CONSULTATION 014

Opioid Agonist Therapy (OAT)

Consultation now closed

Reason for introducing an OAT standard: A new standard is needed to better support physicians in using current, evidence-based guidelines to treat opioid use disorder (OUD) and ensure safe patient care. The language used in the draft also reflects our evolving understanding of OUD and the need to reduce stigma so more Albertans can access this care.

The current clinically-oriented Methadone Maintenance Treatment standard is becoming less relevant as OAT evolves, and will be rescinded once the new OAT standard is approved (likely in spring 2019).

 The College is also streamlining its OAT approval process.

In developing the draft, we worked with medical experts in OUD treatment to create a standard that will:

  • accommodate changes as OAT evolves;
  • identify the education and experience necessary to ensure safe patient care; and
  • align requirements with the type of care being provided (e.g., initiating, maintaining or temporarily prescribing OAT; prescribing injectable OAT or prescribing  methadone for analgesia) 

PLEASE NOTE: For the purpose of this standard, Opioid Agonist Therapy (OAT) refers to full opioid agonist therapies only and excludes the partial agonist/antagonist buprenorphine/naloxone.

Consultation is now closed. However, your feedback will help us improve the draft before it goes to Council in March 2019, and also inform a companion Advice to the Profession document.



“It’s really important to us to hear from physicians if we got this right.”Dr. Monica Weller, CPSA Senior Medical Advisor
 

The profession, stakeholders, other organizations and public members were invited to provide feedback from October 1-November 30, 2018. Council will consider non-nominal feedback when approving final amendments to the standard at its March 2019 meeting. Review the draft OAT standard of practice

All feedback is subject to the College’s Privacy Statement. The College reviews all comments before publication to ensure there is no offensive language, personal attacks or unsubstantiated allegations.

If you have any questions or require further assistance, please contact Chantelle.Dick@cpsa.ab.ca

Comments

After reviewing the draft and reading about the topic, I have noticed it is safe for effective care and having less side effects as compare to Opoids. Based on its properties , it is becoming the drug of choice for suppression of withdrawal symptoms. That will help in rehab and chronic pain syndrome. Even helpful in post op.
analgesia.
Having receptors similar to Morphine, effective in MSK conditions.
Clearance from liver is slow, in pts taking, chemotherapeutic agents or anticonvulsant.
However before reaching to rehab, indications
of treatment with narcotics should be clear for the initial start, it need understanding of disease, pt doctor relationship, comorbidities , follow ups, and bold decisions.
I am very behind trying to learn, but all these program for example ARCH is very effective and I have seen the impact on hospital admissions, and congrulate all those helping the community.

RUKHSANA AMEEN
Clinical associate
30/11/2018
Alberta Physician

Consideration needs to be given to solo/isolated physicians who may have limited access to another prescribing physician in case of practice closure. There are currently prescribing physicians who are already in this position. Does the current wording of the proposed standards mean that their practice is now below standard?

CPSA should set minimum criteria as to what constitutes the transfer of care letter (which must now be copied to the College). Perhaps a template provided as an appendix.

Krishna Balachandra
Addiction Medicine Psychiatrist
27/11/2018
Alberta Physician

The practicing physician , has to have a effective alternative available for pain control other than marihuana, before patients using opioids are going to change present usage. All prescriptions for opioids has to be filled once a week only to reduce the amount of these drugs lying around. It however will put a further burden on for the dispenser but on the other hand will result in the user be more aware of the necessary control over these drugs and its availability.

Ernst Snyman
13/11/2018
Alberta Physician

I have inherited some patients who have been on Opiates and some on Benzodiazepines.
I strive to pursue dose reductions with difficulty. Referral is not easy and some patients resist.
Thankfully I only have a few of these patients. I find them difficult to manage.

Dr Farook N Oosman
Family Physician
09/11/2018
Alberta Physician

I agree with the Draft OAT Standard of Practice Document - Do I require any further Educational requirements regarding OAT with this revised Document being Implemented?

Gregory D van Wyk
Primary care Physician in Correctional Service of Canada Facilities
07/11/2018
Alberta Physician

This is a realm of medicine in which I do not practice so it will have little effect on my practice. However, in section 4 C and D, there is no provision for emergent care of an overdose. If the patient who is on OAT presented to a hospital in an overdose condition from taking either too much methadone or a different narcotic, as these rules are currently written, the treating emergency physician would be not allowed to stop the next scheduled dose of methadone, even if it was going to make the patient worse, without first consulting with the patient's prescribing physician.

Earl Campbell
self employed
07/11/2018
Alberta Physician

OAT and in particular, methadone have become businesses. Patients are kept on them for too long. There needs to be an expectation that patients will be weaned, the longer they’re on these, the higher the chance of overdose death. In particular, those who are prescribing in a correctional facility have the opportunity to wean over most periods of incarceration. On top of that, there must be a duty to ensure that the inmates have their medications transferred. There has to be a plan. These patients often end up being discharged without refills and wind up in withdrawal in the Emergency Department or expecting refills of meds that can’t be refilled from an ED. There is lots of time to have this planned, it shouldn’t become an emergency and there has to be an attempt to get these patients off narcotics. Though it may be an inconvenience for the business people who are profiting from it and not great for their business plan.

Dr. David Wood
Emergency Physician
07/11/2018
Alberta Physician

They seem very appropriate to me. Though I neither prescribe Opiates nor treat Opioid abuse.

Stuart Sanders
Medical Director Community Geriatric Mental Health, Calgary
07/11/2018
Alberta Physician

Upon reviewing this standard of practice for opioid agonist treatment, I am confused as to the definition for opioid agonist treatment. Are we talking primarily about methadone or are we dealing with all opioid agonists prescribed such as oxycodone, hydromorphone, morphine and fentanyl? Because if we are talking all opioids, this will be another significant restriction to physicians' practices in prescribing opioids for pain management.

I am currently dealing with the repercussions of the opioid standard of care and guidelines for chronic noncancer pain. The result of this standard of care is that a number of physicians are refusing to prescribe opioids for chronic non-cancer pain. In addition, patients that we have initiated opioids are no longer being followed by their family physicians and we are now responsible for their follow-up every 3 months as per the standard of care. In my practice, this has consumed the majority of my time resulting in longer wait-lists and my interventional practice becoming restricted.

I would hope that there will be some clarification regarding the definition of opioid agonist treatment and the population this particular standard is addressing. I do appreciate the fact that opioid use disorder is the purpose of the standard but a clear definition of opioid use disorder needs to be made in the standard.

I would agree with other comments that a focus on further education regarding pain management with opioids should be a mission of the College. The limited education received in medical school and residency training on the use of opioids is a major problem for future care. I think what a lot of people in particular physicians fail to appreciate is that the only pain relievers we have are opioid agonists. NSAIDs are great in an acute injury and reducing swelling and inflammation but do not help much with chronic ongoing osteoarthritic (non-cancer) pain. Another important thing to understand is that a pain clinic like HealthPointe struggles trying to manage large volumes of pain patients on opioids requiring increasing resources with no public funding. Majority of new establishing pain clinics are focusing primarily on interventions and less on medication management. So unless more physicians are willing to take on an opioid agonist role, more patients will be going to the street for their pain relievers and unfortunately obtaining pills containing fentanyl/carfentanil versus oxycodone. And we all know this unfortunate outcome.

Jamie Irvine
HealthPointe Medical - Chronic Pain (Physiatrist)
07/11/2018
Alberta Physician

Excellent ideas and standard of practice. One of my concerns is are you going to get enough Family Doctors prepared to take on this extra responsibility this may be problematic in a busy rural practice. A real problem I have encountered in dealing with WCB patients with acute physical injuries is how ready the junior staff in A&E prescribe Tylenol 3 when all the research has shown it is ineffective and this then leaves the family physician having to deal with patients requesting more Tylenol 3 or stronger opioids. I know the College is aware but the college should continue to emphasize alternative modes of treatment to reduce dependence on opioids.

Anthony Lynch
Consultant in Occupational Medicine
07/11/2018
Alberta Physician

What about Targin?

conrad schulte
06/11/2018
Alberta Physician

I echo Dr. David Falk's view of this.
I am uncertain how this will affect me as I don't do addiction medicine but do use opioids and methadone for analgesia.

Marie Moreau
General internist doing oncology and palliation
06/11/2018
Alberta Physician

It would be of great help to provide a list of preceptors, mentors and programs to assist geographically isolated physicians with resources to aid in prescribing OAT. 24/7 on call addiction counselor guiding to available resources and available for physicians and patients who needs access to those resources, for example, via RAAPID NORTH, would also be beneficial.

Islam Elawadly
Rural ER / Family / Hospital medicine
06/11/2018
Alberta Physician

I find it interesting to know that they must be attached to a Pharmacy system like PIN or netcare to prescribe, as this was not the way we have been practicing. But its very important.

As well, we would need to know to know if it goes through as it affects us, in that we must send a letter to the CPSA if a client transfers. Right now we just do it if they discontinue.

It is good that the prescriber in hospital/corrections would have to contact our Doctor/us if they prescribe to one of our clients while they are in their care. As of now we have to find out through the Pharmacy or family members.

I think that Doctors that are prescribing in hospital or in correction facilities should have more than 72 hours to bridge a prescription as it is safer for the client to be properly bridged to a program and that may not happen in 72 hours.

Gwen
AHS
24/10/2018
Other healthcare professional

I must say, I find this draft most confusing from the perspective of who it is addressing. Some places it sounds like any physician who is going to prescribe any opioid, even Tylenol #3, will need a course in OUDs. In other places it sounds like it is addressing only physicians engaged in addiction services using opioids to manage the addiction. And then, at the end, it addresses the use of just one opioid (methadone) for use in analgesia. Which of these three groups of physician prescribers is the draft addressing, or is it addressing all three areas.
If it is addressing any physician prescribing any opioid, then there will be massive re-percussions in the palliative world as we are asking family physicians to follow their terminal patients and prescribe analgesics for them. If these family physicians cannot do this without a course, then my job will be filling one refill after another all day long.

If it is addressing only those who are dealing with addiction issues as in the old methadone maintenance program, then, I can follow the flow of the standard except for the addendum of METHADONE FOR ANALGESIA. Why do we add this to the standard when we are creating a standard addressing ALL opioid agonist therapies? The place of methadone for analgesia should be dealt with separately as the simplicity of the one half page point (6) is not clear enough. Also, if the standard is addressing just this group of prescribers, then it should be stated clearly in the first (1) & (2) points. I had to read down to the middle of the standard before it was clear that the group was being addressed.

If it is addressing the special status of methadone historically, then that requires a whole different approach, in my mind. The sigma of using methadone has come about because of it's "special authorization status". If methadone, and not the other opioid agonists, needs special prescription status, then, that should be a medical competency point, not so much a "standard of practice" point for one drug. Does methadone need a special licensing authorization to be prescribed as an analgesic? This is a question that would be answered depending upon whether ALL opioid agonist prescribers need to take a course, or whether this standard applies only to those in addiction services as I have attempted to outline above. If this course is for ALL opioid agonist prescribers, then include methadone for analgesia in the training. If this standard is for those prescribing for addictions, then there is no need to solely address methadone as it would be included under opioid agonist therapy.

Thanks for letting me share my perspectives on this.

David Falk
palliative care physician in the community
12/10/2018
Alberta Physician

Please Section 2 subsection d (I) and d (II)
initiate OAT for a patient only in an appropriate setting with:
(i) access to medical laboratory services and pharmacy;
(ii) access to at least one other prescriber trained and approved to provide OAT to
ensure continuity of care if the initiating prescriber is absent or suspends their
practice;
Questions - what does access to laboratory service mean- (ability to do urine screen on site or is the ability to collect urine sample and ship to provincial lab sufficient? )
2. Access to at least one subscriber- does the location of another prescriber matter - what if the one other presciber is in a remote/different location?

Uche Nwadike
10/10/2018
Alberta Physician

I do not treat OUD in my practice

Franco Leoni
05/10/2018
Alberta Physician

I think at this time, we should be doing as much as possible to remove barriers that prevent physicians from being involved in OAT and I don’t really see much that removes these barriers. This will make it difficult especially in rural areas.

Brian Knight
05/10/2018
Alberta Physician

The policy is good as far as I am concerned

Elyahu Gilad
Alberta Children's Hospital
04/10/2018
Alberta Physician

I agree but due to practice restrictions not involved.

Johan Jacobus Swart
Lakemed, Chestermere.
04/10/2018
Alberta Physician

Consider removing requirement for letter from palliative or chronic pain doctor to maintain a palliative patient on methadone.

Landon Berger
03/10/2018
Alberta Physician

I agree with above draft OAT standard of practise

Ruchika Swaro
Family Physician, Medicare Clinic, Calgary
03/10/2018
Alberta Physician

The draft looks good. However will there be online courses for rural physicians? More information is needed even to understand the language in the draft ie what is truly opioid misuse disorder. What is an OAT? What do we do with people currently on butrans? I have a patient on methadone x 10 years, It was originally prescribed by a pain specialist and I obtained a limited license for this one patient. What now do I need to do?
I have had people come to the ER withdrawing from narcotics wanting OAT ? What is the process now? Who can we send this people to?
Lots more education needed.
I feel like this is just one more area where it is hard to keep up but have patients on meds and how do I now meet standards of care?

Katherine Sorenson
02/10/2018
Alberta Physician

I am going to make my comments simple - this is an incredibly restrictive standard that will actually see a decrease in OAT prescribers during a time of crisis. AH, PCN's and everyone else is pushing for opening up Suboxone prescribing and increasing prescribers to aid in the issue of increasing opioid deaths, with this standard in place that job will become almost impossible. This is going to decrease access to OAT and increase opioid deaths.

Brad Bahler
SMD Primary Health Care Integration Network, SMD Provincial Primary Care Networks, Chair Primary Care Alliance, Physician Sylvan Lake AB
02/10/2018
Alberta Physician

Seems reasonable to me
However there should be much effort to get patients off narcotics unless absolutely indicated

Michael Nutting
02/10/2018
Alberta Physician

Not all patients dependent on opioids meet DSM-V criteria for opioid use disorder. A patient who is dependent on opioids, experiences withdrawal when dose is reduced or when abstinent is also in need of opioid agonist therapy, partial agonist therapy, or medically supervised gradual weaning.

Colleen Carey
02/10/2018
Alberta Physician

It seems to be a great step .

Ahmed HamoudAli
Paediatric medical clinic
02/10/2018
Alberta Physician

# 6 (c) recommends that "if maintaining methadone for analgesia for a patient, (physicians must) provide the CPSA with a letter of support from a palliative care or chronic pain specialist, as applicable." I think that if a patient is started on Methadone by a specialist and is then referred back to his general practitioner, this should be enough for the generalist to continue prescribing the Methadone without obtaining or sending further documentation to the CPSA.
I was encouraged to note that these fairly restrictive guidelines do not include the prescribing of partial agonists such as Suboxone. The prescribing and de prescribing of opioids (and OAT) is not the favourite part of most family practitioners and some tend to refuse to see patients with chronic pain or opioid use or abuse disorders. These patients often float around and have trouble finding a family doctor willing to take them on. I hope to see more support for and encouragement of family doctors willing to engage with these challenging patients.

Donna Klay
Devon Medical Clinic
02/10/2018
Alberta Physician

I agree with the draft

Amaresh Swaro
Family physician
02/10/2018
Alberta Physician

This standard should be fine and safe, as long as the associated courses and certifications are easily accessible in terms of time, fees and availability for physicians who are likely to need the use of the skills, as OUD appears to be a major and ubiquitous problem..

Neil Heard
Physician
02/10/2018
Alberta Physician

An example on another further encroachment into the practise of medicine. The CDC data which created their guidelines is increasingly being shown to be incorrect. Current opioid deaths are not occurring in regularly followed chronic pain patients in any significantly. Patient advocacy groups have presented evidence of patient harm directly caused by CPSA policy interpretation by doctors. This document contains a requirement for all physicians, including RCPS CERTIFIED Doctors such as myself to retrain. I oppose this proposed CPSA action. If instituted it will require a legal challenge to determine if the value of this action is of sufficient need to justify tha harm to pain patients as reported by pain patient advocacy groups. What is required is a dramatic increase in services available to pain patients not another police action by CPSA.

Gaylord Wardell
Medical Director
02/10/2018
Alberta Physician

The standard appears reasonable for the most part.

One part is a bit fuzzy: (2) (c) maintain competence in OAT ... what does this entail? How many hours over 5 years? Can it be self-study? To the extent that this requirement becomes onerous, this would then be a "cost of doing business" as an initiator and would have to be factored into each person's cost:benefit equation to see whether this is worthwhile to them. To those specializing in the area, this might not matter much. For those who are "trying to pitch in" and take on OAT duties as a peripheral area of interest, this might constitute a barrier.

Also, for those of us who deal with OAT in a "high turnover" patient population (e.g. corrections), we usually have institutional support (e.g. nursing and pharmacy) to help bridge the patients to a community clinic (e.g. Boyle McCauley or MetroCity). Having to provide a "letter of support" and associated paperwork as per (2) (e) would seem to be less applicable and administratively burdensome.

Another difficulty is the codified 72 hour Rx length noted in (4) (a) ... when these patients are discharged to remote locations (hard to find prescribers) or during holiday periods, 72 hours can be a tight timeline. In the past, I have had pregnant patients on methadone or suboxone discharged from jail for whom I needed to provide bridge Rx (no carries, DOT only) for up to 2 weeks. I would no longer be able to do this if the directive as written is implemented.

Thanks for your consideration.

Dave Lounsbury
Correctional Physician (provincial and federal)
02/10/2018
Alberta Physician

I support the proposed document as it is, except, the potential area of gap that may require attention. This has been increasingly recognized the past several years that the patients with advanced cancer are increasingly living longer, with longer duration of symptom of pain and suffering. Some of them, may have unfortunately exposed to very high dose opioid therapy when diagnosed with cancer esp. AYA population, who went through extensive surgeries, bone marrow transplants, etc. or those who have underlined borderline personality disorder/bipolar disorder (or even with severe PTSD) who learned to cope with opioid analgesia for their psychological distress while also experiencing cancer associated phsyical pain syndrome or sometimes already on Methadone maintenance therapy (MMT) already.

Also the definition of palliative care has been changing and increasingly palliative care practitioners are seeing patients who are no yet facing life threatening illness though they do have potential life limiting illness, while experiencing severe symptoms for longer duration that we typically encountered previously (often less than three months of life expectancy).

I practice as a palliative care consultant, and have experienced occasions where patients with MMT was discharged from MMT clinic despite patients have many months or beyond years of prognosis, or patients with problematic behaviours related opioid taking and use unstable dose of very high dose of non-methadone full opioid agonists. As a palliative care physician, I do provide methadone for analgesics, however, some patients do require MMT than analgesics. Although I have taken the MMT course number of years ago in U of C, and taken the online buprenorphine assisted treatment course already, I would not be able to maintain the number of experience in full license for MMT/buprenorphine assisted treatment due to the nature of practice.

For very difficult cases, I have consulted Dr. Weller and found very helpful, however, wish to see some comment on patients/population who may require co-management between MMT and analgesics until such time when a new practice guideline for those population available. JAMA September 4, 2018 Volume 320, Number 9 871-872 well-summarizes the same concern that I have been experiencing.

Yoko Tarumi
Clinical Professor, Division of Palliative Care Medicine, Department of Oncology, UofA/ Symptom Control and Palliative Care, Cross Cancer Institute
02/10/2018
Alberta Physician

Disappointed to see the new standard requires specific completion of a program about addiction without a complementary program of the place of opioids in pain control, maybe with a transition document about changes in the thoughts of regulators from the past decades of encouragement for physicians to more adequately treat disabling pain, to the more recent emphasis on the toxic effects of opioids in the context of of treating pain.

My now limited practice part-time in a community cancer centre has reduced my opioid prescribing from the past many years. Will I be able to participate in a CPSA approval program online?

D Neil Graham
High River Community Cancer Centre
02/10/2018
Alberta Physician

This is a clear standard and allows for changes in Clinical practice guidelines as they develop to address the " opioid crisis". I wonder if it needs to be clear what exactly is replacement therapy: includes methadone but does this also include use of other prescription narcotics as replacement? I am assuming that it does but this is not clear.

Janet Wright
BMHC
02/10/2018
Alberta Physician

After reviewing the draft and reading about the topic, I have noticed it is safe for effective care and having less side effects as compare to Opoids. Based on its properties , it is becoming the drug of choice for suppression of withdrawal symptoms. That will help in rehab and chronic pain syndrome. Even helpful in post op.
analgesia.
Having receptors similar to Morphine, effective in MSK conditions.
Clearance from liver is slow, in pts taking, chemotherapeutic agents or anticonvulsant.
However before reaching to rehab, indications
of treatment with narcotics should be clear for the initial start, it need understanding of disease, pt doctor relationship, comorbidities , follow ups, and bold decisions.
I am very behind trying to learn, but all these program for example ARCH is very effective and I have seen the impact on hospital admissions, and congrulate all those helping the community.

RUKHSANA AMEEN
Clinical associate
30/11/2018
Alberta Physician

Consideration needs to be given to solo/isolated physicians who may have limited access to another prescribing physician in case of practice closure. There are currently prescribing physicians who are already in this position. Does the current wording of the proposed standards mean that their practice is now below standard?

CPSA should set minimum criteria as to what constitutes the transfer of care letter (which must now be copied to the College). Perhaps a template provided as an appendix.

Krishna Balachandra
Addiction Medicine Psychiatrist
27/11/2018
Alberta Physician

The practicing physician , has to have a effective alternative available for pain control other than marihuana, before patients using opioids are going to change present usage. All prescriptions for opioids has to be filled once a week only to reduce the amount of these drugs lying around. It however will put a further burden on for the dispenser but on the other hand will result in the user be more aware of the necessary control over these drugs and its availability.

Ernst Snyman
13/11/2018
Alberta Physician

I have inherited some patients who have been on Opiates and some on Benzodiazepines.
I strive to pursue dose reductions with difficulty. Referral is not easy and some patients resist.
Thankfully I only have a few of these patients. I find them difficult to manage.

Dr Farook N Oosman
Family Physician
09/11/2018
Alberta Physician

I agree with the Draft OAT Standard of Practice Document - Do I require any further Educational requirements regarding OAT with this revised Document being Implemented?

Gregory D van Wyk
Primary care Physician in Correctional Service of Canada Facilities
07/11/2018
Alberta Physician

This is a realm of medicine in which I do not practice so it will have little effect on my practice. However, in section 4 C and D, there is no provision for emergent care of an overdose. If the patient who is on OAT presented to a hospital in an overdose condition from taking either too much methadone or a different narcotic, as these rules are currently written, the treating emergency physician would be not allowed to stop the next scheduled dose of methadone, even if it was going to make the patient worse, without first consulting with the patient's prescribing physician.

Earl Campbell
self employed
07/11/2018
Alberta Physician

OAT and in particular, methadone have become businesses. Patients are kept on them for too long. There needs to be an expectation that patients will be weaned, the longer they’re on these, the higher the chance of overdose death. In particular, those who are prescribing in a correctional facility have the opportunity to wean over most periods of incarceration. On top of that, there must be a duty to ensure that the inmates have their medications transferred. There has to be a plan. These patients often end up being discharged without refills and wind up in withdrawal in the Emergency Department or expecting refills of meds that can’t be refilled from an ED. There is lots of time to have this planned, it shouldn’t become an emergency and there has to be an attempt to get these patients off narcotics. Though it may be an inconvenience for the business people who are profiting from it and not great for their business plan.

Dr. David Wood
Emergency Physician
07/11/2018
Alberta Physician

They seem very appropriate to me. Though I neither prescribe Opiates nor treat Opioid abuse.

Stuart Sanders
Medical Director Community Geriatric Mental Health, Calgary
07/11/2018
Alberta Physician

Upon reviewing this standard of practice for opioid agonist treatment, I am confused as to the definition for opioid agonist treatment. Are we talking primarily about methadone or are we dealing with all opioid agonists prescribed such as oxycodone, hydromorphone, morphine and fentanyl? Because if we are talking all opioids, this will be another significant restriction to physicians' practices in prescribing opioids for pain management.

I am currently dealing with the repercussions of the opioid standard of care and guidelines for chronic noncancer pain. The result of this standard of care is that a number of physicians are refusing to prescribe opioids for chronic non-cancer pain. In addition, patients that we have initiated opioids are no longer being followed by their family physicians and we are now responsible for their follow-up every 3 months as per the standard of care. In my practice, this has consumed the majority of my time resulting in longer wait-lists and my interventional practice becoming restricted.

I would hope that there will be some clarification regarding the definition of opioid agonist treatment and the population this particular standard is addressing. I do appreciate the fact that opioid use disorder is the purpose of the standard but a clear definition of opioid use disorder needs to be made in the standard.

I would agree with other comments that a focus on further education regarding pain management with opioids should be a mission of the College. The limited education received in medical school and residency training on the use of opioids is a major problem for future care. I think what a lot of people in particular physicians fail to appreciate is that the only pain relievers we have are opioid agonists. NSAIDs are great in an acute injury and reducing swelling and inflammation but do not help much with chronic ongoing osteoarthritic (non-cancer) pain. Another important thing to understand is that a pain clinic like HealthPointe struggles trying to manage large volumes of pain patients on opioids requiring increasing resources with no public funding. Majority of new establishing pain clinics are focusing primarily on interventions and less on medication management. So unless more physicians are willing to take on an opioid agonist role, more patients will be going to the street for their pain relievers and unfortunately obtaining pills containing fentanyl/carfentanil versus oxycodone. And we all know this unfortunate outcome.

Jamie Irvine
HealthPointe Medical - Chronic Pain (Physiatrist)
07/11/2018
Alberta Physician

Excellent ideas and standard of practice. One of my concerns is are you going to get enough Family Doctors prepared to take on this extra responsibility this may be problematic in a busy rural practice. A real problem I have encountered in dealing with WCB patients with acute physical injuries is how ready the junior staff in A&E prescribe Tylenol 3 when all the research has shown it is ineffective and this then leaves the family physician having to deal with patients requesting more Tylenol 3 or stronger opioids. I know the College is aware but the college should continue to emphasize alternative modes of treatment to reduce dependence on opioids.

Anthony Lynch
Consultant in Occupational Medicine
07/11/2018
Alberta Physician

What about Targin?

conrad schulte
06/11/2018
Alberta Physician

I echo Dr. David Falk's view of this.
I am uncertain how this will affect me as I don't do addiction medicine but do use opioids and methadone for analgesia.

Marie Moreau
General internist doing oncology and palliation
06/11/2018
Alberta Physician

It would be of great help to provide a list of preceptors, mentors and programs to assist geographically isolated physicians with resources to aid in prescribing OAT. 24/7 on call addiction counselor guiding to available resources and available for physicians and patients who needs access to those resources, for example, via RAAPID NORTH, would also be beneficial.

Islam Elawadly
Rural ER / Family / Hospital medicine
06/11/2018
Alberta Physician

I find it interesting to know that they must be attached to a Pharmacy system like PIN or netcare to prescribe, as this was not the way we have been practicing. But its very important.

As well, we would need to know to know if it goes through as it affects us, in that we must send a letter to the CPSA if a client transfers. Right now we just do it if they discontinue.

It is good that the prescriber in hospital/corrections would have to contact our Doctor/us if they prescribe to one of our clients while they are in their care. As of now we have to find out through the Pharmacy or family members.

I think that Doctors that are prescribing in hospital or in correction facilities should have more than 72 hours to bridge a prescription as it is safer for the client to be properly bridged to a program and that may not happen in 72 hours.

Gwen
AHS
24/10/2018
Other healthcare professional

I must say, I find this draft most confusing from the perspective of who it is addressing. Some places it sounds like any physician who is going to prescribe any opioid, even Tylenol #3, will need a course in OUDs. In other places it sounds like it is addressing only physicians engaged in addiction services using opioids to manage the addiction. And then, at the end, it addresses the use of just one opioid (methadone) for use in analgesia. Which of these three groups of physician prescribers is the draft addressing, or is it addressing all three areas.
If it is addressing any physician prescribing any opioid, then there will be massive re-percussions in the palliative world as we are asking family physicians to follow their terminal patients and prescribe analgesics for them. If these family physicians cannot do this without a course, then my job will be filling one refill after another all day long.

If it is addressing only those who are dealing with addiction issues as in the old methadone maintenance program, then, I can follow the flow of the standard except for the addendum of METHADONE FOR ANALGESIA. Why do we add this to the standard when we are creating a standard addressing ALL opioid agonist therapies? The place of methadone for analgesia should be dealt with separately as the simplicity of the one half page point (6) is not clear enough. Also, if the standard is addressing just this group of prescribers, then it should be stated clearly in the first (1) & (2) points. I had to read down to the middle of the standard before it was clear that the group was being addressed.

If it is addressing the special status of methadone historically, then that requires a whole different approach, in my mind. The sigma of using methadone has come about because of it's "special authorization status". If methadone, and not the other opioid agonists, needs special prescription status, then, that should be a medical competency point, not so much a "standard of practice" point for one drug. Does methadone need a special licensing authorization to be prescribed as an analgesic? This is a question that would be answered depending upon whether ALL opioid agonist prescribers need to take a course, or whether this standard applies only to those in addiction services as I have attempted to outline above. If this course is for ALL opioid agonist prescribers, then include methadone for analgesia in the training. If this standard is for those prescribing for addictions, then there is no need to solely address methadone as it would be included under opioid agonist therapy.

Thanks for letting me share my perspectives on this.

David Falk
palliative care physician in the community
12/10/2018
Alberta Physician

Please Section 2 subsection d (I) and d (II)
initiate OAT for a patient only in an appropriate setting with:
(i) access to medical laboratory services and pharmacy;
(ii) access to at least one other prescriber trained and approved to provide OAT to
ensure continuity of care if the initiating prescriber is absent or suspends their
practice;
Questions - what does access to laboratory service mean- (ability to do urine screen on site or is the ability to collect urine sample and ship to provincial lab sufficient? )
2. Access to at least one subscriber- does the location of another prescriber matter - what if the one other presciber is in a remote/different location?

Uche Nwadike
10/10/2018
Alberta Physician

I do not treat OUD in my practice

Franco Leoni
05/10/2018
Alberta Physician

I think at this time, we should be doing as much as possible to remove barriers that prevent physicians from being involved in OAT and I don’t really see much that removes these barriers. This will make it difficult especially in rural areas.

Brian Knight
05/10/2018
Alberta Physician

The policy is good as far as I am concerned

Elyahu Gilad
Alberta Children's Hospital
04/10/2018
Alberta Physician

I agree but due to practice restrictions not involved.

Johan Jacobus Swart
Lakemed, Chestermere.
04/10/2018
Alberta Physician

Consider removing requirement for letter from palliative or chronic pain doctor to maintain a palliative patient on methadone.

Landon Berger
03/10/2018
Alberta Physician

I agree with above draft OAT standard of practise

Ruchika Swaro
Family Physician, Medicare Clinic, Calgary
03/10/2018
Alberta Physician

The draft looks good. However will there be online courses for rural physicians? More information is needed even to understand the language in the draft ie what is truly opioid misuse disorder. What is an OAT? What do we do with people currently on butrans? I have a patient on methadone x 10 years, It was originally prescribed by a pain specialist and I obtained a limited license for this one patient. What now do I need to do?
I have had people come to the ER withdrawing from narcotics wanting OAT ? What is the process now? Who can we send this people to?
Lots more education needed.
I feel like this is just one more area where it is hard to keep up but have patients on meds and how do I now meet standards of care?

Katherine Sorenson
02/10/2018
Alberta Physician

I am going to make my comments simple - this is an incredibly restrictive standard that will actually see a decrease in OAT prescribers during a time of crisis. AH, PCN's and everyone else is pushing for opening up Suboxone prescribing and increasing prescribers to aid in the issue of increasing opioid deaths, with this standard in place that job will become almost impossible. This is going to decrease access to OAT and increase opioid deaths.

Brad Bahler
SMD Primary Health Care Integration Network, SMD Provincial Primary Care Networks, Chair Primary Care Alliance, Physician Sylvan Lake AB
02/10/2018
Alberta Physician

Seems reasonable to me
However there should be much effort to get patients off narcotics unless absolutely indicated

Michael Nutting
02/10/2018
Alberta Physician

Not all patients dependent on opioids meet DSM-V criteria for opioid use disorder. A patient who is dependent on opioids, experiences withdrawal when dose is reduced or when abstinent is also in need of opioid agonist therapy, partial agonist therapy, or medically supervised gradual weaning.

Colleen Carey
02/10/2018
Alberta Physician

It seems to be a great step .

Ahmed HamoudAli
Paediatric medical clinic
02/10/2018
Alberta Physician

# 6 (c) recommends that "if maintaining methadone for analgesia for a patient, (physicians must) provide the CPSA with a letter of support from a palliative care or chronic pain specialist, as applicable." I think that if a patient is started on Methadone by a specialist and is then referred back to his general practitioner, this should be enough for the generalist to continue prescribing the Methadone without obtaining or sending further documentation to the CPSA.
I was encouraged to note that these fairly restrictive guidelines do not include the prescribing of partial agonists such as Suboxone. The prescribing and de prescribing of opioids (and OAT) is not the favourite part of most family practitioners and some tend to refuse to see patients with chronic pain or opioid use or abuse disorders. These patients often float around and have trouble finding a family doctor willing to take them on. I hope to see more support for and encouragement of family doctors willing to engage with these challenging patients.

Donna Klay
Devon Medical Clinic
02/10/2018
Alberta Physician

I agree with the draft

Amaresh Swaro
Family physician
02/10/2018
Alberta Physician

This standard should be fine and safe, as long as the associated courses and certifications are easily accessible in terms of time, fees and availability for physicians who are likely to need the use of the skills, as OUD appears to be a major and ubiquitous problem..

Neil Heard
Physician
02/10/2018
Alberta Physician

An example on another further encroachment into the practise of medicine. The CDC data which created their guidelines is increasingly being shown to be incorrect. Current opioid deaths are not occurring in regularly followed chronic pain patients in any significantly. Patient advocacy groups have presented evidence of patient harm directly caused by CPSA policy interpretation by doctors. This document contains a requirement for all physicians, including RCPS CERTIFIED Doctors such as myself to retrain. I oppose this proposed CPSA action. If instituted it will require a legal challenge to determine if the value of this action is of sufficient need to justify tha harm to pain patients as reported by pain patient advocacy groups. What is required is a dramatic increase in services available to pain patients not another police action by CPSA.

Gaylord Wardell
Medical Director
02/10/2018
Alberta Physician

The standard appears reasonable for the most part.

One part is a bit fuzzy: (2) (c) maintain competence in OAT ... what does this entail? How many hours over 5 years? Can it be self-study? To the extent that this requirement becomes onerous, this would then be a "cost of doing business" as an initiator and would have to be factored into each person's cost:benefit equation to see whether this is worthwhile to them. To those specializing in the area, this might not matter much. For those who are "trying to pitch in" and take on OAT duties as a peripheral area of interest, this might constitute a barrier.

Also, for those of us who deal with OAT in a "high turnover" patient population (e.g. corrections), we usually have institutional support (e.g. nursing and pharmacy) to help bridge the patients to a community clinic (e.g. Boyle McCauley or MetroCity). Having to provide a "letter of support" and associated paperwork as per (2) (e) would seem to be less applicable and administratively burdensome.

Another difficulty is the codified 72 hour Rx length noted in (4) (a) ... when these patients are discharged to remote locations (hard to find prescribers) or during holiday periods, 72 hours can be a tight timeline. In the past, I have had pregnant patients on methadone or suboxone discharged from jail for whom I needed to provide bridge Rx (no carries, DOT only) for up to 2 weeks. I would no longer be able to do this if the directive as written is implemented.

Thanks for your consideration.

Dave Lounsbury
Correctional Physician (provincial and federal)
02/10/2018
Alberta Physician

I support the proposed document as it is, except, the potential area of gap that may require attention. This has been increasingly recognized the past several years that the patients with advanced cancer are increasingly living longer, with longer duration of symptom of pain and suffering. Some of them, may have unfortunately exposed to very high dose opioid therapy when diagnosed with cancer esp. AYA population, who went through extensive surgeries, bone marrow transplants, etc. or those who have underlined borderline personality disorder/bipolar disorder (or even with severe PTSD) who learned to cope with opioid analgesia for their psychological distress while also experiencing cancer associated phsyical pain syndrome or sometimes already on Methadone maintenance therapy (MMT) already.

Also the definition of palliative care has been changing and increasingly palliative care practitioners are seeing patients who are no yet facing life threatening illness though they do have potential life limiting illness, while experiencing severe symptoms for longer duration that we typically encountered previously (often less than three months of life expectancy).

I practice as a palliative care consultant, and have experienced occasions where patients with MMT was discharged from MMT clinic despite patients have many months or beyond years of prognosis, or patients with problematic behaviours related opioid taking and use unstable dose of very high dose of non-methadone full opioid agonists. As a palliative care physician, I do provide methadone for analgesics, however, some patients do require MMT than analgesics. Although I have taken the MMT course number of years ago in U of C, and taken the online buprenorphine assisted treatment course already, I would not be able to maintain the number of experience in full license for MMT/buprenorphine assisted treatment due to the nature of practice.

For very difficult cases, I have consulted Dr. Weller and found very helpful, however, wish to see some comment on patients/population who may require co-management between MMT and analgesics until such time when a new practice guideline for those population available. JAMA September 4, 2018 Volume 320, Number 9 871-872 well-summarizes the same concern that I have been experiencing.

Yoko Tarumi
Clinical Professor, Division of Palliative Care Medicine, Department of Oncology, UofA/ Symptom Control and Palliative Care, Cross Cancer Institute
02/10/2018
Alberta Physician

Disappointed to see the new standard requires specific completion of a program about addiction without a complementary program of the place of opioids in pain control, maybe with a transition document about changes in the thoughts of regulators from the past decades of encouragement for physicians to more adequately treat disabling pain, to the more recent emphasis on the toxic effects of opioids in the context of of treating pain.

My now limited practice part-time in a community cancer centre has reduced my opioid prescribing from the past many years. Will I be able to participate in a CPSA approval program online?

D Neil Graham
High River Community Cancer Centre
02/10/2018
Alberta Physician

This is a clear standard and allows for changes in Clinical practice guidelines as they develop to address the " opioid crisis". I wonder if it needs to be clear what exactly is replacement therapy: includes methadone but does this also include use of other prescription narcotics as replacement? I am assuming that it does but this is not clear.

Janet Wright
BMHC
02/10/2018
Alberta Physician

After reviewing the draft and reading about the topic, I have noticed it is safe for effective care and having less side effects as compare to Opoids. Based on its properties , it is becoming the drug of choice for suppression of withdrawal symptoms. That will help in rehab and chronic pain syndrome. Even helpful in post op.
analgesia.
Having receptors similar to Morphine, effective in MSK conditions.
Clearance from liver is slow, in pts taking, chemotherapeutic agents or anticonvulsant.
However before reaching to rehab, indications
of treatment with narcotics should be clear for the initial start, it need understanding of disease, pt doctor relationship, comorbidities , follow ups, and bold decisions.
I am very behind trying to learn, but all these program for example ARCH is very effective and I have seen the impact on hospital admissions, and congrulate all those helping the community.

RUKHSANA AMEEN
Clinical associate
30/11/2018
Alberta Physician

Consideration needs to be given to solo/isolated physicians who may have limited access to another prescribing physician in case of practice closure. There are currently prescribing physicians who are already in this position. Does the current wording of the proposed standards mean that their practice is now below standard?

CPSA should set minimum criteria as to what constitutes the transfer of care letter (which must now be copied to the College). Perhaps a template provided as an appendix.

Krishna Balachandra
Addiction Medicine Psychiatrist
27/11/2018
Alberta Physician

The practicing physician , has to have a effective alternative available for pain control other than marihuana, before patients using opioids are going to change present usage. All prescriptions for opioids has to be filled once a week only to reduce the amount of these drugs lying around. It however will put a further burden on for the dispenser but on the other hand will result in the user be more aware of the necessary control over these drugs and its availability.

Ernst Snyman
13/11/2018
Alberta Physician

I have inherited some patients who have been on Opiates and some on Benzodiazepines.
I strive to pursue dose reductions with difficulty. Referral is not easy and some patients resist.
Thankfully I only have a few of these patients. I find them difficult to manage.

Dr Farook N Oosman
Family Physician
09/11/2018
Alberta Physician

I agree with the Draft OAT Standard of Practice Document - Do I require any further Educational requirements regarding OAT with this revised Document being Implemented?

Gregory D van Wyk
Primary care Physician in Correctional Service of Canada Facilities
07/11/2018
Alberta Physician

This is a realm of medicine in which I do not practice so it will have little effect on my practice. However, in section 4 C and D, there is no provision for emergent care of an overdose. If the patient who is on OAT presented to a hospital in an overdose condition from taking either too much methadone or a different narcotic, as these rules are currently written, the treating emergency physician would be not allowed to stop the next scheduled dose of methadone, even if it was going to make the patient worse, without first consulting with the patient's prescribing physician.

Earl Campbell
self employed
07/11/2018
Alberta Physician

OAT and in particular, methadone have become businesses. Patients are kept on them for too long. There needs to be an expectation that patients will be weaned, the longer they’re on these, the higher the chance of overdose death. In particular, those who are prescribing in a correctional facility have the opportunity to wean over most periods of incarceration. On top of that, there must be a duty to ensure that the inmates have their medications transferred. There has to be a plan. These patients often end up being discharged without refills and wind up in withdrawal in the Emergency Department or expecting refills of meds that can’t be refilled from an ED. There is lots of time to have this planned, it shouldn’t become an emergency and there has to be an attempt to get these patients off narcotics. Though it may be an inconvenience for the business people who are profiting from it and not great for their business plan.

Dr. David Wood
Emergency Physician
07/11/2018
Alberta Physician

They seem very appropriate to me. Though I neither prescribe Opiates nor treat Opioid abuse.

Stuart Sanders
Medical Director Community Geriatric Mental Health, Calgary
07/11/2018
Alberta Physician

Upon reviewing this standard of practice for opioid agonist treatment, I am confused as to the definition for opioid agonist treatment. Are we talking primarily about methadone or are we dealing with all opioid agonists prescribed such as oxycodone, hydromorphone, morphine and fentanyl? Because if we are talking all opioids, this will be another significant restriction to physicians' practices in prescribing opioids for pain management.

I am currently dealing with the repercussions of the opioid standard of care and guidelines for chronic noncancer pain. The result of this standard of care is that a number of physicians are refusing to prescribe opioids for chronic non-cancer pain. In addition, patients that we have initiated opioids are no longer being followed by their family physicians and we are now responsible for their follow-up every 3 months as per the standard of care. In my practice, this has consumed the majority of my time resulting in longer wait-lists and my interventional practice becoming restricted.

I would hope that there will be some clarification regarding the definition of opioid agonist treatment and the population this particular standard is addressing. I do appreciate the fact that opioid use disorder is the purpose of the standard but a clear definition of opioid use disorder needs to be made in the standard.

I would agree with other comments that a focus on further education regarding pain management with opioids should be a mission of the College. The limited education received in medical school and residency training on the use of opioids is a major problem for future care. I think what a lot of people in particular physicians fail to appreciate is that the only pain relievers we have are opioid agonists. NSAIDs are great in an acute injury and reducing swelling and inflammation but do not help much with chronic ongoing osteoarthritic (non-cancer) pain. Another important thing to understand is that a pain clinic like HealthPointe struggles trying to manage large volumes of pain patients on opioids requiring increasing resources with no public funding. Majority of new establishing pain clinics are focusing primarily on interventions and less on medication management. So unless more physicians are willing to take on an opioid agonist role, more patients will be going to the street for their pain relievers and unfortunately obtaining pills containing fentanyl/carfentanil versus oxycodone. And we all know this unfortunate outcome.

Jamie Irvine
HealthPointe Medical - Chronic Pain (Physiatrist)
07/11/2018
Alberta Physician

Excellent ideas and standard of practice. One of my concerns is are you going to get enough Family Doctors prepared to take on this extra responsibility this may be problematic in a busy rural practice. A real problem I have encountered in dealing with WCB patients with acute physical injuries is how ready the junior staff in A&E prescribe Tylenol 3 when all the research has shown it is ineffective and this then leaves the family physician having to deal with patients requesting more Tylenol 3 or stronger opioids. I know the College is aware but the college should continue to emphasize alternative modes of treatment to reduce dependence on opioids.

Anthony Lynch
Consultant in Occupational Medicine
07/11/2018
Alberta Physician

What about Targin?

conrad schulte
06/11/2018
Alberta Physician

I echo Dr. David Falk's view of this.
I am uncertain how this will affect me as I don't do addiction medicine but do use opioids and methadone for analgesia.

Marie Moreau
General internist doing oncology and palliation
06/11/2018
Alberta Physician

It would be of great help to provide a list of preceptors, mentors and programs to assist geographically isolated physicians with resources to aid in prescribing OAT. 24/7 on call addiction counselor guiding to available resources and available for physicians and patients who needs access to those resources, for example, via RAAPID NORTH, would also be beneficial.

Islam Elawadly
Rural ER / Family / Hospital medicine
06/11/2018
Alberta Physician

I find it interesting to know that they must be attached to a Pharmacy system like PIN or netcare to prescribe, as this was not the way we have been practicing. But its very important.

As well, we would need to know to know if it goes through as it affects us, in that we must send a letter to the CPSA if a client transfers. Right now we just do it if they discontinue.

It is good that the prescriber in hospital/corrections would have to contact our Doctor/us if they prescribe to one of our clients while they are in their care. As of now we have to find out through the Pharmacy or family members.

I think that Doctors that are prescribing in hospital or in correction facilities should have more than 72 hours to bridge a prescription as it is safer for the client to be properly bridged to a program and that may not happen in 72 hours.

Gwen
AHS
24/10/2018
Other healthcare professional

I must say, I find this draft most confusing from the perspective of who it is addressing. Some places it sounds like any physician who is going to prescribe any opioid, even Tylenol #3, will need a course in OUDs. In other places it sounds like it is addressing only physicians engaged in addiction services using opioids to manage the addiction. And then, at the end, it addresses the use of just one opioid (methadone) for use in analgesia. Which of these three groups of physician prescribers is the draft addressing, or is it addressing all three areas.
If it is addressing any physician prescribing any opioid, then there will be massive re-percussions in the palliative world as we are asking family physicians to follow their terminal patients and prescribe analgesics for them. If these family physicians cannot do this without a course, then my job will be filling one refill after another all day long.

If it is addressing only those who are dealing with addiction issues as in the old methadone maintenance program, then, I can follow the flow of the standard except for the addendum of METHADONE FOR ANALGESIA. Why do we add this to the standard when we are creating a standard addressing ALL opioid agonist therapies? The place of methadone for analgesia should be dealt with separately as the simplicity of the one half page point (6) is not clear enough. Also, if the standard is addressing just this group of prescribers, then it should be stated clearly in the first (1) & (2) points. I had to read down to the middle of the standard before it was clear that the group was being addressed.

If it is addressing the special status of methadone historically, then that requires a whole different approach, in my mind. The sigma of using methadone has come about because of it's "special authorization status". If methadone, and not the other opioid agonists, needs special prescription status, then, that should be a medical competency point, not so much a "standard of practice" point for one drug. Does methadone need a special licensing authorization to be prescribed as an analgesic? This is a question that would be answered depending upon whether ALL opioid agonist prescribers need to take a course, or whether this standard applies only to those in addiction services as I have attempted to outline above. If this course is for ALL opioid agonist prescribers, then include methadone for analgesia in the training. If this standard is for those prescribing for addictions, then there is no need to solely address methadone as it would be included under opioid agonist therapy.

Thanks for letting me share my perspectives on this.

David Falk
palliative care physician in the community
12/10/2018
Alberta Physician

Please Section 2 subsection d (I) and d (II)
initiate OAT for a patient only in an appropriate setting with:
(i) access to medical laboratory services and pharmacy;
(ii) access to at least one other prescriber trained and approved to provide OAT to
ensure continuity of care if the initiating prescriber is absent or suspends their
practice;
Questions - what does access to laboratory service mean- (ability to do urine screen on site or is the ability to collect urine sample and ship to provincial lab sufficient? )
2. Access to at least one subscriber- does the location of another prescriber matter - what if the one other presciber is in a remote/different location?

Uche Nwadike
10/10/2018
Alberta Physician

I do not treat OUD in my practice

Franco Leoni
05/10/2018
Alberta Physician

I think at this time, we should be doing as much as possible to remove barriers that prevent physicians from being involved in OAT and I don’t really see much that removes these barriers. This will make it difficult especially in rural areas.

Brian Knight
05/10/2018
Alberta Physician

The policy is good as far as I am concerned

Elyahu Gilad
Alberta Children's Hospital
04/10/2018
Alberta Physician

I agree but due to practice restrictions not involved.

Johan Jacobus Swart
Lakemed, Chestermere.
04/10/2018
Alberta Physician

Consider removing requirement for letter from palliative or chronic pain doctor to maintain a palliative patient on methadone.

Landon Berger
03/10/2018
Alberta Physician

I agree with above draft OAT standard of practise

Ruchika Swaro
Family Physician, Medicare Clinic, Calgary
03/10/2018
Alberta Physician

The draft looks good. However will there be online courses for rural physicians? More information is needed even to understand the language in the draft ie what is truly opioid misuse disorder. What is an OAT? What do we do with people currently on butrans? I have a patient on methadone x 10 years, It was originally prescribed by a pain specialist and I obtained a limited license for this one patient. What now do I need to do?
I have had people come to the ER withdrawing from narcotics wanting OAT ? What is the process now? Who can we send this people to?
Lots more education needed.
I feel like this is just one more area where it is hard to keep up but have patients on meds and how do I now meet standards of care?

Katherine Sorenson
02/10/2018
Alberta Physician

I am going to make my comments simple - this is an incredibly restrictive standard that will actually see a decrease in OAT prescribers during a time of crisis. AH, PCN's and everyone else is pushing for opening up Suboxone prescribing and increasing prescribers to aid in the issue of increasing opioid deaths, with this standard in place that job will become almost impossible. This is going to decrease access to OAT and increase opioid deaths.

Brad Bahler
SMD Primary Health Care Integration Network, SMD Provincial Primary Care Networks, Chair Primary Care Alliance, Physician Sylvan Lake AB
02/10/2018
Alberta Physician

Seems reasonable to me
However there should be much effort to get patients off narcotics unless absolutely indicated

Michael Nutting
02/10/2018
Alberta Physician

Not all patients dependent on opioids meet DSM-V criteria for opioid use disorder. A patient who is dependent on opioids, experiences withdrawal when dose is reduced or when abstinent is also in need of opioid agonist therapy, partial agonist therapy, or medically supervised gradual weaning.

Colleen Carey
02/10/2018
Alberta Physician

It seems to be a great step .

Ahmed HamoudAli
Paediatric medical clinic
02/10/2018
Alberta Physician

# 6 (c) recommends that "if maintaining methadone for analgesia for a patient, (physicians must) provide the CPSA with a letter of support from a palliative care or chronic pain specialist, as applicable." I think that if a patient is started on Methadone by a specialist and is then referred back to his general practitioner, this should be enough for the generalist to continue prescribing the Methadone without obtaining or sending further documentation to the CPSA.
I was encouraged to note that these fairly restrictive guidelines do not include the prescribing of partial agonists such as Suboxone. The prescribing and de prescribing of opioids (and OAT) is not the favourite part of most family practitioners and some tend to refuse to see patients with chronic pain or opioid use or abuse disorders. These patients often float around and have trouble finding a family doctor willing to take them on. I hope to see more support for and encouragement of family doctors willing to engage with these challenging patients.

Donna Klay
Devon Medical Clinic
02/10/2018
Alberta Physician

I agree with the draft

Amaresh Swaro
Family physician
02/10/2018
Alberta Physician

This standard should be fine and safe, as long as the associated courses and certifications are easily accessible in terms of time, fees and availability for physicians who are likely to need the use of the skills, as OUD appears to be a major and ubiquitous problem..

Neil Heard
Physician
02/10/2018
Alberta Physician

An example on another further encroachment into the practise of medicine. The CDC data which created their guidelines is increasingly being shown to be incorrect. Current opioid deaths are not occurring in regularly followed chronic pain patients in any significantly. Patient advocacy groups have presented evidence of patient harm directly caused by CPSA policy interpretation by doctors. This document contains a requirement for all physicians, including RCPS CERTIFIED Doctors such as myself to retrain. I oppose this proposed CPSA action. If instituted it will require a legal challenge to determine if the value of this action is of sufficient need to justify tha harm to pain patients as reported by pain patient advocacy groups. What is required is a dramatic increase in services available to pain patients not another police action by CPSA.

Gaylord Wardell
Medical Director
02/10/2018
Alberta Physician

The standard appears reasonable for the most part.

One part is a bit fuzzy: (2) (c) maintain competence in OAT ... what does this entail? How many hours over 5 years? Can it be self-study? To the extent that this requirement becomes onerous, this would then be a "cost of doing business" as an initiator and would have to be factored into each person's cost:benefit equation to see whether this is worthwhile to them. To those specializing in the area, this might not matter much. For those who are "trying to pitch in" and take on OAT duties as a peripheral area of interest, this might constitute a barrier.

Also, for those of us who deal with OAT in a "high turnover" patient population (e.g. corrections), we usually have institutional support (e.g. nursing and pharmacy) to help bridge the patients to a community clinic (e.g. Boyle McCauley or MetroCity). Having to provide a "letter of support" and associated paperwork as per (2) (e) would seem to be less applicable and administratively burdensome.

Another difficulty is the codified 72 hour Rx length noted in (4) (a) ... when these patients are discharged to remote locations (hard to find prescribers) or during holiday periods, 72 hours can be a tight timeline. In the past, I have had pregnant patients on methadone or suboxone discharged from jail for whom I needed to provide bridge Rx (no carries, DOT only) for up to 2 weeks. I would no longer be able to do this if the directive as written is implemented.

Thanks for your consideration.

Dave Lounsbury
Correctional Physician (provincial and federal)
02/10/2018
Alberta Physician

I support the proposed document as it is, except, the potential area of gap that may require attention. This has been increasingly recognized the past several years that the patients with advanced cancer are increasingly living longer, with longer duration of symptom of pain and suffering. Some of them, may have unfortunately exposed to very high dose opioid therapy when diagnosed with cancer esp. AYA population, who went through extensive surgeries, bone marrow transplants, etc. or those who have underlined borderline personality disorder/bipolar disorder (or even with severe PTSD) who learned to cope with opioid analgesia for their psychological distress while also experiencing cancer associated phsyical pain syndrome or sometimes already on Methadone maintenance therapy (MMT) already.

Also the definition of palliative care has been changing and increasingly palliative care practitioners are seeing patients who are no yet facing life threatening illness though they do have potential life limiting illness, while experiencing severe symptoms for longer duration that we typically encountered previously (often less than three months of life expectancy).

I practice as a palliative care consultant, and have experienced occasions where patients with MMT was discharged from MMT clinic despite patients have many months or beyond years of prognosis, or patients with problematic behaviours related opioid taking and use unstable dose of very high dose of non-methadone full opioid agonists. As a palliative care physician, I do provide methadone for analgesics, however, some patients do require MMT than analgesics. Although I have taken the MMT course number of years ago in U of C, and taken the online buprenorphine assisted treatment course already, I would not be able to maintain the number of experience in full license for MMT/buprenorphine assisted treatment due to the nature of practice.

For very difficult cases, I have consulted Dr. Weller and found very helpful, however, wish to see some comment on patients/population who may require co-management between MMT and analgesics until such time when a new practice guideline for those population available. JAMA September 4, 2018 Volume 320, Number 9 871-872 well-summarizes the same concern that I have been experiencing.

Yoko Tarumi
Clinical Professor, Division of Palliative Care Medicine, Department of Oncology, UofA/ Symptom Control and Palliative Care, Cross Cancer Institute
02/10/2018
Alberta Physician

Disappointed to see the new standard requires specific completion of a program about addiction without a complementary program of the place of opioids in pain control, maybe with a transition document about changes in the thoughts of regulators from the past decades of encouragement for physicians to more adequately treat disabling pain, to the more recent emphasis on the toxic effects of opioids in the context of of treating pain.

My now limited practice part-time in a community cancer centre has reduced my opioid prescribing from the past many years. Will I be able to participate in a CPSA approval program online?

D Neil Graham
High River Community Cancer Centre
02/10/2018
Alberta Physician

This is a clear standard and allows for changes in Clinical practice guidelines as they develop to address the " opioid crisis". I wonder if it needs to be clear what exactly is replacement therapy: includes methadone but does this also include use of other prescription narcotics as replacement? I am assuming that it does but this is not clear.

Janet Wright
BMHC
02/10/2018
Alberta Physician