocating the liberal use of opioids," Dr. Mailis-Gagnon said in an interview. "Gradually many practitioners felt very comfortable prescribing opioids for all kinds of indications and with little knowledge of the potential risks and long-term effects. "It is only over the last five to seven years that opioid abuse, misuse and risks including deaths, started becoming apparent in North America, with numerous studies in Canada and south of the border recognizing the risks and harms of prescription opioids and that over-prescribing is one of the factors contributing to this." In fact, according to IMS Brogan, the number of prescription opioids dispensed from Canadian retail pharmacies climbed from some 14 million in 2006 to over 17 million in 2010. Yet, Dr. Benedikt Fischer (PhD), professor in the department of health sciences at Simon Fraser University, said the increasing awareness about the potential dangers of these drugs has also had a "chilling effect" on prescribing by some physicians. "Healthcare providers realized there's some over-prescribing going on, and with increasing scrutiny and regulation, I think there's some hesitation among medical practitioners (to prescribe opioids), which is of course not the effect we want," he told the Medical Post. A recent report on chronic non-cancer pain in the March 2011 Canadian Family Physician stated that while there may be a number of primarycare physicians (around 40%) who are unwilling to prescribe opioids, there is also a substantial number of physicians who prescribe them frequently, in high doses, and "for questionable indications." Still, the report stated, "many patients who could benefit from an appropriate prescription of opioids continue to be deprived of this option."
Danger on the frontlines
Those on the front lines report feeling at a loss about how to deal with patients on opioids. Dr. Sarah Giles, a locum family physician in Ontario and Western Australia, said she now finds it difficult to discern whether a patient is legitimately suffering from chronic pain and in need of drugs after having a few run-ins with opioid-addicted patients. "The only times I have ever been threatened in the office and the ER—with the exception of drunks—is from people demanding narcotics," she said. Working in small communities, she has faced backlash after attempts to wean people off the drugs, which has left her to draw this conclusion: "I'm not concerned that there is a whole bunch of untreated pain out there. From my experience, there's a whole lot of narcotics out there, and a lot of people who tell good stories who aren't necessarily in pain." Dr. Giles thinks Canada should follow Australia by implementing a program where patients who have been on narcotics for more than a year have to be seen by a pain specialist in order to continue their use of the drugs. "You're getting a second set of eyes," she said, flicking at the lack of support she feels family doctors get in dealing with pain patients. "This way, pain specialists can say, 'I have seen your patient, I have given them a nerve block, I will follow-up on them.' " Dr. Giles' comments reflect the tensions within the profession that have emerged around the subject of opioids. Dr. Mel Kahan, an addictions specialist with the University of Toronto's department of family and community medicine, said he sees any chilling effect that might be happening now as a reaction by family doctors to that early advertising campaign. "Many of them are reluctant to prescribe opioids, even in small doses. They say it's easier not to prescribe at all." But even Dr. Kahan, who is critical about the use of opioids, said he doesn't agree with a "blanket rejection" of these drugs. "I think family doctors have a right to say, 'I'm going to prescribe safely.' "The profession is divided on this: not just family physicians but pain specialists as well." These divisions also illustrate the fact that the question of how and when to prescribe these drugs is a difficult one. Dr. Mailis-Gagnon noted that long-term randomized trials over three months do not exist; "however, longterm epidemiological studies indicate poor outcomes for chronic opioid users in 10-year followups." She added: "There's no question that some people benefit from opioids, but the question is who?" Dr. Norm Buckley, director of the Michael G. DeGroote National Pain Centre at McMaster University in Hamilton, is trying to answer just that. He has been overseeing the 2015 update of Canadian opioid guidelines. "There are clearly indications for using the drugs, where it's appropriate," he said. Indeed, like other physicians who deal with chronic pain, Dr. Buckley said he believes opioids are the most effective drugs we have to treat it. Yet he feels the problem of misuse is the result of health professionals not getting enough information about how to use the drugs safely and appropriately. "It's unacceptable to say, 'I'm not going to prescribe x, y, z because I don't like it.' Opioids have dangers. But it's not clear that the dangers of using opioids are any different from the dangers of any other drugs." Dr. Buckley's hope is that primary-care doctors will employ the forthcoming guidelines as a tool to assess patients' needs, and not "fall back on the old argument that the college will come and investigate me." Another key to helping doctors feel more equipped to deal with pain patients who may need opioids will be the implementation of a comprehensive pain strategy, said Dr. Mailis- Gagnon, who served as the cochair of the Chronic Pain Task Force of the College of Physicians and Surgeons of Ontario and helped to create the 2010 Canadian guidelines for the use of opioids for chronic noncancer pain. She would also like to see the Royal College of Physicians and Surgeons of Canada go ahead with the creation of a pain subspecialty, so that agreed-upon standards for the profession can be enacted. Meanwhile, others believe a more hands-on approach to the problem is necessary—for example, creating a special fee code that allows doctors to be reimbursed for in-office urine drug screens, and implementing electronic systems in every province that allow pharmacies to see whether a patient's opioid Rx has been filled at another shop. For Dr. Russell, it's as simple as supporting the doctors. He would like to see some kind of mechanism by which doctors could break confidentiality to report patients who are trying to scam the system. "It's the only crime where if you get caught, you can't get charged. No one is helping the doctors," he said. For now, he added, "There is no doubt chronic pain is the worst treated illness out there. We need to do something to make this better."