Consultation 012 – Safe Prescribing – Clinical
Deadline to provide feedback was December 12, 2016: consultation is now closed.Read the Safe Prescribing – Clinical draft standard
You may also wish to:
- Read recent comments posted below the form
- Watch a video of the CPSA Opioid Prescribing Forum on Oct. 25, 2016
Can we be sure the CPSA hasn't already adopted the CDC guidelines? It seems to us CPSA jumped the gun on implementing the CDC standards & guidelines prior to all this. I give you my husband's story to explain this. The CPSA blatantly interfered in the dr/patient relationship in different cities with different doctors and several patients, for similar reasons; reduce opioid medication use. My husband (call him Fred) was 1 of those patients. There was only a smattering of talk in Alberta about the CDC document being implemented in March 2016 when this was forced upon Fred & his dr. Fred has been in chronic pain for 30 years; over those years he has seen only 3 doctors regarding his chronic pain: 1 was an accredited pain specialist in Canada. The other is his dr of 20 years, 3rd a dr who takes over when Fred's dr has been absent. Fred has never returned early for prescription refills, has never asked for more than allowed, has never had medication "lost" or stolen, has never exhibited "drug seeking" behaviors. Medication was increased due to Fred becoming tolerant to medications. He has tried different treatments outside of the doctor's office. Fred has reduced himself from pain medication when he is having better times of pain management. No one thing has ever worked permanently though. Fred has gone through severe depressions as a result of his pain condition. He despises having to rely on medication to have anything close to what others perceive as a 'normal functioning lifestyle'. Opioid medication removed Fred's pain to the extent that he was able to work again, even though it was a home-based business due to the unreliability of being in pain; he never knew if it would be a good pain day or if something during the day would increase his pain. As he aged, Fred's body started to act like most every other aging body, he put on weight, he got rheumatoid arthritis, etc. Yet he did his best not to request more medication (despite weighing more) & has maintained fairly well for many years. In 2010 when manufacturers had to change their formula for OxyContin to something the addicts could not easily abuse, Fred (along with countless other patients) discovered the new Oxycontin didn't work as well or as as fast as the previous formula. He got to the point of closing up his home-based business due to not being able to function with the increased pain. He asked his dr to prescribe something that might be able to work as well as that older formula. That is when his oral morphine equivalence was raised for the first time in many years. A few years ago we discovered that the warm dry climate of Arizona was immensely beneficial in reducing Fred's pain, therefore his opioid medication intake. Every October Fred would attend his dr to get RX for 5-6 months so we could stay in AZ and have his pain reduced for most of that time. Prior to Arizona, Fred has been house-bound for most of the winter & his pain increases intensely (even though his meds do not). Although difficult, it has never been problematic to get his medications for the months we are in USA. The best thing is that Fred has been able to reduce his opioid medication by himself while in Arizona; if it's a good day, he didn't take as many pills, if he walked too much he might have to take his regular dose, & so it would go. However, upon returning to Alberta in March or April, he has generally just gone back to his original amounts as the colder climate affects him. After decreasing himself over the warm winters the past 2 years, Fred has worked with his dr & stayed at a lower dose while in Alberta. Last March when we returned from AZ Fred was told another dr from CPSA was going to take over my husband's care & he was no longer allowed to see his trusted dr! Due to the decrease over the 2 years, this was a big surprise.
Fred's dr was not doing anything that needed intervention, we were stunned. Fred and a few other patients were chosen simply because their OME was too high for CPSA's liking. Despite functioning perfectly well on his 'high' dose; able to drive, think, speak, walk, talk, look after babies & small children and otherwise be able to live a normal life because his pain was controlled with the opioid medication he is dependent on. From march, Fred waited for his meeting with this new dr the CPSA had sent to intervene (or interfere) in my husband's care. Fred was not contacted by CPSA or the new dr (I'll call her Dr C). No appointment was made until September (an August appt was cancelled by dr C). After rearranging plans to fly to family in BC to accommodate Dr C, she told Fred we shouldn't have done that, well for 5 months Fred had been worrying & waiting for this appointment. Dr C told Fred she was not going to replace his dr & had no "preconceived plan" on how to reduce his opioids, but reduce him she would. Fred was on board with a controlled, supervised opioid reduction & willing to try it. Dr C also said Fred was free to continue to see his dr for other medical matters, which was a relief as he has other medical issues & Fred trusts his dr. For such an important, life altering meeting, Fred had just 45 minutes to listen to this dr, ask questions & think of new ones. When Fred said we would be leaving for Arizona in just over a month, Dr C pronounced it was a wonderful climate for betterment of pain & was the best thing for him. Dr C assured Fred the reduction would not be continued while he was in AZ, he would have about 6 weeks to start reducing before leaving; however, Fred was told to find a dr and pharmacy in Arizona that would treat him over the winter. We had checked into this before we ever started wintering there & it is not possible. My work insurance covers medical emergencies only. Since he can't get a dr there, pharmacies are unable to take out-of-country prescriptions. Don't forget, USA had implemented the CDC guidelines far more drastically than we ever should hope to see in Alberta. Even though Dr C was tasked with writing Fred;s RX, his dr's name appears on all paperwork. Fred has no way to contact Dr C & questions must be relayed via his own dr. Dr C's instructions are that medications are in blister packs & Fred MUST take every single pill at the allotted time which leaves no room for when Fred is having a good pain day & might not need to take ALL his dose. When Fred visited his dr to pick up the scripts for this winter in AZ, he was in for a huge shock: Dr C only prescribed for 3 months & has continued the reduction throughout! That means UNDUE HARDSHIP financially for us to return in January (when flights are more expensive) to get the remainder of his RXs. Fred has done alright with the initial weeks of his reduction. When he got to about week 6 he started feeling withdrawal effects, his daily functioning has declined also. Where he was able to walk around the block with me when we first arrived in AZ, he is barely able to walk the distance of 2 houses now. His knees are giving him excruciating pain, where only 1 gave him issue prior, it is now difficult for Fred to get up or to stand for more than 15 minutes due to his knees. His pain has exasperated to the point where he is now moody, depressed & irritable. He has pain where he never had pain before. Due to his other medical issues, it is frightening to be in a different country, unable to just visit a dr to ease a worry when we don't know if some of what he is going through is due to the reduction or if it is a trigger to something more serious, like his blood pressure or his heart. What Dr C has endorsed is dangerous! The CDC guidelines & standards have not been endorsed, yet CPSA has barged into doctor practices to oversee the writing of opioid prescriptions with the outcome to be reduction. At what reason if these patients are otherwise healthy, they are not dead or dying? Fred had been working toward a reduction without the intervention of a CPSA overseer; how can CPSA start implementing the CDC guidelines months ahead of any schedule? How can it be accepted policy & practice to reduce a patient without medical supervision? Where is the reward for Fred reducing his medication on his own volition with his doctor's support? A patient builds up trust in their dr over 20 years. Another 'hired gun' dr waltzes into the exam room (uninvited), says 1 thing and does another, unable to contact her, says she is writing RX but won't put her name on them, where is there room to trust?
If 50,000 overdose deaths and the number of suicides at the Veterans Affairs doesn't show you in Canada that the use of the the "theory" of addiction as a brain disease and all the medical zealotry and shenanigans, corruption, cronyism and that comes from it, Tell your citizens to be ready to go to doctors like in the system at the VA hospitals in the USA where they deny you care for conditions you have a disability for because if you enact this, everything will stem from addiction and not the other way around! In other words, you will be judged by what you did 20 or more years ago and what you might due tomorrow to deny you medical care today! That's how the CDC guidelines really work!, just as designed! this isn't about responsible care, because [redacted] and the sycophants here actually believe that all opiate pain medications should be stopped even when they have nothing to replace them with! MONSTERS and EVIL are the words I here the most!
I understand that the opiate standards are going to be the focus of the discussion but I would like to focus on a separate issue.
According to points 4 and 5, if I interpret them right, a radiologist looking at my (hopefully normal) chest X-ray has to review my medication profile, and the profile for each of the patients. Similarly, a physician who treats a patient's wart should similarly review all of that patient's medications. In as much as in some cases this may be a good idea, there are many clinical interactions where the medications simply do not come into the equation. Is that the intent of the standard?
This response is compiled from the opinions of the members of HELP_AB and GotPain? Alberta, Chronic Pain Support and Advocacy Groups:
We have some serious concerns about the new guidelines and the practices they are clarifying. Though we do feel that it is important to have regulations for opioid prescribing, we feel that these new guidelines will result in damage to doctor patient relationships, put patients with under treated pain at risk by making them desperate, and it perpetuate the current issues that both doctors and patients face. The discussions around the guidelines have resulted in them no longer having a clear purpose to improve prescribing practices, but rather a sole purpose of sever reduction of opioid prescribing without first providing needed support, or the effort to ensure their validity. The issues around prescription opioid drugs and the doctors prescribing them, show a lack of consideration about the patient role, need and experience. This has resulted in a focus on effectiveness of opioid therapy, based on the information that was in the CDC guidelines, but they contain little new assistance with how to actually improve safe prescribing in a way that would result in greater patient safety. We believe the new guidelines should be dismissed, and more work put into the design of programs or a new guideline that will be safer and more effective.
Doctor patient relationships are at the heart of safe prescribing. It requires a dialog between doctor and patient that is far to often already a struggle when it begins because the patient has been enduring a pain that has been ignored, or minimized for years. They have been treated as a drug seeker, a hypochondriac, or their pain has been the cause of stress and more pain in past medical relationships. If they show up looking for relief, the quick decision is that they are drug seeking. The problem is that they probably are. They have tried everything they have been presented with, been subjected to test after test, and tried drug after drug but it has left them no where near pain relief. The pain has been destroying their lives, wearing down their self worth, and left them weak and struggling for hope. At this point they are searching for pain relief rather than a cure that seems illusive, not because they are addicts looking for a fix, but because they are suffering. If this new relationship could bring some relief, they would do just about anything to protect it. When they walk in there is a great deal of hope, fear and anxiety, which can appear to be nervousness and mistaken as an addict looking for a cheap high. These guidelines offer no new assistance with how to make a determination as to which may be the case,addict or desperate pain patient, nor do they help in anyway with how to negotiate an even healthier and more productive and safe relationship. Doctors are facing far more documentation and time demands with these guidelines to justify some decisions, but the documentation does not help make the decision better, and we already have guidelines that explain the need to be able to justify the decisions around opioid prescribing. We would much prefer to have doctors tending to their patients and able to have MORE time to adequately have these valuable discussions. In the end, a patient that better understands the process, decision making, risks and responsibilities is less likely to be at risk, and if a doctor was able to do that he would have had to justify his decision to his patient. We believe that these new proposed guidelines would in fact result in more doctors not wanting to treat pain patients. We know that it's been said they can not discriminate, but they can be too busy to be able to take a new patient with complex problems, or not have the expertise to address the issue and let's be honest all they have to do is document pain levels for so long without treatment and the patient will leave, and who wants to see a doctor that is only treating you because they have too?
This leads us to the issue of circular thinking/reasoning. Patient wants anything to stop pain, might be drug seeking, drug seeking is a sign of addiction, addiction could get worse if given opioid, doctor is responsible for prescribing...
AND...a patient wants pain relief, drug seeking, no medication, patients pain is unbearable, goes to another doctor for help, seen as doctor shopping, no pain relief, patient is desperate and goes to the ER, suspect of seeking drugs outside of doctors office, sent away...
AND...Doctor prescribes, doctors judgment is questioned, doctor defends position, doctor is being defiant and unwilling to change prescribing practices, doctor reviews his decision and believes he's right but in the end the decision is really subjective and based on the individual patient, he's questioned about his justification by someone who is also having to make a subjective decision, he sticks to his decision, he's pill happy...
This issue has resulted in some very questionable decision making, and with the new guidelines, the way they have been promoted and the message it's currently sending, we will entrench this issue. The only way to break this is to think differently, and that can start here by not simply following a guideline designed to deal with street drugs and instead change the discussion, and focus on better treatment. Opioids should be a last resort...patient is unable to function and at risk of depression but they can only afford a little physio, patient must try alternative treatment first, can not fully benefit from physio due to pain limitations and limited resources, physio does not work, patient tries many different drugs with wide ranging side effects making them feel more hopeless and sick, years pass trying to get more alternatives in, pain gets worse, patient loses muscle, energy and any belief that the medical system will help, patient commits suicide/turns to self medicating/crawls into bed for 3 years and gives up, doctor prescribes opioid, pain goes down but the ability to fight back is limited and the patient spends the rest of their life on opioids worrying that around every corner is one new threat to their quality of life, doctor wants to try reduction to try and make the medication dose last longer and work better but the patient is resistant (fearfully all he can hear is 'taking away'), doctor thinks maybe there is an addiction, new patient comes in and doctor is afraid to try opioid.
This is exactly what is happening already to far to many patients. What about a change...patient and doctor make a plan, patient does all the reasonable testing that has not been done yet, doctor prescribes medications to try controlling pain (with in reason, and until the effect is that the patient is at risk of giving up or has lost some function and quality of life is impacted) , the doctor and patient discuss physio and how much the patient would be able to afford, they will try an opioid short term to test out it's effectiveness, patients ability to comply, and other things while also giving the patient the ability to use the limited amount of physio to their fullest, reduction and stop of opioid to determine the impact of physio, patient and doctor discuss the way the patient may be able to use the new information to continue improving their pain and at what point they feel it would be reasonable to start opioid OR ANY medication to ease the pain, once they find some relief the patient works harder to find a better path because they are not totally broken, patient slowly improves and the opioid is removed as the alternatives are found...
The dialog around opioids being a last resort and the wording in the guidelines has shocked and disappointed us a great deal. We can not stop trying to improve or to recover once opioids have been effective in lowering pain (for those that there is a hope of a treatment or cure), but rather must use it as the starting place to try again to find another path. If we are told that this is a last resort, then once we need to use it there is no point in trying anymore and it is a life sentence. Doctors that reach that point with a patient need to be educated on what to do with this new opportunity, instead the guidelines tell them it's over except for the part where they have to increase, reduce or cut off a patient.
The meetings that we have seen here in Alberta and around the country have clearly been continuing the thought process that if a problem arises from opioid therapy that the doctor is at fault. Again we take acceptation to this. We do believe that doctors have a responsibility to patient safety, but we have left out the responsibility that the patient has for their own well-being and to the doctor prescribing. History has shown that if you lay more and more responsibility for all possible out comes at the feet of one person, they usually choose to walk away. We understand that the College is responsible for overseeing doctor conduct and practices, but how can you possibly create a plan to minimize the risks if you do not in anyway also assign responsibility to all parties involved? We are thinking, reasoning people, even with chronic pain. If you do not ensure that a patient fully understands, and recognizes their responsibilities in using these medications, you have little hope of reducing the all ready low rates of misuse, diversion, death and addiction. No matter how much you regulate the retailers of alcohol, in the end you have to educate and hold the person drinking responsible for their actions while drinking. This guideline in no way assists a doctor in figuring out how to do that. It may not be the place of Standard of Practice for doctors to do that. It can still be done by creation of an educational program that would be required for people who begin LTOT. It could include risk awareness, an outline of the standard methods of dispensing, why we regulate, the consequences of misuse or abuse of medications, and how to safely store them. It would give a much more in depth examination of these topics and arm patients with everything they need to know about how to stay safe, what to ask a doctor, how to recognize a medical mistake and so on. If we are seriously focused on harm reduction we believe that educating doctors on safe prescribing is important, but patient education and responsibility is also critical. If after that and a doctor showing the proper procedure had been followed in talking with his patient, and the patient has demonstrated knowledge, a patient is found with heroin in their system or too much medication considering their dose or has shown clear signs of abuse or misuse it will be clear that the doctor had done everything reasonably possible to make a safe decision. Using a method like this we would not interfere with the doctors decision making process, their relationship, or the treatment and well being of the patient, but rather supported it. Using these guidelines does the exact opposite.
The new approach to this old issue is not so new. If you look at the old guidelines and the new ones, there is little new information except suggestions about doses. The Canadian guidelines have a 200MME which was not based on any research, but rather a professional agreement that this was a reasonable dose to use as STOP, THINK, BE SAFE point. We have no new evidence or research that supports the lower 90MME. I think that any reasonable doctor does that at every dose. Assigning a number like that upon which we put such weight resulted in biased, prejudiced stereotyping by health care professionals who chronic pain patients have to deal with. This divide has resulted in harm to patients, doctors refusing to treat them, and doctors actually predetermining the course and outcome of a medical encounter with patients that has resulted in much poorer medical and prescribing practice in some doctors. It has done nothing to assist them in actually learning more, holding themselves to the standards expected, and in no way protects the well being of patients or reduces harm. At the same time assigning a response to the number of triplicates a doctor prescribes is equally ineffective, and wrong. One doctor in a town with 3 others takes on the role of the local pain doctor and sees the toughest cases from the other 3. His practice ends up having an 80% chronic pain patient make up, while the other three sit at 40, 10 and 20%. He gets the toughest cases and that results in 18% of his chronic pain patients being on LTOT while 2 others are at 5 and 2% and the third will not prescribe opioids at all. Doctor 1 prescribes 100 triplicates, and the others only 0, 10, 15. ( We realize these are not accurate numbers, this is just an illustration.) If you see his number of triplicates as unreasonably high but do not consider the dynamic in the area, it's very easy to draw a quick conclusion that he has a 'pill happy' approach to pain management. These stereotypes will only be made worse if we keep striving to define safe or quality care by such numbers, and the new guidelines do exactly that. We believe that in the best interest of all patients and doctors that we take this moment to STOP, THINK and figure out a better approach to patient safety.
Off the top, I am a patient of the AHS as a patient suffering a chronic disease. While the pain of my condition is not treatable by opioids it is managed by another drug that is on the block list to be restricted in the future. Even that scenario doesn't prepare me to understand what you folks are doing to patients that require opiods to deal with the overwhelming pain of their conditions. I find that fact that you're letting another country dictate your drug policy repugnant. I know many people that are using pain killer that are responsible and nowhere near addicted. The horrible part is the changes you're implementing, and yes I've actually seen 4 doctors following the foreign directives, will throw these responsible patients toward street drugs. These street bought sources of pain relief are what are killing people. That course of action is harming your patients, it's clear as 1+1=2. Plain and simple, history shows the pattern. You swore an oath to do no harm. These ill-conceived, foolish and dangerous actions will only cause an increase in overdoses rather than a decrease that is hoped for. Mark my words this is bad. I will be retaining a copy of this message to show that you've been warned that more people will suffer as as result.
Fix the source of the pain rather than take away the treatment. That is what a sweet good doctor does.
Before I became a Chronic Pain patient, I was an RN for 15 years in Alberta. I had to retire due to a Chronic Health condition. I fought like crazy to get a diagnosis and the treatment I needed. I diagnosed myself, which was later confirmed by a Neurologist, then I was able to receive treatment. I have been living with Chronic Pain for over 4 years now.
I require on average 2 Percocet 6 times a month. This allows me to avoid going to the ER for 'treatment' which always involves being treated like a 'drug seeker' I want to be able to treat the pain myself, so I don't have to be subject to the judgement and abuse of ER staff.
I recently had an ACUTE severe infection that was very painful. I was given 1 Percocet every 8 hours for 3 days. 10 Percocet in total that was supposed to last me for 2 weeks. It has taken me 2 months to heal, but I have permanent damage.
While these are PROPOSED guidelines, it's quite obvious it is already being implemented. Asking for feedback from the public, stakeholders, Physicians and other Health Care Professionals probably just a formality perhaps.
I was under the impression that these proposed guidelines are for CHRONIC, non malignant Pain?
But it seems that it also applies to ACUTE Pain? Or are only Chronic Pain patients going to be treated this way?
While reviewing your proposed "Safe Prescribing" guidelines, I clicked on the link provided about safe dosage prescribing and I was forwarded to a page on the CDC's website, the US Centre for Disease Control website on US Guidelines. I thought this must be a mistake, surely the CPSA would not adopt outright the policy from another country? A country that has a completely different health care system, 10x the population of Canada and a different set of values and beliefs than Canada.
This must simply be a mistake on your website right?
While I agree that there needs to be some sort of control over safe prescribing for opiates, I believe this guideline fails to take a lot of things into consideration. I have personally seen a lot of patients thinking that suicide is their only option to relieve the pain. Not only are they thinking this but they are attempting and succeeding. Patients that have no pain relief prescribed by their doctors are very likely to turn to street drugs, such as heroin, to control the pain which will in turn put much more stress on the medical community, society and families. Alternative therapies such as physical therapy, massage, acupuncture, bio feedback etc are not readily available to many pain patients as their income has diminished due to their circumstances. These therapies are not covered by low income insurance such as the Alberta adult health benefit. Also, physic therapy that is covered by Alberta health care is NOT the same quality as that provided by private therapists. Urine screening is a good idea but doctors need to take into consideration that some drug interactions and diseases will make the results look dirty. By not giving pain medications to patients in need, along with alternate therapy, we are causing more harm than good. Pain that is not treated gets worse, causes depression, causes patients to feel like they are second class citizens and that they are drug addicts and causes people to take drastic measures. This puts a greater stress on hospital ERs. Addiction and dependence are two completely different things. Addiction controls lives and the meds are taken to escape life. Pain patients take the meds to have a life that they can be productive in. I think more thought and research needs to go into this and I believe pain patients should have the right to medications that help them to be successful in life.
...pain clinics and PCN's. We need to create lists of needs, figure out who can bring what resources, figure out how to share the knowledge and information, and a time line and plan to ensure that our goals will in fact improve the care of patients, support our doctors and medical professionals, and develop the research in order to continue the process into the future. At the October CPSA meeting, Dr Theman asked if anyone knew why the Scandinavia prescribing rates were so much lower that here? What were they doing that was working? We had not considered that question and so we went home and did our homework. Admittedly we did not actually compare their prescribing rates, but what we did find fascinating is that they too realized that chronic pain cost the system a great deal, but they put their efforts into building the resources to treat it, prevent pain from becoming chronic and spent their time focused on how to get treatments in a timely fashion. As they built the system to deal with the physical demand, they also put tremendous effort into educating the profession on the new direction, the treatment of pain, how the new guidelines will impact their practice. Once they had the system ready, they made a law that chronic pain must be treated in a timely and appropriate manner, and clearly outlined the expectations of a doctor treating a pain patient (Guidelines) to ensure the best possible outcome. In other words, they made the treatment of chronic pain a health care priority. In our years of research we had learned that if we focused ourselves on the development of resources, education for both doctors and patients, then created a plan that moved us towards a guideline on HOW to manage and treat chronic pain, we could find a way to make the biggest changes to this aspect of health care. We learned we need to focus on a way to bring more interdisciplinary collaboration, creatively support doctors that are uncomfortable in this role and create open dialog and trusting relationships. As patients learn to trust that help can be found without judgment or fear, and can feel secure in their relationship with their health care team, we can also hold them more responsible in the care of their pain, and research shows that they will be more willing to try and succeed in other treatments, have better mental health, a usually this leads to better coping skills. We believe that current research in to many aspects of such treatment approaches, indicates that not only would we reduce the incidents of pain becoming chronic but also the industry dependency on opioids, and there by lower prescribing rates and of course risk and side effects.
After consideration of these points, and a great deal of other research, keeping a close eye on the impact of the CDC guidelines in the States, listening to current dialog between patients, doctors and other stakeholders, then watching the initial reactions to the news of the implementation of these new standards and practices in Alberta, we believe they should be dismissed. The conversations however, that they have created during this time of unprecedented collaboration, should be used to help bring about team work from all stakeholders to begin a more well rounded plan with the support needed to ensure it's successful implementation. Alberta use to be the leader in Canada's treatment of chronic pain. We are so close to having a system that could set the standard for all of Canada, perhaps North America. We have doctors who have proven to be some of the world best, resources that we simply failed to effectively develop, researchers who have amazing ideas and concepts about how to help attain the goals these drafts set out to accomplish, but in ways that do not require doctors to watch helplessly as patients suffer. The minds, commitment to our health care system, and passionate drives we have seen over the last few months as we contemplate a new course, has shown that we have the people, the experts, creativity and at last a common goal. We put to you a suggestion, that now that this wave has begun it's not time to end these discussions and press forward with a plan that may fall short of the tremendous potential Alberta has in the field of medicine but rather, at the very least, take pause to consider the potential of working together to explore all options and then set a course that minds the well being of all parties. The College was faced with an issue that has been deemed very important by the conversations we have been hearing, but like chronic pain patients with out doctors and doctors with out options, it is in a difficult place that requires outside support to truly be effective. What the industry has said, no matter what side of the fence they stand, is that changing the way we prescribe opioids, and treat chronic pain, is their priority too. The challenge of getting this many stakeholders to sit together and openly discuss this topic has not gone unnoticed by us, but where so many others have failed, this has succeeded. We believe that this is the spark that can ignite a profound change in Alberta and by closing the doors on such an opportunity would be a tremendous loss. With this in mind we must say that we can not support the current plan before us, because we believe that it falls far short of what we in Alberta are capable of attaining should we choose to forge a new path.
This response was created based on the discussions, reviews, concerns and research of the members of HELP_AB and GotPain?Alberta, Chronic Pain Support and Advocacy groups:
We believe that the very fundamental issue of patient care and safety must be a priority for every stakeholder involved in Alberta's health care system, and that there has been a need for change in the way we treat chronic pain for at least the 10 years, since we began investigating our approach. We recognize the need to balance patient need, quality of life, safety and risk as well as the challenges that chronic pain treatment offers doctors and regulators. Over prescribing, diversion, medication abuse and addiction when dealing with opioids, are all issues that we would like to see reduced, because at the end of the day WE are talking about OUR lives and safety. Though we can agree with the need to regulated these medications and ensure the best possible prescribing practices for all Albertans is important, we do not believe that the use of the CDC guidelines to do this, is appropriate for this province, that the new proposed practices in prescribing should be set aside. This approach to managing these issues falls short because they tend to concerns about opioid prescribing but outside the complex situation in which these guidelines or the practice standard clarifications are designed to be used. If prescribing opioids was as simple as assigning arbitrary numbers and fitting every one in pain into the same prescription plan, then we simply would not need guidelines. We have a profound fear, based on historical and current evidence, that the outcome of the implementation of such changes, with out much greater preparation, consideration and resources, would result in the suffering of many people, suicides and high risk street drug use increases. There will be a financial cost to such a change that we have not seen much discussion about, and the current resources in our medical system will be taxed to the point that service for everyone may be profoundly and negatively impacted. When determining the potential impact of a decision like this, consideration of how it will fit into a sustainable and progressive health care system is important, and this requires looking at the possibilities of other options or decisions. To date we hear little about a long term plan or alternative solutions being considered by the medical bodies in this province. It is our opinion that not only does this approach risk patient lives now, but also fails to offer any sort of long term viability unless we choose to accept that quality of life is no longer the concern of the field of medicine or it's practitioners.
The CDC guidelines arrived in the United States in a furry of controversy, an environment of fear, and poor communication. What we do know for sure, is that those who were tasked for it's development had a strong bias towards an anti opioid position. We also know that the decision making process for determination of inclusion of data was skewed. It failed to meet any reasonable research criteria, and again leaned to an anti opioid sentiment. It excluded any research on the effectiveness of opioid treatment that failed to have a duration of more that 12 months, and inclusion of data about alternative treatments that did not require a duration of even 12 months. The recommendations were made on poor and low quality data and lead to poor and low quality determinations. There was no new or helpful information of prescribing practices, but there was a great deal about limiting opioid use. The guidelines clearly state that the use of opioid should be replaced by alternative treatment options, however did not offer any suggestions as to how or when to make decisions about when to begin, end or retry such options. With out the support of the rest of the health care system making such options readily available, the new prescribing practices arrival, has resulted in the suffering of patients physically and mentally, with suicide increases and the intolerable desperation leading to new street drug use. The doctors were then tasked with resolving the conflict of their responsibility to the well being of their patients with the harsher new guideline. They had been received as more law then guideline because of the relationship between the governing bodies and physicians prior too their release being so hostile and fraught with fear and mistrust. Now faced with employment risks, moral and ethical dilemmas, as well as the back lash from patients and public who felt the negative impact of the new environment, and physicians were unprotected and left in a deplorable situation. The entire medical system quickly reached a point where alternative solutions, civilized discussion and reasonable balance between fact and opinion became impossible. The words used to describe the state of the industry was frenzy, hysteric, and demoralizing. Since it's first views, the CDC guidelines have proven to fail in their original goal which was to reduce opioid prescribing to limit diversion, misuse and opioid addiction, with the final out come to be a reduction of illegal drug use and death.
The United States' statistics have long been used as our source for an over view of our medical system (10% of US population = Canadian). We have followed many of their practices and research from their institutions. The difficult fact with opioid misuses and abuse is that it is not that static. You simply can not apply a statistic that holds true everywhere, with every body and in every setting. It is complex and strongly tied to social-economic factors, historical experience and socially accepted norms, among other things. We are not Americans. Alberta is not California. The controls and balances in the States are not nearly as effective as we have in this province, and the size of the medical profession in Alberta does not offer as many challenges to regulate, but the vast distances and population dispersion do. It would be foolish to suggest that over prescribing does not happen, or that no patients abuse their medications. It is equally as foolish to believe that you can assume that we have a clear enough picture to fully determine why our prescribing practices are higher in Alberta than other provinces with the evidence we currently have. In 2006 a research paper from Canada, was created to discuss the number of patients that die due to under treated chronic pain, but determined that there was not enough statistical information to even estimate the number. In 2016 we attempted again to find the answer to that question, because it seems relevant to determining the potential risk of the implementation of the new guidelines. We can find none, nor could we find any changes that would help to determine this answer next year. Through the last 60 days, we have heard a great number of important questions who's answers are important in defining a direction for chronic pain treatment and the regulation of opioid prescribing. The answer to too many was...we don't know. If we can not define this issue, determine it's contributing factors here in Alberta, how can we put any confidence in a Standard of Practice that was designed for a different population, with a questionable pedigree, and dismal outcome for their population? We believe that we simply can not.
Once these new practices come into place and are accepted as the norm for the prescribing of opioid, the rest of the medical industry will have the a platform on which to make their determinations and patients not meant to be swept up in these practices will be afforded no protection. When this happens there will be no way to control or prevent the harm that can occur. In the States, BC and Ontario we are already seeing evidence of this. Health benefit programs decided to make the 90/50 a limiting factor in how much they will cover of a prescription. For those that need to exceed these limits or who are palliative these new limits could make the medication they depend on too costly. A doctor in an area with little other physician choice decides to not prescribe opioids at all could prevent a palliative patient from access to pain relief at all, and if they did not require assistance other then financial and pain relief, they may not have been considered palliative, yet once their pain medication is out of reach they suddenly require assisted living support. If government benefits and protection insurers decided to make these a limit for everyone they deal with, yet the guidelines clearly state that they can be exceeded by a doctor with well founded justification, who will be prescribing to our population? When an entire ER in the States decided to become opioid free, the CDC stated that the guidelines were not meant to cover acute or trauma pain in that way, but they have no more say over the decisions inside the hospitals than our College has here. The administration was pressed to find a way to offer doctors some small method to legally access them if they felt it was absolutely needed, because a patient brought in by ambulance had no choice in ER, was in agonizing pain but the wait time was unusually long, even for that busy ER, and he had a lawyer with him. The doctor was informed that if some sort of effective relief was not found that a law suit would follow and the medical insurer threatened to with hold payment of treatment if the doctor did not follow common practice they would see it as a failure to provide service. The doctor realized that the policy applied to outpatient not inpatient care so he admitted the patient. This began to happen more and more, but it only took a patient or two a day being admitted above the normal admitting rate before serious problems began to arise, and it meant that patients with insurance or money could afford to pay for pain relief of their choice. Would we have Pharmacists decide who can and can not exceed, and which doctors are right in their prescribing rates? Their role in the treatment of chronic pain has been poorly defined and we have failed to use their expertise to our benefit to date, and it would be detrimental to place them in a position in which a greater rift divides patients from their potential value in our care. If a doctor prescribed an opioid with out clear consideration for the risk, he would fail to maintain any reasonable definition of proper practice? Guidelines and standards of practice are sort of like a prescription for doctors, telling them the best way to manage the situation,and then when they choose to 'fill' it, they consented to it's guidance and direction. We feel there is not enough consideration of the risks of pursuing this course of action to warrant using it to guide our medical professions course in future opioid prescribing.
At the meeting put on by the CPSA in October we asked about how we would protect the patient/ doctor relationship, and the answer was to keep an open dialog. We know that for many there is already a tenuous strain in their professional relationship. Patients feel that doctors may be placed in such a position that many will look for a way to justify reduction or stopping opioid prescribing to escape it. Sadly while we discuss this new strategy we are already seeing this happen across the province. When a doctor is gaining consent, when a third party may be involved, every law, regulation, explanation of proper consent practices, dictates that a doctor must ensure they are choosing a treatment that is in the best interest of the patient with out undue influence by the third party. Courts consider this to be a fundamental right that needs to be protected and take it very seriously. If the process should be potentially influenced by an outside party, or conflict of interest or belief, the doctor must always err on the side of the patient, and when making a medical decision the same value is placed on ensuring they are prescribing or recommending procedures with the same diligence and care. Doctors are already choosing to cut of patients with the justification that this is expected, or the new regulations require it (right or wrong it is happening). We have doctors stating that they will no longer prescribe opioid no matter what, and comments on the CPSA website that say 'just say no' and 'it should never happen'. These statements are telling the patients of Alberta that the goal of safe prescribing is at risk of becoming about the safety of doctors, and their prescribing will begin to minister to a piece of paper, not the chronic pain patients unique and individual needs. Can you honestly say that this is not a risk? We recognize that consideration of self in decision making is going to happen. We do not know a patient that would think a doctor could or should be held to a standard that is contrary to basic human nature. In fact if our doctor would never consider their own well-being at all we would worry about their judgement! If they prescribe and do not consider the guidelines and standards designed to ensure our protection and safety, we would walk away. There must however be a balance. Some people will with stand the added pressure well, but considering that there are decisions being made already that are not considering the well-being of the patients individually, but are made about the new pressure and feelings of being vilified by the profession and public and worry about professional actions against them down the road.
The number of deaths in the province (2014) by poisoning by exposure to drugs and biological substances, undetermined intent, was 440. It's the ninth highest cause of death in Alberta that year. We know that 120 of those deaths were from fentynal on the street. The remainder of the 320 includes illicit drugs, legitimate medically prescribed drugs, as well as other substances. The population was 4.146 million, and the total number of deaths was 266 164. If 30% of the population has chronic pain it would impact 1 243 800 people. The high estimate of the number of chronic pain sufferers that may currently be treated with LTOT would be approximately 8% or 99 504. IF you consider these numbers (all of which were found on Alberta or Canada statistics sites, using a basic google search), IF you unfairly attributed all of the unspecified deaths in this category to only chronic pain patients using LTOT (320/99504) that would suggest that 0.00322 of them died from an exposure to drugs. According to the Canadian Center on Substance Abuse 2015 Drug Summary, the number of people in Canada using opioid pain relief was 14.9% down from 21.6% in 2008, and only 2% reported abusing them which was also down from 5% . We have a serious concern when comparing these numbers, which are confirmed and documented, that the fear that current prescribing practices are causing pain patients high risk of addiction and death are simply not representative of the actual picture. Yet this is the message that is being sent and upon which some doctors are already choosing to restricted or reduce their prescribing. It is at the least, reason to stop for a moment and consider if the evidence says prescribing rates are indeed up, but number of people receiving is down, and addiction rates are down, and the loss of life of actual opioid therapy is this low...Aren't our doctors doing a great job considering all of the missing pieces and support they are lacking to better treat chronic pain? In fact this shows that they are excelling. Just like these statistics the water has been even more greatly muddied by the confusing use of terminology. Opioid Dependence Disorder...what does that mean? We use to know what addiction, misuse disorder and dependence meant. If you have to identify it, diagnosis it and treat it, don't you also need a clear definition? We have found 7 different definitions to date that ranged from the classic addiction definition, to using your medication outside of prescribed treatments, to a definition of dependency that also highlighted that a great deal of non opioid medications are dependency causing. When we asked emergency room doctors how many chronic pain patients they see who are withdrawing from medications they were prescribed they thought the number was very very low, and it's hard for us to imagine that very many pain patients just run into the ER to get a refill or because they are suffering from withdrawal when so many will risk their lives to avoid going to the ER for non chronic pain issues. We need to have a much better understanding of the actual numbers with out confusion, better terminology and a better method of determining if what ever practices we alter do indeed have the impact we are looking for. At this moment there is no way to determine if there is an increase in the number of suicides directly linked to a new opioid prescribing practice, or exactly how many of the opioid incidences are actually caused by properly prescribed medications. We heard that the number of pill bottles at crime scenes reached hundreds and that indicated a serious connection between prescriptions and street drugs. In the States it was discovered that people were collecting pill bottles from recycle places in order to give or sell them to drug dealers. Transporting a drug in a bottle feels less visible and by scraping the label off there was a feeling there was no immediate way to determine if they were indeed yours or not. This kind of change will impact the lives of many Albertans, so we had better be sure we are right.
Since the guidelines depend on alternative options to treating chronic pain, and that requires more knowledge, and planning on how to supply and inform the industry, we know that moving forward before such resources are readily available we are accepting the greater suffering of many people. There is no money today to open physiotherapy clinics, and already long waiting lists for essential services like mental health and addiction support. Emergency rooms are complaining about the demands they are facing and specialists and tests are taking too long. If we were to move forward with the current plans some one has to input a great deal of work and money to instantly create an entirely new system to prevent an overwhelming new pressure from chronic pain patients and those that will develop it in the next few years. To accomplish development of a plan that can supply as much support in as many places, in the most timely and cost effective way possible (which it is going to require) will take some time. With out support from such efforts, this new plan will result in doctors having no better idea of what to do to help a chronic pain patient then before, but he will be facing more patients who will be looking to him for a solution. The mental health of pain patients is at risk the longer pain goes poorly managed, and the poorer the mental health of the patient the harder it is to treat the pain. When patients feel heard, respected and as though they have someone in their corner they are more likely to be compliant and participate in alternative therapy, try new non opioid drugs, comply with prescription orders. After years of nothing that eases the pain, feeling like no one understands the damage it's doing to our lives and nobody is fighting for our quality of life, when a doctor suggests some sort of alternative therapy, patients will more likely feel that it is an attempt to avoid actually dealing with pain, rather than a valid consideration. We know that patients who feel hopeless and have reached their limits of suffering, can have desperate reactions that would never have been a consideration if not for their pain. Reports are coming out of BC where patients were cut so far back or totally removed from their opioid medication, that they have now turned to heroin for relief. They know the risk of buying street drugs, they know the potential cost of getting caught, but they also know the way the pain has stolen their quality of life, function, lively hood, family, and spirit. For them, it has come down to a matter of nothing left to lose. Doctors working alone, or who have a poorer understanding, have a challenge in defining and determining how badly the pain is impacting a patients life, and there are no definitive tests to prove their opinion, yet must also explain their subjective findings, in a way that clarifies the little signs a good doctor learns to read through conversations with the patient during the appointments. Pain is a beast to label and explain. It's a lot like describing the taste of an apple. In one patient you may find that extreme pain brings tears and in another sarcasm or joking. One person says it's a 5 and another says it is an 11 out of 10. Then there is the issue of trying to understand the language that a patient uses, because stabbing or throbbing may not adequately describe it, so instead they say it is like being run over by a stampeding cow. How does that feel? Likely the doctor has never experienced it. To make it even harder, a patient may describe the pain of sore muscles as unbearable but the same patient had a sever ear infection and said they could manage it. These conversations are already challenging enough, and very important. Any potential damage to this process puts patients at risk of poor diagnosis or treatment, and doctors at risk of not getting the information they need. We also know that the longer it takes to treat chronic pain, the harder it is to manage, the less likely a satisfactory out come will emerge, and we are more likely to develop other health complications that will make the entire situation more challenging. By not preparing the system before putting these kinds of policy changes into effect, we will delay treatment, damage doctor patient relations and allow pain to complicate the diagnosis and treatment of it's sufferer. Doctors will avoid discussions because they know they will face hostility or pressure they would prefer to avoid, and in turn patients will soon learn that the doctor is resistant and assume it's about a lack of belief in them personally. This path risks setting both up for a painful, and non cooperative relationship that is riddled with second guessing and fails to improve treatment or prescribing.
Our system was already suffering from a lack of trust. Those dealing with chronic pain on every level have felt persecuted, but the discussions around these new practices have created a more fertile landscape in which to talk about the struggles we are all facing. There is a much greater determination to find answers and resolve problems that have prevented the most effective treatment of pain, and we are profoundly grateful for this because if there is a way to improve care of chronic pain, prevent pain from becoming chronic, and reduce reliance on opioid prescribing, this is it. One of the many things that our research has shown us about how to attain the ultimate in chronic pain care, it's that we need more people to talk, more ideas to be put forward, more concerns to be heard, and more solutions to be considered. The major stakeholders need to step away from the model of specialized independent care and follow the example of our multi-modal pain clinics and PCN's. We need to create lists of needs, figure out who can bring what resources, figure out how to share the knowledge and information, and a time line and plan to ensure that our goals will in fact improve the care of patients, support our doctors and medical professionals, and develop the research in order to continue the process into the future. At the October CPSA meeting, Dr Theman asked if anyone knew why the Scandinavia prescribing rates were so much lower than here? What were they doing that was working? We had not considered that question and so we went home and did our homework. Admittedly we did not actually compare their prescribing rates, but what we did find fascinating is that they too realized that chronic pain cost the system a great deal, but they put their efforts into building the resources to treat it, prevent pain from becoming chronic and spent their time focused on how to get treatments in a timely fashion. As they built the system to deal with the physical demand, they also put tremendous effort into educating the profession on the new direction, the treatment of pain, how the new guidelines will impact their practice. Once they had the system ready, they made a law that chronic pain must be treated in a timely and appropriate manner, and clearly outlined the expectations of a doctor treating a pain patient (Guidelines) to ensure the best possible outcome. In other words, they made the treatment of chronic pain a health care priority. In our years of research we had learned that if we focused ourselves on the development of resources, education for both doctors and patients, then created a plan that moved us towards a guideline on HOW to manage and treat chronic pain, we could find a way to make the biggest changes to this aspect of health care. We learned we need to focus on a way to bring more interdisciplinary collaboration, creatively support doctors that are uncomfortable in this role and create open dialog and trusting relationships. As patients learn to trust that help can be found without judgment or fear, and can feel secure in their relationship with their health care team, we can also hold them more responsible in the care of their pain, and research shows that they will be more willing to try and succeed in other treatments, have better mental health, a usually this leads to better coping skills. We believe that current research in to many aspects of such treatment approaches, indicates that not only would we reduce the incidents of pain becoming chronic but also the industry dependency on opioids, and there by lower prescribing rates and of course risk and side effects.
After consideration of these points, and a great deal of other research, keeping a close eye on the impact of the CDC guidelines in the States, listening to current dialog between patients, doctors and other stakeholders, then watching the initial reactions to the news of the implementation of these new standards and practices in Alberta, we believe they should be dismissed. The conversations however, that they have created during this time of unprecedented collaboration, should be used to help bring about team work from all stakeholders to begin a more well rounded plan with the support needed to ensure it's successful implementation. Alberta use to be the leader in Canada's treatment of chronic pain. We are so close to having a system that could set the standard for all of Canada, perhaps North America. We have doctors who have proven to be some of the world best, resources that we simply failed to effectively develop, researchers who have amazing ideas and concepts about how to help attain the goals these drafts set out to accomplish, but in ways that do not require doctors to watch helplessly as patients suffer. The minds, commitment to our health care system, and passionate drives we have seen over the last few months as we contemplate a new course, has shown that we have the people, the experts, creativity and at last a common goal. We put to you a suggestion, now that this wave has begun it's not time to end these discussions and press forward with a plan that may fall short of the tremendous potential Alberta has in the field of medicine but rather, at the very least, take pause to consider the potential of working together to explore all options and then set a course that minds the well being of all parties. The College was faced with an issue that has been deemed very important according to the conversations we have been hearing, but like chronic pain patients with out doctors and doctors with out options, it is in a difficult place that requires outside support to truly be effective. What the industry has said, no matter what side of the fence they stand, is that changing the way we prescribe opioids, and treat chronic pain, is their priority too. The challenge of getting this many stakeholders to sit together and openly discuss this topic has not gone unnoticed by us, but where so many others have failed, this has succeeded. We believe that this is the spark that can ignite a profound change in Alberta and closing the doors on such an opportunity would be a tremendous loss. With this in mind we must say that we can not support the current plan before us, because we believe that it falls far short of what we in Alberta are capable of attaining should we choose to forge a new path.
A recent review and analysis reported that some policies restricting opioid prescriptions to hopefully curb overdose deaths may be harming those who need them most: pain patients. The report "Negative Outcomes of Unbalanced Opioid Policy Supported by Clinicians, Politicians and the Media," was published in the Journal of Pain and Palliative Care Pharmacotherapy and suggested the opioid epidemic, some refer to, has been misrepresented by politicians and media. Your proposed Standard of Practice on Safe Prescribing will be included in that statement. You appear to be basing your standards and dosage requirements on the recent flawed guidelines issued by the Centers for Disease Control (CDC) in the United States. These guidelines were written by a small group of individuals heavily involved in the addiction field, with little or no experience in the area of pain medicine, but with close ties to a large addiction Rehab chain. In fact, one group of medical professional critics reported the Guidelines are, "Neat, Plausible, and Generally Wrong." Their article and many others have enumerated a profound lack of balance, science and medical evidence behind the guidelines. It is bewildering that the CPSA would, it seems in a kneejerk reaction, move forward with such a misguided program. Recent research also shows the CDC actually manipulated the data it used as a basis for its guidelines. This should not be surprising based on the group that wrote them in the first place.
Another review of the CDC Guidelines found a number of contradicting statements based on the presented evidence and the recommendation strength. According to the National Guideline Clearinghouse, "a level A rating requires at least two consistent Class 1 studies. However, all 12 recommendations provided are based on case series (level 3 evidence) or expert opinion (level 4 evidence) yet were assigned a Grade A recommendation. Also, according to the guidelines, providers should implement additional precautions when prescribing dosage to more than 50 morphine equivalents (MME)/day, and should generally avoid increasing dosage to more than 90 MME/day (recommendation category A, evidence type: 3) This recommendation was based on ONE randomized un-blinded study of only 135 patients (94% male; 74% had musculoskeletal pain) who received 40 MME/day compared to 52 MME/day, yet the recommendation was generalized to "chronic non cancer pain" and the recommendation "to avoid increasing dosage to more than 90MME/day was not even evaluated by the referenced study. Really scientific, right! We believe that increasing awareness of opioid overdose risk is appropriate, but claiming certain unsubstantiated risks outweigh the benefits of using opioids to treat pain lacks scientific foundation. According to a recent study by Dasgupta et al, of 2,182,372 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Based on this it is amazing you would use the CDC Guidelines as your template for your program. Additionally, reports from the U.S., including from the CDC and the DEA say: "the massive surge in the use of heroin and counterfeit painkillers are fueling the many overdose deaths in the country." The 2016 National Drug Threat Assessment report verified this. This problem really started in 2011, but because regulators, politicians, law enforcement and the media were so intent on blaming doctors for the problem the situation grew to where it is, now--out-of-hand. When you won't admit what the problem is you can't solve it. The campaign to demonize opioids has done only harm to those addicted and to those who suffer with pain.
It is unfortunate you have chosen the path you are now on and listened to the anti-opioid crusaders instead of listening to people who are suffering. Those with pain are seldom asked and then ACTUALLY listened to when it comes to their pain. It is unfortunate the media has exacerbated the problem with sensational stories and passed on false or semi-truthful stories. Such as 80% of heroin users started on prescription medication, when the simple reality is" "According to the large, annually repeated and representative National Survey on Drug Use and Health, 75 percent of all opioid misuse starts with people using medication that wasn't prescribed for them--obtained from a friend, family member or dealer. And 90 percent of all addictions--no matter what the substance--start in the adolescent and young adult years. Young people who misuse prescription opioids are heavy users of alcohol and other substances, This type of substance use, not medical treatment with opioids is by far the greatest risk factor for opioid addiction according to a study by Richard Miech of the University of Michigan and his colleagues. Their research analyzed data from the nationally representative "Monitoring for the Future Survey," which includes thousands of students. In general, new addictions are uncommon among people who take opioids for pain. Another report from a large study of emergency room visits stated that less than 5 percent of attempted suicides involved pain medication. This was from a data base of more than one billion emergency room visits from 2006 to 2013. So, you are again "dead wrong" in the many assumptions you have made in moving forward with this ill-advises program and you should stop it.
We also find it quite disturbing the CPSA would accept the flawed CDC Guidelines that are based on expert opinion and not evidence; especially when the majority of those "experts" are strongly biased, as indicated by their affiliations to anti-opioid advocacy groups. It is equally disturbing, you would unflinchingly accept these Guidelines, when in 2014 guidelines on the "role of opioids in the treatment of chronic pain" by the National Institutes of Health, based on an extensive literature review by an unbiased expert panel concluded: "What was particularly striking to the panel was the realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience." It was observed that the target should be what the patient and their healthcare provider have decided between themselves as a reasonable goal to accomplish. We concur with this observation that the patient and their doctor should decide what is reasonable or not. It also surprises us you would not work closely with a number of physicians in this province who have worked extremely hard over the past twenty some years to refine their practices and increase their knowledge of the treatment of pain. Many have furthered their education every year with some receiving the Royal Colleges specialty certification in Pain Medicine, FRCP (c) Pain. We expect much more from the CPSA than simply reacting to a situation that is beyond the control of people with pain and their healthcare providers; ILLICIT SUBSTANCES and following the path of a few academics who have an extreme bias.
We are sure you are also reacting to the recent uptick of ILLICIT FENTANYL overdose deaths, but if you actually think this program will mitigate that problem you are "dead wrong." Indeed, as with the lessons learned from Prohibition of alcohol, the consequences are only greater harm. Restricting the legitimate use of opioids drives patients to illicit substances, which are not only potentially contaminated and of unpredictable potency, but they also support crime. Addicts have never had their disease mitigated by the restriction of supply. Criminal suppliers always find the means to meet their demands. If you think the present problem with ILLICIT substances is new you are again wrong. You don't need to look further than the Prescription Drug Research Center to understand this has reared up every decade since fentanyl was developed in 1963 at the Janssen Research Laboratory in Belgium. After this, in 1970, in California a substance being sold on the street as heroin (called "China White") was discovered, it was an actual analog of fentanyl. In the intervening 25 years, clandestinely produced analogs have appeared in the street drug trade, with the usually predictable consequences. This has led to where we are today with even more potent illegal substances on the street and according to the Drug Research Center even worse ones on the way. But, when you don't admit what the real problem is, and try to obfuscate it, you can't solve it.
Your proposal concerning the safe prescribing of opioids by imposing more requirements on physician prescribers is a dreadful folly. You are doing a disservice to people with pain, people addicted and those thrill seekers who feel they cannot be affected by trying these ILLICIT substances. If you really want to reduce opioid addiction you have to target the real risk factors: child trauma, mental illness and unemployment. You should be working to create better mental programs and then funding them. Perhaps some of those people on the street would not have been there if you had. You should work to actually spend some real dollars on pain research and education in our medical schools. You should work to have funders give proper budgets to law enforcement agencies so they can effectively fight the illicit smuggling. But, when you won't admit what the real problem is you can't solve it.
You are failing the citizens of this province when it comes to treating a condition that affects more people than heart disease, cancer and diabetes combined. Of course, we all want to ensure the safety of society and patients through the proper use of opioids, and trying to ensure the safety for those who are addicted or misusing opioids is laudable, but in effect you are punishing legitimate users of opioids. Those who are misusing are in effect breaking the law, so are they more important than those who follow all the rules. We think not. One of the most important things in medicine is the trust that develops between doctor and patient, a key to getting well. Your present approach to opioid prescribing (and we won't even get into that) has broken this basic tenet of medicine and has undermined the trust many people with pain had with their doctor. It has had a profound negative effect on those people, affecting their health. You should work with those very qualified doctors in this province to better attitudes and treatment of pain that prevail.
After the triplicate prescription program was introduced the demand for oxycodone increased! It was like advertising a list of drugs that would be harder to obtain. Their value went up overnight. Prohibition always increases the value of a commodity. Since then we have had the heroin crisis, the Ecstasy crisis, the cocaine crisis, and now we have the fentanyl “crisis”. I really do not see what all of these crises have to do with the prescribing of medications. I have recently seen a survivor of street fentanyl who was also using cocaine. He has schizophrenia. He has never been prescribed a pain killer in his life! He lives in a parallel universe. He is a drug abuser plain and simple. He did not get there from having to wait, in pain, for surgery.
While I was certainly aware of "professionals" who were seeking opiate medications for resale when my patient population was younger it is something I see rarely now that my patients and I have grown old together and I work in a quiet neighborhood.
It is not surprising that legitimate demand for opiate medication increases year by year. The population is aging. Many have painful conditions for which there is no ready fix. Patients in Calgary have to wait one year before seeing an orthopedic surgeon regarding knee replacement. If accepted they will have to wait another 4-5 months before getting surgery. During that time they will have been taking pain medication. The pain may be relieved by surgery. Occasionally it is worse! In any case, many patients take opiate medication for far longer than any of us would like because definitive treatment is not available.
We keep hearing about other ways of managing chronic pain: physiotherapy, psychology… But access to these services has not increased one bit since I entered practice. The drugs have not improved either. So many physicians would rather prescribe anything other than an opiate that there is now widespread prescribing of gabapentin. The result is that there has been a significant increase in the number of "gabapentin-associated deaths" according to the medical examiner's office. (A "gabapentin-associated death" is a death in which there was gabapentin in the blood but not at a level sufficient to cause death on its own.) Gabapentin has now also become a drug of abuse. "Gabbies" are sold on the street. Users pull the capsules apart and "hot knife" the drug.
It seems to me that the new "standard" is a reinvention of the wheel. The wheel was the triplicate prescription program. The triplicate prescription program was meant to prevent improper prescribing, abuse & diversion, and it is still in force. Is the triplicate prescription program to be dismantled when the new standards comes into effect? If not, why the duplication of effort and the extra paperwork?
We hear in the press stories of patients who were given opiates in hospital when they had terrible pain and who are now addicted. I must say that that such stories sound unusual to me. I have not come across such people. But it is great press and a great excuse. "The doctors hooked me on drugs."
I have just reread the proposed standard through different lenses. I always assumed that this standard was intended for narcotic medications, not all medications. If it is indeed for all medications than it really should be thrown out. It is so impractical as to be impossible to comply with. Furthermore, I deal with many elderly patients with multiple conditions. To put indications on each one would be a ridiculous waste of time. And there are also many cases where I do not want the patient to read my indication - "for paranoia"; "for delusions"; "for syphilis". I often get patients who arrive in my office with nothing more than a bag full of prescriptions. It is not difficult to determine why most elderly patients are taking furosemide + spironolactone, metformin + repaglinide, etc... I am sure that pharmacists are similarly intelligent. I know it is hard, but there comes a time when it is simply better to sit on one's hands than to legislate.
I used to have NetCare but I got rid of it because I found it to be such a total waste of time. That was a long time ago. Now I am trying to get it back, but have found that the legal hurdles to do so are now numerous and high. There is only my receptionist and me and yet we have to have written agreements for this and that, and a privacy officer, and what happens to the key to the front door, and so on ad nauseam. All this for 2 people who have worked together for 25 years. The pharmacist next-door told me that it took over 6 months for her to be able to access NetCare so she has told me not to hold my breath. I understand that 20% of Alberta physicians do not have NetCare. There are reasons for this.
I have carefully read the new draft standard "safe prescribing".
I would like to add a No 10) to the list. That any contract signed between patient and physician for opiates be binding for 18 months. Also that a copy of the contract be sent to our College.
I would also like to see a modification to the triplicate prescription that provides a space for the designated pharmacy.
We in our clinic find it VERY EASY to access NetCare/PIN. I was surprised the other day to discover that a long time somewhat psychotic female patient of several years
maintained on Percocet two daily for back pain has for the past several months gone to the local Walk in Clinic and was receiving in addition not just valium and zopiclone but morphine 200 mg twice daily. Was she selling these drugs to supplement a meager income? Clinically none of these additional drugs were indicated. Adding No 10) to the new draft standard would have helped to prevent this occurrence.
Our society is inundated with prescription opiates and street drugs. Have we become a nation of wimps and addicts? The Chinese Ministry has agreed to work with the Canadian government to reduce Fentanyl exports where in Canada the drug is cut up to look like Cocaine, Heroin and Oxycodone.
Dr. Theman has taken the initiative. Our College is trying to get "our house in order" and I applaud their efforts. I have a moral obligation to endorse these new draft standards. We are in a crisis and innovative measures are required.
The physicians of the Multidisciplinary Pain Centre at the University of Alberta offer the following observation: The requirement to see patients every three months will significantly clog up already overfull specialty clinics like ours. This is compounded by the fact that many of our patients are from a long way away. We often make a clinical judgement that a stable patient without concerns can be seen twice yearly. We suggest that this be left to physician discretion
My main concern as already stated by others is the " indication " on the presription for two reasons:
1. my EMR does not support this - I would be adding free text to the prescription which is not searchable for quality improvement purposes. Also if the hope is that pharmacists will then enter said indication into Netcare I am not sure this is a valid assumption - many prescriptions don't make it on nectar and often I am calling pharmacies to pull original prescriptions to sort out missed refills
2. confidentiality purposes - if my chart note accurately outlines my assessment and reason for prescription that should serve
As the wife of a chronic pain patient I am terrified of what the propsed new prescription rules will mean for my family! My husband uses prescription opioids to help manage his pain. Without them our home life will be unbearable as pain makes even the strongest person grumpy. This will tear our family apart. My husband takes his prescriptions seriously and under close direction of his doctor and pharmacists. Don't force us to turn to illegal street drugs as a solution to street drug problems!
Re: Provision of medication changes to the next care provider
Is it possible for the physician to provide the patient with their changes to medications with the instruction for them to provide a copy to their next care provider?
We have been attempting to address this from the rural ER perspective and are finding it very difficult to ensure that we actually are getting the information to the right next care provider when we discharge. Often there are not the human resources available to search for the addresses and/or contact information at the time of discharge and Netcare has some limitations around inputting that information in a timely enough fashion with notes attached regarding the reasons for the medication changes.
If the standard of practice states that they need to provide to the family physician, pharmacist, and........ I think it will be a difficult practice to meet. Perhaps the physician needs to send to just 1 or more members of the patient's healthcare team in order to potentially meet that one.
By all of the comments posted , the College should not only scrap these standards but also should and MUST UNendorse the CDC guidelines.
We have Candian Standards developed by Canadians
Much of the discussion surrounding the opioid issue appears to be aimed at blaming physicians. I do not doubt we have some responsibility and should act professionally. We need to accept and deal with that but the problem is mainly societal and to make ANY difference, society and those that represent society, must also accept their share and do something more than smile nicely for the TV and demand a fix from everyone but themselves.
I believe we will have to address many issues and some if not all of them may be physically or politically difficult. We must be realistic and cannot allow political correctness and social taboos from exploring all answers.
Specifically I do not want to see addicts routinely imprisoned but if they also deal and encourage others then yes. Dealers must be caught and punished severely, sorry but if necessary build more prisons!
Real and adequate resources must be provided by Government to check cargo's for drugs or their precursors. It is a well known joke that CBSA and the RCMP as so busy chasing after 'terrorists' they are unable to also properly deal with organised crime and drugs. If Society wants a real answer they do need to pay.
Healthcare: Safe injection sites are essential and we may need to establish them against some opposition.
Increased rehab places and addiction specialists. Provision in smaller communities as well as big cities.
Increased GP fees properly reflecting the time and complexity of dealing with opiates (Certainly capping modifiers will NOT allow the time necessary for opiate contracts, testing and counselling)
If society doesn't pay properly for the service they have no right to expect it (no one else works for free!)
CPSA needs to be realistic about demands and expectations!
The CPSA must be realistic and not just blindly enthusiastic about more rules and regulations when the resources are not available.
Simple statement such as 'use alternative' methods for pain control when the services are unavailable is ludicrous. Do you understand outside of the ivory towers CBT, adequate physiotherapy, pain clinics are generally not available or cost more than the patients can or will pay and have excessive waiting times.
How are we supposed to cope when we cannot get people seen by any specialists in under 18 months
How are we supposed to investigate the patients when there is an unofficial moratorium on such things as MRI and if you can get them its not for 6 months. Not to mention we have to beg and fill out even more 'questionnaires' which takes time.
Drug diversion. I am not sure how we may be expected to control this? However if it is suspected by CPSA, Pharmacy or prescriber we should be allowed, if not required, to report it to police.
If drugs are being requested and sold off the offender should be prosecuted as a dealer, if suspected they should be reported.
Tamper resistant drugs have been available for a long time but government, WCB, AISH, Blue Cross wont pay for them. Neither will they cover short controlled prescription charges eg 7 day of tablets at a time.
If physicians are prescribing heavily there should be a properly funded mechanism whereby we can defend our patients and ourselves and not get financially punished for doing our job.
There are many aspects to this issue. Its not so much we don't have a responsibility and role to play in this but all stakeholders must take part or take the blame. Answers need to be pragmatic and if we cannot afford or don't like them then we should say so publically and not play the blame game.
I have one suggestion to be taken in consideration please. I worked in the UK before. In the NHS if you want to register with a GP you must fill unified form, that requires presenting proof of address and eligibility. That form will be posted to regional office and you will get a card with NHS number and name of your physician. and all your old file will be transferred from your old GP automatically. So the patient can`t just go and tell a any doctor that he is his regular GP while he sees others. In this way, you can control billing for CCP and physical, referrals, request for investigations and of course avoid double doctoring. The control needs centralisation.
We have the right to have our pain treated
We have the right to be believed
We have the right to be treated with respect
We have the right to all the best possible technology in pain management
We have the right to know about all the pain management options so we can make best decisions for our own pain
We have the right to live with the least amount of pain possible
I linked to these standards via an article specifically about opioid use, but find that these are for all prescribing. I can't really understand that. They are clearly aimed at opioid prescribing, just admit it!
I am afraid what we are witnessing is a wave of political correctness triggered by a reaction to a different issue, i.e. the availability of street fentanyl and the consequences of this. Adopting the CDC standard is nothing more than bandwagoneering and contributes to this. I know there are problems associated with opioid use, but I would guess maybe 20% of patients on them have some issue, but for the other 80% there is definite benefit, and very little in the way of problems. I would love to avoid the problems that the 20% cause, but I cannot abandon the other 80% just because I want to avoid those 20%.
The standard should not include statements such as, "..given the literature indicates non-pharmacological therapy and non-opioid medications are preferred, and the potential benefits of LTOT are modest and the risks significant..". It is up to the individual to interpret the literature, and in my view this issue is still up for debate. Including it shows the bias of the authors against using opioids.
There are many other very valid objections that have been contributed already, so I don't want to repeat those. I do think though, that there is a long way to go before this standard is adopted.
The standards do not address the additional risks found in obese patients. I work in Sleep Disorders Medicine and interpret Level 1 polysomnograms. Over the past 5 years I have seen are greater and greater numbers of patients with BMI greater than 35 on high dose narcotics for joint pain who show a sleep disordered breathing pattern that is almost impossible to treat. The combination of morbid obesity with narcotic medications can result in severe obstructive apnea with additional frequent central events that precludes control with CPAP or even BPAP therapy. The CDC guideline mentions not using opiates in patients with obstructive sleep apnea. I believe this recommendations should be stronger. Obese patients should be screened using a simple office questionnaire (e.g. STOP-BANG) and those at high risk for having pre-existing sleep apnea should not receive opiates other than very short term. I do not know how many obese, sleep apnea patients in the community do not go on to develop this profoundly deranged breathing pattern but the ones that do become profoundly impaired by it.
I find this prescribing policy heavy handed, overbearing, and vague in it's intent. I think the opiate prescribing issue should be addressed as a separate specific issue. I get the impression that this policy is trying hard to fix a big problem in fell swoop. I think most of these issues would be better solved with education and support than policy. Has there been any integration of this policy with our pharmacy colleagues? Let's not be hasty and reactionary. I think we all recognize the difficulty created by over prescribing of narcotics and the risk of harm with prescribing of other non-narcotic medications. I think we can be more thoughtful in our solutions.
I agree with Dr. Hauptmann's and Dr. Knight's comments regarding this important standard of practice. Though the draft guidelines are well-intended, several practical issues emerge including the proposed reduction of the daily recommended maximum of OME to 90 mg a day from 200mg a day; as Dr. Hauptmann mentions, what evidence do we need to justify a dosage of 120mg daily in an otherwise well-functioning individual?. I have a concern regarding patients who may have dosage reductions, which will lead to increased pain and thus decreased function due to potential change in standards. As with any medication, we endeavour to use the lowest effective dosage.
There needs to be increased medical education regarding this subject, and more resources dedicated to chronic pain, including the use of pain clinics (multi-disciplinary such as PCN) which are of significant assistance for community physicians. Unfortunately, more physicians may have a reluctance to take on chronic pain patients (in some cases by avoidance by not obtaining a triplicate prescription pad) however this issue can be potentially alleviated by a having a balanced standard of practice , more clinical support and education for physicians. Thanks for your consideration.
I am most concerned about point no. 8
8) A regulated member must identify the “indication for use” on all prescriptions
I believe this a breach of confidentiality, and it increases the administrative burden on the physician.
What steps have you taken to involve actual Chronic Pain patients in this process?
I am a former RN who had to retire too early due to Chronic Health issues. I am available if you would like to speak to someone about their experience.
It is important to remember that everyone is different. You need to recognize that people respond to medications differently. A one size fits all approach does not recognize this.
Listen to your patients. Stop treating all Chronic Pain patients as addicts. There is a difference between someone who USES opioids for pain management and someone who ABUSES opioids.
Opioids can be used responsibly.
What currently available, effective and affordable medication is available to replace them?
This is a quality of life issue. I believe that no one should suffer unnecessary pain when there is medication available that is helping them to live some resemblance of a life.
This is an issue that affects everyone. In the future it may be you with a Chronic Pain condition. Then you will truly understand.
You need to focus your efforts on educating health care providers about the patient's perspective, particularly the way we are treated like addicts and drug seekers when attempting to obtain treatment in an Emergency or Urgent Care facility.
This is already creating barriers to access care.
You have an obligation to do no harm. This also includes not adequately treating Pain.
"I attended forum am member of csam ASAM and work on orthopaedics at royal Alec where 90% of patients or more are on opiates work at homeless shelter for homeless addicts called McCullough center(Gunn) and am the methadone suboxone dr at Edmonton remand center I feel qualified to offer some suggestions I'll share the following recommendations
1 adopt British Columbia benzodiazepine taper as part of ALL opiate prescriptions ASAM has recommended no benzodiazepines or etoh with narcotics for almost 20 years I have this conversation(fight)daily and would love to have some backup to initiate change
2 I feel we must acknowledge WE are part of problem and initiate a strategy stating we are part of solution relative to narcotics Such strategies worked with bugs and drugs and radical decreased antiobiotic use and hand washing campaigns
3 I like the fact that we acknowledge the population we helped develop a problem for BUT I FEEL THE CHRONIC PAIN prescribers will state my patients need 90 or less but there's are different and the problem won't change I'm afraid my colleagues don't take any ownership of problem
4 need to make it easier to prescribe suboxone consider subsidizing camh course or using pharmacy course on line
5 need to have physician support for problem high dose patients I have created patients like this in past even though I was well intended and found myself wondering how I got there I Support CDC guideline whole heartedly but wish management of acute pain for surgical patients was better delineated lots of our patients 2700 hips and knees as well as spine surgery a year get up to 8 mg of dilaudid every four hours and for example I just saw a preop spine coming in on 1700 a day of morphine
6 I have a passion for this topic and am angry with the deaths and angry that fentanyl which I can't do much about takes the focus off myself and my colleagues which I can do something about I would offer my assistance to help with any of these guidelines
7 I'd appreciate a phone call to confirm someone read this"
Not a very good first effort. Well intentioned I am sure but several issues:
1&2- already covered in other Standards at national and provincial College levels
3- Too vague in terms of communications. Will add effort to prescriber.
4- Too onerous and accuracy still not 110%. "Must" is too strong an imperative.
5- Again too onerous for busy clinicians. Many of their patients will not be on medications or are new patients. Busy clinicians already have EMRs, sometimes more than one, they have paper charts or referral notes and many testing entities are not on NetCare. Sorry but Netcare is a LONG way from the Bible (insert your own religious text here if you like) and I work primarily in a hospital and find that for MOST of my patients I have to get information elsewhere in addition to Netcare.
6- So what other methods exactly? A visit to the area pharmacies? Really? Not practical at all. This should simply state they should make attempts to determine what medications their patients are on. As written this applies to all of their medications, when really this is primarily directed to drugs of abuse. No.
7- 7a is fine but 7b- 'by any means possible' - Are you kidding me? How can you put this crazy requirement into a document?
8- Confidentiality if compromised by such a requirement. Patients may not want this - Nearly every pharmacy I have been to does not have a proper place for confidential medication consultation or dispensation and while it is desirable that patients carry their important health information around with them, the College should not mandate that we do it for them without their consent.
9- I am not an expert on narcotics prescribing, but most of the comments I have read do make sense to me. I will defer to others on this though.
While I appreciate the CPSA effort to more effectively guide the profession and serve the public, I particularly agree with the Rob Hauptman and Brian Knight commentary and critique.
It seems we are trying to accommodate a disorganized health system where respective accountabilities (the public and the profession) are blurred. Are the issues surrounding safe prescribing as challenging in health systems where citizens are 'registered' with a particular physician or group? Reliance on NetCare and PIN to track people and see with whom they been given an Rx or had a consultation seems to be the only option in a poorly organized system. More effective relationships need to be grounded and supported by structure. I am a more effective family physician when I have a commitment to an individual and they have a commitment to me.
The wording suggests a dogmatic and bureaucratic approach to prescribing hence inevitably slow to complete, creating an opportunity lost to see other patients. Compliance in the format suggested, making the medication central to the encounter, would be consistent with a defensive and drug-oriented mindset-is that the best way to practice medicine? It promotes a culture that minimizes the alternative management options although these are referred to in the text and militates against recording the naturalistic flow of an encounter , making documentation seem more contrived and less authentic ( important when clinical reasoning is being explored) and not reflective of the actual discussion/patient encounter, hence also unlikely to encompass a motivational format and the patient' response to it. For example, if a first line agent for hypertension is being presribed according to guidelines, is this dogmatic approach either helpful or necessary? This approach appears not to serve the patient, the physician or the regulator and could be covered adequately in more general terms.
I think this standard is far too onerous, impractical, and may conflict with the duty of confidentiality. I do not see why all this detail is necessary for all medications. If "must" was changed to "should", that would improve the draft substantially. Where is the evidence for these changes?
I agree with most of the comments here. In an era where we are trying to be fiscally responsible, struggling with too few physicians for too many patients, the college has added another bureaucratic hoop to jump through. Checking Net care on each patient, is untenable. Writing down on each prescription the 'reason for it', not only affects privacy issues (will I now have to get a patient to sign a consent releasing his medical information to the pharmacist?), ties up valuable time, and my guess is, the pharmacist likely knows why I am prescribing a certain medication. These 'standards', much like many of the 'sterilization' standards are a knee jerk response to pressure from government or administrative bodies, and have NO good research to back them up, and will tie up much of a physician's time, that would be much better spent clinically (not administratively) on the patient's well being. We need some common sense.
Reading all the already written opinions makes me hope that the College will listen and act on the advice from those working "in the field". Everyone agrees that opioids can be and are misused, but clinical misuse and addict use are different and should not really be treated with the same rules. Cutting down on dose or "changing to N.S.A.I.D.S." (crazy thought) is not a valid answer in most cases. When I started a pain control clinic in this area another doctor and I went to Edmonton for "training", then I went to other provinces and countries (Europe) to learn more. Some years later I moved from the clinic and it came under the care of Dr. Hauptman, see his comments here also. I agree strongly with what he states. Another fact...Increasing the dose slowly may sometimes assist in creating an addict . . . sometimes you have to bang up the dose and conquer the pain and then come down to maintenance. More... there is no "maximum" dose to be written on paper, Every pain is different. Proper use of opioids depends on each case, not on figures worked out in a non-clinical or criticizing type of setting. However one MUST be concerned for the present misuse of these drugs throughout the world, and for the poor addicts. God help them, and us too, and, yes, the College who is trying to find an answer. As for constant use of Netcare...give us as many assistants as government bodies and we might have time to use it. One more comment. I work closely with pharmacy (I am not in a big city with a hundred pharmacies) and we communicate well. I can write on a "Script..."Pain worse, titrating'... Quickly. I have had a few times a message from pharm "he's getting it from two other drs. in other towns" which leads to a nasty confrontation!
Easy access to interprovincial prescription records would help alot . Another important issue is that patients dont have similar access to pain meds . e.g. Why long acting meds are not covered for natives while short acting are ?? . Another important point we should never forger is that pain is SUBJECTIVE not objective and its all about quality of life at the end .
The level of usage of "must" seems excessive. In many of the cases it will be impossible or at least very difficult to enforce.
I don't know what is meant by # 8. Seems excessive.
Personally I don't find a problem with the standard as it applies to triplicate prescriptions, but is it meant to apply to all prescribing?
Do I really need to add an indication for insulin?
Will the EMR even allow this?
Back to the drawing board...
I am concerned about having to write the indication for every medication on every prescription. Is there strong evidence for positive safety impact of this measure, that is not out-weighed by unintended consequences such as time-delay (patients waiting longer in ED for physician to see them) and privacy concerns (patient's acquaintance sees why they are on a certain medication)?
As a sub specialist who sees patients with sexual and forensic problems, I am very concerned about the suggestion that the indication would need to be written on the prescription. I think it highly unlikely that a patient would fill the prescription if it states pedophilia or hypersexuality, for example. The confidentiality issues are not insignificant.
All opiates must be only prescribed or recorded on Netcare to provide full documentation as to amount and frequency. This allows proper dosing and keeps everyone informed.
The triplicate system is not an open approach and is always after the fact. It is out dated as it now exists
I agree with Dr. Hauptman's excellent well thought out statement.
Clearly opioids on the street are coming from somewhere (almost all the fentanyl on the street is coming from off-shore and has nothing to do with prescription opioids). No one has ever looked at where they are coming from.
These are a few suggestions that might reduce the street supply.
1. Make a public campaign asking patients to return unused medication to pharmacies right away. A lot of patients who are started on opioids get a months supply, can't tolerate them and they sit in the medicine cabinet where they could be stolen.
2. Change the rules about dispensing fees. If I prescribe small amounts of medications in high risk or for that matter for any patient, the patient will come to me complaining about having to pay a dispensing fee every 1-2 weeks instead of every month. If a patient is getting a partial fill rx with short interval prescribing for his or societies protection, why should he have to pay $12 each time.?
3. Many surgeons will prescribe large amounts of opioids post-operatively for patients so they don't have to see them in follow up as soon (some on the other hand prescribe little or no analgesia which is worse). The problem is that many patients don't use these at all or not for the full course which again means drugs sitting in medicine cabinets. Why not have acute management programs where patients can be given small amounts of analgesics and be reassessed every few days.
Further education in pain and addiction is lacking as are resources for treating chronic pain or addiction. The CPSA could make huge progress in this by putting pressure on just three physicians:
The CEO of AHS
The deans of medicine at UofA and U of C.
The requirement to review the netcare PIN profile for each episodic encounter, while clearly useful for complex problems, would be onerous and unnecessary for many patients seen in Emergency Medicine eg those with sprains and other minor complaints.
As other commenters note, the proposed requirement to notify pharmacists of medication changes would be unworkable. Patients attend multiple pharmacies and many of our prescriptions are filled outside normal hours where the patient's usual pharmacy may be closed. We have no mechanism for forwarding this information.
I am happy to see increased safeguards regarding narcotic prescriptions as we see ever increasing iatrogenic issues related to high dose narcotics in the ED.
I agree with the basic principles outlined, but I'm not sure the guidelines work with those lacking capacity due to Dementia or Psychosis.How would these apply to those under a community treatment order?
I am fearful as to what will emerge from this dialogue.
I suffer greatly from pain caused by old sports' injuries and from severe fibromyalgia and have been prescribed Oxycodone to relieve the pain. Should I be forced to reduce the dosage or, 'heaven forbid', I could no longer obtain that prescription, my quality of my life, as well as that of my wife, would be adversely affected.
I have tried physio therapy, massage therapy, and acupuncture, as well as cortisone shots, and find that many of these options provide only temporary relief. Oxycodone provides me with the relief I require to enable me to move around and enjoy life.
As a retired Police Officer I am well informed about the illegal drug scene but fail to understand why I need to relinquish something that helps me, because of the abuse of others. I understand the need for control but hopefully all doctors review their patients' requirements with each new prescription, as my Doctor does.
Please take into account everyone who needs these drugs before banning or reducing the dosages.
Curious regulations at best as a person who has been prescribed oxycodone for over twenty years, these regs are far too onerous. In my case I am a busy professional that has a very busy travel schedule, at least twice a year I am out of province for a period of at least 2.5-3 months at a time. The fact that my doctor has to see me on a monthly basis, in order to prescribe the oxycodone is an impossible situation for me. I ask you to please advise as to how I am to proceed in this situation. My physician seems to be mortified of your college , I am sure I'm not alone in this situation, surely after so many years on this medication I should not be considered a risk of abuse or misuse. Please advise as to how I am to proceed.
In addition to agreeing to all the other comments, I would suggest that the guidelines are 'naive' with respect to opioid naive patients. In a number of patients, I will try to start with short and long acting Tramadol preparations. Yet, drug plans (especially Native affairs) don't cover the long acting preparations. Consequently, if you are going to dictate how I practice, you need to make sure that my hands are not tied by the fact that patients don't have equal access to all medications
I have reviewed the guidelines at length and have mixed feelings about the document.
As a tertiary pain consultant, I see value in promoting the safe prescribing of ALL medications. I commend the CPSA for their leadership
in recognizing that it is not all about opioids. Many other medications including antibiotics, antidepressants and benzodiazepines can cause
significant harm and we need to reflect at all times about the risk benefit ratio of all the medications we prescribe. Early in my medical career I had
a 46 year old mother die of complications from an antibiotic that was used to treat a UTI. I had another patient die from a phenothiazine used to
treat schizophrenia. Harm can come from medications in virtually every class of drug.
However I am concerned with all the attention that is being given to the opioid class of drugs. I am already seeing the implications of this focus on opioids including many physicians refusing to see patients with chronic pain who are on opioids.
Now while the CPSA will argue that a physician does not have the right to refuse to see certain groups of patients, the practical reality is that this
There is little doubt that some patients with chronic non cancer pain benefit from opioid therapy. This is supported in the medical literature. For those who are interested I keep with me a USB stick with over 60 studies on the use of opioids for the management of chronic non cancer pain. However, it is also clear, that no one drug class, including opioids, are by themselves effective in the management of chronic pain. Skillful management of chronic pain requires a mix of non pharmacological and pharmacological therapies.
My current concerns with the the proposed CPSA standard are as follows:
1) The current standard states that prescribing of opioids should be done in accordance with the current CPSA endorsed guidelines.
We know that the NOUGG guidelines are being updated in 2017. Will the CPSA change their endorsement at that time? Who is advising
the CPSA which pain guideline they should endorse? Both the Pain Society of Alberta and the AMA Section of Chronic Pain are willing and
ready to assist the CPSA in their review of pain guidelines.
2) If a physician has patients over the 90 mg morphine equivalence a day, what evidence will they have to document to justify the dose.
The proposed standard section 9 subsection e states that the dose will have to be justified but does not state the standard for which one
could justify the higher dose. Is it pain reduction, improved function or both? Will this have to be proven in some objective manner or will a patients subjective reporting of improvement be enough?
3) Will pain consultants be held to the same scrutiny as primary care doctors. The current CDC guidelines explicitly state that the guidelines are intended
for primary care physicians and internists. They do not appear to be intended for tertiary care pain clinics or consultants.
4) For many years we have been teaching primary care physicians that it was acceptable to have patients on up to 200 mg a day of MED. If the guidelines go down to 90 mg MED for chronic pain patients, are all the patients on over this dose and their physicians going to be investigated?
5) Most of the guidelines for chronic pain endorse urine drug screening for monitoring and managing chronic pain patients. With the increased awareness that the guidelines have caused, I suspect there will be a rise in urine drug screening. According to a clinical toxicologist at the U of A their work has already doubled and they suspect it will continue to increase. How will this increased cost be addressed?
As a pain consultant I am deeply concerned with the abuse of opioids and opioid related prescribing. I feel that pain consultants are part of the solution and not the problem. My hope is that we can all continue to work with the CPSA for the betterment of both the chronic pain population and the substance
Robert Hauptman MD
Assistant Clinical Professor U of A
"I think the proposed prescribing guidelines are too onerous for family physicians. I have been on oxycodone for approximately 5 years for treatment of chronic pain. My doctor did not select this medication hastily in one visit, but rather after investigating all my options after several visits seeking help for poorly managed pain. I tried several medications with poor results and intolerable side effects before having good results with oxycodone. I think most physicians are diligent in their efforts to treat patients with chronic pain and only choose opioids as a last resort.
I have tried physio therapy, massage therapy, counselling, mindfulness, acupuncture and many clinical interventions at a pain clinic in my quest for pain relief. Many of these options provide only temporary relief if at all and the costs can be burdensome with minimal coverage through supplemental plans and high costs for these treatments. When my pain was not being managed well, I developed a severe anxiety disorder and panic attacks. So not only did I have to cope with constant pain, but also with debilitating anxiety and panic attacks that left me unable to work for over 2 years.
If I were forced to reduce my dosage or be taken off the oxycodone, with no equally effective pain reliever, my quality of life would be adversely affected to the point where I would likely become severely clinically depressed once again. Living with constant pain with no hope for relief is a miserable existence that leads many people to contemplate suicide as I once did. I fear that my anxiety, which has finally become manageable enough that I could work part time, would once again become debilitating and prevent me from living a full life and affect my marriage.
I should not have to suffer in pain because some unscrupulous individuals are abusing the system or because some doctors don't do their due diligence before prescribing these medications. Once a family doctor, together with the patient, makes the decision to treat chronic pain with opioids, a yearly review should be sufficient after the first year providing the chronic pain condition still exists, which in my case it does.
If the government and the medical profession want to reduce the use of opioid medications, then the government needs to fully fund alternative treatment options if prescribed by a physician such as physio therapy, massage and acupuncture. The reason they don't fully fund them is because the evidence does not support their efficacy. Alternatively, more research into treatment of chronic pain and development of new, safer drugs is required.
I fear that if these prescribing guidelines are approved, patients with chronic pain will increasingly find it difficult to find good physicians to accept them as patients and many will go under treated with tragic consequences.
It seems to me restrictions on opioid prescriptions will be counter productive. And lead to more deaths from street drugs. If a person is on a maintenance dose of say, (MS Contin 75 mgs a day) and they have been high functioning and productive for years. If their legal means to obtain the drug is restricted or made difficult. Some may turn to street drugs to function. And risk harm from the unknown quality and quantity of the drug. Isn't this whole exercise a knee jerk reaction to a current problem? Get a grip. I'm speaking as the husband of a woman who has had spinal surgery, two hip replacements and would not be able to get out of bed let alone contribute, without the relief the opiate provides. Her physician has expressed his concern to us already about these changes. And how they may affect her.
As a retired nurse who worked 18 plus years in long term care and recently looked after my husband with a terminal illness I have seen both the good and bad prescribing of opioids. The problem as I see it is the lack of opportunity for physicians to use the palliative consultants available who are expert in managing chronic, terminal care pain needs. There are not enough of them. If opioids are used, sometimes other meds are necessary to combat opioid side effects. Nurses also need further training to assist in the observations needed to insure prompt intervention of side effect suppression. It is a fine line to optimum resolution but when achieved it is remarkably effective insuring the patient a comfortable,aware life. Putting too many restrictions in front of physicians only harms the one they are trying to help. Making information available to physicians in a timely manner and establishing a pharmacy consultant may help.
I am unlikely to comply since if I leave my computer connected it times out as I do my consultations 30 - 60 minutes. I stopped using net care ie. poor access and equally poor typist since I cannot enter code fast enough. Narcotics are a fact of life for surgeons as you finish cases , talk to family members, check with recovery room and answer the ER doctor. ( net care drug check is probably ninth on any priority scale if that } Most importantly to talk to next surgical patient prop and decide on which post op medication will work for them especially if an outpatient.
I'm a child psychiatrist. I'm struggling to understand the rational for some of these recommendations. Why we are expected to tell the pharmacist more about why we are making changes or even prescribing a med? What if the patient does not want us to tell the pharmacist? Why do we need netcare? These guidelines seem relevant for opioids but should it apply to all of medicine? What if my patient does not want the pharmacist to know they are struggling with depression? Once again, it would be helpful to know what the problem is that we are trying to solve rather than just changing/outlining expectations.
Adding to the complexity of presribing by adding documentation to prescription, as well as having to wade through the login process of Netcare for every patient with every visit will add significant time to consultation time. It will detract significantly to actual face to face time with patient, and will reduce number of consultation slots for patients.
Indded, Benzo's and opiods warrant more attention and care, but the standard blankets all prescriptions.
Adding dx to prescription? Patient confidentiality has been paramount, and now having (potentially embarrasing) detail on prescription is risky and unnecessary.
I agree with previous comments, and I hope that if enough of us express our concerns the college with listen and change this policy. At a time when we are trying to save 100 million dollars, we need to try to be more efficient not less. If I see less patients in a day, more of my patients will end up going to medicenters or to emergency and that is very expensive. We need to start thinking about the costs of these decisions. It seems the college simply decides what is theoretically best without any thought to what happens in real life. My experience with cleaning and sterilizing guidelines have shown me how unrealistic these policies can be.
This policy does not make things better for patient care, it makes things worse.
I agree with many of the comments stated below. As a *standard* it is overbearing and impractical in an actual clinic setting. I feel a number of these attributions have "high risk" medications in mind, but any standard needs to balance the risk versus the benefit of having the increased work requirements for doing a med reconciliation via netcare for every patient, as would be required in episodic care. For narcotic or benzo prescription, I agree these should be as part of the standard. However for a pregnant patient with nausea needing Diclectin? for a young female with a UTI? for someone coming in to ask for a TwinRx vaccine? For an asthmatic requiring a refill of their PRN Ventolin? The significant time requirements to log in with a FOB, log in, type in the information, and check a netcare profile for medication review can easily add 5 - 10 minutes to each encounter. Some of these situations it may be reasonable to check a medication profile. But it should be the clinical discretion of the provider to determine the risk/benefit. There are also a number of medication reconciliation options that are superior to netcare (sheets provided by the pharmacy, a MAR, for example) that need to be addressed in this standard.
This draft was not written by somebody who works in a real world. clinical situation. This might work if I saw four people a day.
I echo the concerns of my colleagues. As written, this STANDARD is very unwieldy, resulting in prescriptions of several pages in length and extremely time-consuming, resulting in fewer patients seen per day (this would take at least 10-15 minutes per patient). As a standard, it would open physicians up to medical liability, as it is so difficult to meet.
What is the reasoning behind this? Is there a specific e-prescription program in mind to unify the province and improve communication that meets these onerous requirements? Are these requirements a means to track off-label prescribing for some reason (off-label prescribing being a common occurrence/standard of care in my specialty, Psychiatry)? These requirements even exceed the relatively recent medication reconciliation forms used in our (Edmonton) hospitals.
Please reconsider this standard. Was the Alberta Pharmacist's Association consulted with respect to what they would find most helpful?
The processes are adding work and expectations on clinical providers in the context of limited time. There is also the assumption that these practices will in fact create a meaningful clinical care improvement. Considering the added burden that these processes would create, I feel that these must first be studied in a real world scenario with actual clinical improvement endpoints while also examining the overall healthcare practice burden. In the age of evidence based medicine, we should also make sure that our standards are based on sound evidence as this affects the care of our community. If the information is available, I suggest releasing the information as part of the consultation process. The other question that would be important to examine is if there is evidence that the current method is in fact broken and needs adjustment as the release of this information would also be beneficial to those giving input. In my opinion, Netcare/PIN is a great tool that gives providers the ability to augment their care in the proper clinical setting. Making it mandatory may not always give added value and potentially subtracts from the time for more pertinent care activities.
Agree with all the comments below about the excessive time that would be lost due to this policy.
What if the patient does not want the indication on their prescription (for chlamydia, for schizophrenia, etc)? Do we choose violating College policy or breaching confidentiality? I think the policy would take the back seat on that one.
What if the patient is from out of province. Are we then not allowed to fill the Rx until a chart transfer has come in from another province (to meet the review criteria and possibly to meet the indication criteria). What if they are from out of country?
What if the patient doesn't know why they are on the medication? Hardly uncommon in certain demographics. Will the pharmacies be empowered to reject the prescription, pending clarification from a chart transfer that could take weeks to come? Not everything is on netcare.
Suggestion - Indications are a nice thought but can't be mandatory. Can be a suggested, although I suspect then it just won't happen.
In a health care system that becomes more and more inefficient, with more and more paper work and less patient care I do feel that this type of micro management will create more and more frustration for physicians and especially family physicians. The demands that are suggested by administrators are most of the time unrealistic and just again proof how out of touch they are with reality. We are all striving to provide excellent care to our patients so please respect that.
I have several serious concerns about the the liberal use of the word MUST in the draft standard, and the severe disconnect between these mandatory requirements and a physician's work reality.
Why would we be required to explain the rationale for dosage changes to pharmacists? Isn't documenting it in our own charts sufficient. Isn't pharmacists main role to dispense the medication we prescribe? While I think this is a nice idea to give a rationale, I don't think it is practical as it would require excessive time out of the prescribing physician's day to write a note for every change that could "represent a material change" in the patient's care. I also do not believe it is in any way essential to a physician's job to fully understand the rationale for a dosage change or addition of a medication (e.g. I should not be required to write a note to the pharmacist "I'm adding a diuretic to this patient's ARB for uncontrolled hypertension". Certainly such a change could represent a "material change" in the patient's care, but the pharmacist does not need to know that.)
It seems unreasonable to require an indication for use on every medication and would require a lot of additional work on the part of the prescribing physician within the context of our current EMRs. Furthermore, this is complicated by the fact that some medications may be used for more than one condition. Would it be required then for every indication to be listed for a given medication? While it would certainly be helpful for physicians who see patients for periodic care to know why something was prescribed I just cannot see how it is practical given our work environment's time and technological constraints.
I don't believe mandatory review of EVERY patient's Netcare PIN record should be required. It would require checking of Netcare for every healthy child or teenager that presents to urgent care or the emergency department or walk in clinic for a cold or flu or otalgia. Practically this means many trees would die for PIN printouts that include no medications. It would slow down the process of caring for straightforward patient complaints and ultimately increase waiting times to some extent.
I am concerned that the requirement to consult PIN for ANY prescription casts too wide a net. I certainly support the opiate prescribing portion. Part of my concern is that the PIN outputs are not necessarily easy to scan quickly, and some prescriptions are not of any substantial risk for either abuse/addiction or substantial drug-drug interaction.
It would seem by reading the comments that this standard need to be taken back to the drawing board. I would be very nice to see that this consultation process actually makes a difference and the college considers the input on this page rather than just making this the standard.
I do not think it is reasonable to put the indications for use of each and every agent the patient is taking on their prescription pad. This is unnecessary and will take up excessive amount of time and space on the prescription. In todays day and age, Netcare is available to check a patient's investigative reports, hospital admission and discharge summaries, etc which gives us quite a bit of information on them. We are also documenting on the patient's chart the diagnoses and putting in billing codes as well. Pharmacies also carry out medical reviews where they produce reports listing the patient's diagnoses and medications. Therefore putting in the "indication for use" after each medication is a redundant and wasteful service for physicians to perform on each prescription pad as there is already so much documentation we and other members of the health care team perform.
The safe prescribing draft seems to be solving an issue that I don't really have, and none of my patients had.
I see a lot of 'episodic' patients, who would now require Netcare check with every visit and I would therefore probably be justified to use a Complex Modifier with each of those episodic patients. Netcare is problematic to access at the best of times, and the letter writing (when changing dosages) will also add to the time being spend on patients).
Personally I think healthcare money could be spend better, especially under the current economic times.
Ps. I do like the fact that some attention is being given to concerns, for me, as a family physician - see: 'Physician Responsibility'.
Has the requirement to include the 'indication' on the prescription been vetted by the Office of the Privacy Commissioner?
Will you be enlarging the already-cumbersome TPP prescriptions to allow for space for indications? I already use all the space available to specify detailed safeguard instructions.
A regulated member must obtain access to the provincial Pharmaceutical Information
5) A regulated member must review a patient’s PIN/Netcare profile:
a) at intervals commensurate with the patient’s condition; or
b) at every visit, if providing episodic care.
seems ridiculous to me. It is seriously out of touch with reality. If I checked Netcare at every visit for every patient to whom I provide episodic care, since I am providing typical episodic care of family practice, I would have to add an hour and a half or more onto my day given the amount of time it takes to log on to NetCare, review documents, etc.
I do not understand the necessity for checking into NetCare at every visit for patients whom I know well and have been following for weeks months or years. Logging into NetCare is a cumbersome and time-consuming process.
I fear that, if this draft becomes a minimal professional standard as written, many primary care physicians will be in breach and at risk for disciplinary action by the college.
Others have already commented on the difficulties surrounding access to PIN and the limitations of existing EMRs (Items 4-6 and 8).
The LTOT section also presents significant concerns. I have not initiated LTOT recently as far as I can recall but have a number of patients in my practice who have been on LTOT for many years, largely with stable doses. The statement in 9h that prescribing LTOT should continue only if pain and/or function are measurably improved is short-sighted - the aim in most instances is a maintenance of function. Perhaps minimum clinical standards in terms of province-wide "third-next-available" for chronic pain programmes should be implemented alongside this prescribing standard, in addition to making chronic pain programmes physically easier to access for those who need them (i.e. patients in chronic pain who have mobility limitations).
These regulations will make each encounter with these already needy and time consuming patients even longer. This may also lead more doctors to stop providing care to this group of patients. Does the pain clinics have the capacity to take them back? This may also push the burden of prescribing all kinds of medications back to the family docs as specialist could suggest the treatment, but not actually prescribe iT. There seems to be a lot of changes in this one standard. Maybe a slower and gradual introduction would be easier to conform to.
Regarding item #3 "A regulated member changing the dosage or quantity of a patient’s medication must document the rationale for the change and, when the change represents a material difference in the patient’s care, communicate the change and the rationale behind it to the patient’s pharmacist and other relevant members of the patient’s care team." - Here I am unclear as to what is expected with respect to the pharmacist? Does that mean we have to constantly justify on the prescription pads in writing to the pharmacist why we changed the previous dose of ongoing medication or why we discontinued the previous medication (because a better one is on the market)? For example if a patient is on two glaucoma medications (drops) and I do surgery that improves glaucoma and I tell the patient to stop one of his drops because he no longer requires it , I now have to contact his/her pharmacist too and let them know? Patients often frequent different pharmacies at their convenience, I certainly do. How will that be even possible?
Another scenario: I have chronic patients on steroids for autoimmune conditions and it sometimes improves after a few months. During the patient regular followup visit in my office I renew their Rx but at a lower dose and tell the patients why etc. Does this new rule then mean that I have to actively try to figure out who all their pharmacists are (patients often do not know themselves and change pharmacies ) and then I have to write a nice letter to the pharmacists (instead of moving on to see the next patient) because it insufficient to tell the patient during the visit? Are we now answerable to pharmacists too? If that is the case we will need very large prescription pads and there will be a lot of faxing every day because chronically ill patients have medications changed very often which may translate into us seeing less patients in a day (reduced access to health care) as we will be too busy explaining things to pharmacists. I think we should drop this pharmacy part from the rule, it could just be a suggestion. Too many rules like this will create too much unnecessary administrative bureaucracy in the system.
I agree with Aaron below that a clinical pharmacist who works as part of a multi-disciplinary team provides a far superior med-review than reviewing on Netcare alone, therefore this should be provided as an alternative to looking on Netcare.
The indication of a prescription is usually not indicated on the Netcare PIN of a patient's drug profile. If we are required to indicate the rational for a certain prescription, then there should be a requirement that this indication is then copied by the pharmacy for information on the PIN.
In principal, not much wrong with suggestions as layed out except that it shoud stay as a suggestion of good practice standards , but not enforcible
I saw many patients with chronic pain. Many were on narcotics . Extensive investigation in most was negative. Most had seen chiropractors naturopath's etc. The family docs had tried all the non narcotics,antidepressants,and many were sent to the pain clinics.who usually rxed narcotics. Acupuncture was also tried by many patients, and it failed. So what is a body to do? WE MUST go through the whole process again? I just reviewed the history of addiction. Do you know it was rampant in Victorian England? Especially in upper class women who were treated for the"vapors"with laudanum? It is said that 1/500 men in the US were also addicted to cocaine before the first world war. Freud prescribed it for depression,and used it himself, and was clearly addicted. Halstead the famous surgeon was hooked on it as well! "Life as we find it, is to hard for us; it brings us too many pains, disappointments and impossible tasks" Sigmund Freud, in Civilization and its Discontents the standard edition of the complete psychological works of Sigmund Freud. Schopenhauer, another great German philosopher, stated that "life is just suffering, a constant struggle in which physical pain and mental anguish are forever present, so much indeed that ones judgments must be that it would be better if nothing ever existed at all!" Perhaps we must accept the fact that some people are just completely unhappy and require a crutch!
Has there been any discussion with AH regarding making Netcare/PIN access easier to obtain? As access is facility based, this creates a hurdle for some physicians trying to obtain Netcare access that they will not have the ability to overcome on their own.
As well, have there been discussions with EMR vendors about providing indication fields that print on the prescriptions? Many if not most EMRs are currently unable to do this well, and so will be difficult for physicians to comply, even if they wish to.
I work in rural Alberta and accessing NetCare is very problematic often unable to get on for days at a time. So what are we to do if we cannot access netcare medprofile? (with regards to prescribing opioids to a new patient or changing their Rx)
In the Emergency Department (and I suspect on other multi disciplinary teams) a clinical pharmacist often provides a best possible medication history, which involves both review of the netcare profile as well as interview with the patient. This medication history is superior to the information obtainable from looking at netcare. Section 5/6 should allow this as an alternative.