If not opioids, what?

College of Physicians and Surgeons of Alberta CPSA, Designing Quality Blog 36 Comments

The medical profession was taught that opioids were effective and safe. But they’re less effective and less safe than we thought. They’re also contributing to a health crisis in our communities. Over-prescribing is part of Alberta’s opioid problem. As a profession, physicians need to own that problem, and help fix it.

CPSA recently hosted a unique prescribing forum for invited stakeholders to discuss solutions to the opioid crisis. Forum presenters included physicians, other health professionals and representatives from law enforcement, Alberta Health and Alberta Health Services.

Speakers addressed the broad issue of over-supply of opioids, both legal and illegal, identifying implications for physicians and other health care team members, and looking for opportunities to promote appropriate prescribing.

Discussions resulted in a five-point framework for action:

1. Focus on appropriate prescribing
2. Seek additional emergency (rescue) interventions for patients in crisis
3. Address addiction treatment
4. Explore other options for pain treatment
5. Seek access to more data and information

“I don’t think that I’ve taken from this that we need to take our chronic pain patients and rapidly dial back what they’re taking, what I’m taking from this is that how we need to prevent further addictions from developing in the first place. “Family Physician & Opioid Forum Audience Participant

What do you think should be first? Why? What’s at stake if we don’t?

Join the conversation & share your thoughts below in a comment. 

Work on the framework continues. Bookmark and check back to this page for progress. You are also invited to weigh in on the draft Standard of Practice on Safe Prescribing – out for consultation until December 12, 2016.

36 Comments on If not opioids, what?

Wayne said : Subscribe Oct 20, 2017 at 3:45 PM

I posted some months ago about the dire need for more treatment options.  For chronic pain patients falling between the cracks and for opiate dependent addicts. I believe a few more opiate based treatment options will be helpful and can save lives. After reading my comment, I sincerely hope the College would consider this seriously enough to bring it up to politicians and those with the will and political power to make it happen. It could save lives and research has shown it helpful in other Europe. The College must have a say in the so called opioid task force and would be taken seriously.

I will address a few things, so this will be lengthy.

Between patients being tapered who just aren't doing well, other perhaps falling between the cracks (more on that below)  and all the opiate addiction out there (obviously opiate addicts are more at risk then they've ever been) it's obvious, we NEED more treatment options. I will mention one I think would help.  Making available to those who choose, an opiate dependency clinic with doctors that can prescribe long acting oral morphine formulations for eg and non racemic methadone. This would be a better option than pain patients falling through the cracks.  ***It is definitely a needed option for those who don't do well on methadone, or buprenorphine. This would assuredly bring in more people who could benefit from treatment, but will not, or can not take methadone, or Subutex. So more people would get treatment. Win win!****  I'd go as far as saying perhaps we might consider heroin treatment for those who respond to little else.

I've already mentioned in a previous post that methadone, as a racemic drug, (opioid/NMDA antagonist)  causes many more side effects in most patients than a straight opiate, or non racemic methadone. These side effects are severe in some patients. QT interval prolongation, weight gain, water retention, excess sweating, hormonal changes more severe than with most other opiates, such as extremely low testosterone and galactorrhoea in some women . I could go on. Also, what effect does being on an NMDA antagonist for years have when there is no medical need? Sure, the long term effects of methadone and opiates have been studied, but the long term effects of NMDA antagonists on a 21 yr olds brain likely haven't been. So another option could be the non racemic  formulation of methadone as is used in some countries in Europe. (1)

It is a pure opioid and does not have as many side effects as the enantiomeric formulation.  It seems as if some doctors are not aware that it's the NMDA antagonist properties that add to the side effect profile of methadone.  As for Subutex, it is just not a very good pain reliever for some patients and also not strong enough for some addicts. Some don't want to take it because of the added Narcan.  I think it is obvious more medication options would bring more people to treatment.

I stated that I was concerned that chronic pain patients who have been on opioids long term and made to taper against their will, may choose options that are much more dangerous than the opiates prescribed by their doctor. The college says patients being tapered against their will isn't their intent. Perhaps not, but it seems to be happening as we see from comments here. If a few patients are commenting here, rest assured there are many more this is happening to.  According to an article from CBC news in Ottawa, my fear that some chronic pain patients who are tapered, and/or fall between the cracks, will turn to the streets is seems to be becoming a reality. (2)  There's no need to mention how dangerous this is with all the fentanyl out there.   It certainly does speak to how desperate some patients must feel if they believe this is their only option. Perhaps, for some they feel it is their only option for continuing to get an opioid for pain management, or to ease the withdrawals from a poorly managed taper? Safe injection sites will not help patients who are being tapered from oral formulations they get from their doctors! Though I applaud the political will behind trying things that research shows can be helpful, even when many complain, or are against it. I fear however, that there are not many options for those who are doing fine on their opiate medication, but are being tapered anyway. It seems some long term patients are able to taper and some have extreme difficulty and end up in a tail spin.

  Another concern is that, in some cases, the taper may not have a lot to do with what is actually going on with the patient.

If forced tapers are occurring when it may be putting some patients at risk, I can't speak to facts regarding that.   I can only repeat what I have heard from others, though I don't know how helpful that is.  Since there are two sides to every story, perhaps hearing from the doctors themselves may help.   I have heard doctors are now more fearful than ever of getting in trouble for prescribing opioids. Especially if they have a number of patients already on them, or if they have long term patients that are on dosages past this 90mg of morphine, or it's equivalent ceiling. So perhaps tapering them to a lower level, even if the patient was doing fine, is what they feel they must do because of the atmosphere that now exists around any type of opioid prescribing other than to cancer patients? I have heard doctors comment that with all the new regulations, it now takes much more time to manage patients on opiods.

While we are addressing the so called opioid crisis, perhaps more problems are being caused?

(1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723395/

(2) http://www.cbc.ca/news/canada/ottawa/prescription-limits-driving-patients-street-drugs-1.4351816

 

 

 

    Dr. Karen Mazurek, Deputy Registrar said : Subscribe Oct 26, 2017 at 2:37 PM

    Dear Wayne - thank you for sharing your comments. We are very much aware of the risk of patients who are dependent on opioids turning to illegal drugs to replace prescribed opioids if their dose is reduced too fast. The welfare of the patient has to come first. We have been very explicit in our advice to physicians and the public about this. It has never been our position that physicians cannot provide opioids to a patient or that they cannot exceed 90 OME. We have advised physicians to consider a reasonable taper for patients on high doses to the lowest effective dose. This is good medicine and ensures safety for the patient. We recognize that for many patients who have been on large amounts of opioids that it may not be possible to reduce the dose to less than 90 OME. Any physician who tells a chronic pain patient that they can no longer prescribe opioids because the CPSA prohibits it or that they will get in trouble if they do is abrogating their responsibility to their patient. Patients have responsibilities too, such as sticking to one doctor and one pharmacist and being responsible with their prescriptions to prevent diversion. Often when we hear of issues from patients about their physician it is due to a misunderstanding between the doctor and patient. Patients need to bring concerns up with their physician; good communication and mutual trust and respect between patient and physician is essential to an effective doctor patient relationship. If a patient needs help with their physician because he/she is refusing to prescribe or is abruptly tapering they should call us. I appreciate your comments about treatment options for opioid use disorder. While it is beyond our mandate to establish clinical treatment protocols for opioid use disorder using the agents you describe, the CPSA is open to evidence based treatment options and is prepared to support such options with appropriate regulatory policy if there is consensus among stakeholders that these options are appropriate for Alberta patients.

      RicardoH said : Subscribe Sep 08, 2017 at 7:04 PM

      Thank you for making my life even more miserable than it already was.

      The day before my birthday in 2014, I got horrible pain in my right leg and then my left leg went numb.  I thought it was a bad case of a herniated disc and since I had a discectomy back in 1984, I was concerned but not panicking.  Unfortunately, the diagnostic was much worse, I had Cauda Equina Syndrome.  2 herniated discs damaged my spinal cord and left me unable to walk and bladder/bowel incontinent.  I went from exercising, working, having a normal life one day to being the wheelchair bound/diaper wearing mess I am today.  I take Pregabalin to manage the nerve pain I get constantly but there are times when the pain in my bladder and feet gets so bad that I wish I was dead.  I have gone to emergency and what they give me is Percocet or something similar and then send me home with 5 or 6 tablets and tell me to go see my doctor.  In the past, I got a prescription from my doctor for Endocet and I only took it when the pain got unbearable.  I used 50 tablets in 3 to 4 months (recorded by the pharmacy where I fill my prescription and by my doctor).  However, due to this new regulation, my doctor will not prescribe the medication anymore and instead gave me something else that I've taken before and we both know doesn't work.  His main concern was whether my insurance would cover the cost of the medication and now whether it would really help with the pain.  

      I guess this new guideline you have developed includes making someone's life even more miserable than it already was and when I can't take the pain anymore, you prefer I go to emergency and take up the time and resources for them to give me a prescription for something that I could have gotten at my doctor's office.  Add to that the cost for me of having to call an ambulance to get to emergency and then a cab to bring me back and also the risk of falls when getting back home.  I honestly don't think that's in my best interest and it sure does not fit within the Hippocratic oath of "first do no harm."  

      In a perfect world we would have access to the "multidisciplinary team for pain management" that you mention in your guidelines but in reality, aside from the basics, most everything is not covered and results in out of pocket expenses that puts even more of financial burden on people, many of whom cannot even work anymore so they are on a fixed income.   

        RUKHSANA AMEEN said : Subscribe Oct 03, 2017 at 10:59 AM

        Our target is to relieve the suffering, it is seen when the patient needs medicine especially with musculoskeletal issues, reorder is a problem. I have attended one seminar on pain management, I got the home message for me, my target is to bring my patient to its baseline function, monitor him regularly, manage side effects of narcotics and NSAID. Once close to baseline, supportive therapy, physiotherapy, gradully taper dosing Communication, understanding of the disease, dr.patient relationship definitely matters. In my opinion for reordering prescription is a unecessary burden to ER and to the pocket of the patient.

          GLYN AXWORTHY said : Subscribe Aug 10, 2017 at 9:10 AM

          I have had restless leg syndrome since the early 80's. It started out fairly mild for several years but became increasingly worse. I put up with the annoying pain and discomfort.  In the early 90's it began to travel up into my arms and now is a serious problem. The flailing of of any of my arms or legs IS NOT controllable and is now such a violent movement that my shoulder, elbow or legs joints hurt a lot when an uncontrollable jerk occurs. I have come close to knocking people out if they are to close when the jerk happens. My wife and I sleep in separate beds because I have punched or kicked her extremely hard in my sleep. I hurt my back at work  in the mid 70's. For years I suffered from acute back pain until a new family doctor gave me a script for low dose oxycocette in 1996. My god!!!!! Finally no back pain. Unknown to me at the time, he also gave it to me to stop the RLS. It did. How do you spell relief? Nothing I had taken OTC or prescribed had an effect anywhere close to this. In 2006 my doctor retired and I had to find a new one. The new Dr. swore she was going to get me off oxy. I spent several agonizing months trying all her different types of drugs that had been used to try and treat RLS. Nothing worked.  The only combination of drugs that work is low doses of oxyneo, oxycocette and pramipexole. The pramipexole will not work on its own. Without these drugs the jerking occurs every minute or two. It is violent and it hurts. I have had a couple doctors question the effectiveness of these drugs on RLS. I asked them respectfully how many patients they have had with RLS. The answer - none; which means they didn't know much about it. I have been to 3 specialists for testing in the past 12 years. Thankfully they understand the problem. If RLS could be cured, I'd be happy not to take the drugs. I still have back problems. For me, the Dr. who first gave me oxy killed 2 birds with one stone. Thank god I met him. 

            Habenom said : Subscribe Jul 23, 2017 at 1:30 PM

            As I read through all the comments, it appears to me that CNCP and acute pain due to the different cause haven't been addressed up to standard on the evidence based practice by lots of practitioners perhaps due to lack of resource or knowledge based awareness. Pain is complex and as it is, need to be individualized by the expert in the field.

            Lots of Gp's will have the understanding of pain simply the route of peripheral sensitization to central sensitization as Descartes’ view of pain. However, pain's complexity is far beyond that explanation of ascending and descending orders of neurons. It has first pain pathway-the anterior cingulate cortex which is a perception of pain and the second pathway the medial prefrontal cortex and nucleus accumbens which is associated with emotion and motivation where could have a significant impact on the understanding of pain as lots of neuronal immune interaction and chemical release are taking place. 

            Long term opioids use in the management of NCCP is not advised due to potential undesired effects of the medication, such as opioid misuse, opioid induced hyperalgesia (OIH), opioid overdose, endocrine disorder, sleep disturbance and respiratory depression are some to mention. Therefore, clinicians need to follow the guideline on opioid prescribing that is clearly designed by the college of physicians and need to look at some resources that are available like, ECHO Ontario, CAMH, BCCSU for tremendous resources in pain and addiction disorders.  It is also important to understand on opioid tapering and opioid rotation by consulting pain specialist and doctors who have a better experience on handling chronic pain and addiction medicine rather than complicating things.

            Few suggestions: 

            • Opioid should be used only in acute (post trauma or post surgery, not more than 2 weeks)
            • We need to follow the WHO pain management step ladder or the newly published Canadian opioid guide line 
            • CNCP sufferers should be well assessed for their pain by mapping while we also clearly identifying their understanding in the pain and their perception of pain.
            • Need to explain pros and cons of opioid use as pain management
            • get to know the patient well (to avoid mistrust)
            •  If we have to start opioids, we need to engage them in their treatment modalities, have fixed schedule on their response every 2 weeks and ask to have diary about their pain
            • Clearly, identify patient if they have concurrent disorder
            • make an appropriate referral,  be it to a psychiatrist if there is depression or  anxiety disorder or to addiction medicine if a substance misuse is suspected 
            • Don't be judgmental and be culturally sensitive (be aware of the patient's value)
            • Do not taper or rotate medication if a patient hasn't  reached an agreement, in doing so patient like to be empowered by providing full participation in their care.

            Provide alternative pain management such as PT, OT, and counseling. If the pain is due to post trauma, plenty of research has shown benefits of exercise as there is exercise induced hypoalgesia (EIH) and definitely we can overcome opioid misuse and addiction diorders. The college need to encourage doctors to pursue in addiction medicine as I see lots of gap in Alberta compared to BC and Ontario. (just personal observation)

              ron said : Subscribe Jun 19, 2017 at 7:51 PM

              As a long term opioid patient that has chronic pain issue what am i to do to continue my job as a bricklayer as i keep getting reduced on my medication and soon will not be able to deal with the pain to keep working.I understand there is a problem but i feel like i am being punished for an epidemic that i have nothing to do with. All i want to do is be able to provide for my family which i will not be able to do with the dose of medication somebody sitting at a desk tells my doctor that i need . I would love nothing more to be pain and medication free but that is not an option for me. What are the people that have very physical jobs to do.

                Res Steven said : Subscribe Mar 04, 2017 at 11:50 AM

                Opioids work for chronic pain and so does cananibis. But it is not a first line treatment.  And the least effective dosage needs to be used. I have patients on opiods who are more functional and able to do function well. These are people who have tried or have been intolerant of: gabapentin, lyrica, elavil, tramdol, tylenol, advil and topical medications. 

                The other options I have found useful is for patients that have more locazlied problems is to refer them for trial of regenerative injections such as prolotherapy or PRP at clinics such as ipax pain clinic or healthpointe. These resources have been useful. But it is foolish for the college to act from their ivory tower based on guidelines when they are no on the front lines treating their patients.

                  Wayne said : Subscribe Feb 14, 2017 at 8:02 PM

                   I wanted to address other treatment options.  I don't know where else,  on the website, to post this. This seemed to be the closest topic.

                  I keep hearing mention of better availability of opioid treatment and maintenance programs. The maintenance medications we have, while very helpful,  do not work for all patients. We NEED more options!  Some find subtutex isn't strong enough and while methadone may be, it has serious side effects in some people.  I have seen many patients quickly gain excess weight on methadone. (for some patients this is in direct relation to methadone and has nothing to do with diet) I know of some patients in their 40's who had very high cholesterol and triglyceride numbers while on methadone. When they came off methadone, within a couple months, their numbers were within normal range. So it seemed to be a direct result of methadone.

                  Something that many don't seem to know about methadone,  is it comes in an enantiomeric form, (L and D isomers). The racemic mixture is what is used clinically in Canada and most other countries.  This being the case, methadone acts not only as an opioid, but as an NMDA antagonist too.  NMDA antagonists can have mild stimulant affects, as well as other side effects.  Some people are sensitive to this stimulant effect and it is probably why methadone has side effects not seen in straight opiate/opioid formulations such as weight gain and excessive sweating.

                  Dr Kammerer, in his post,  mentions using other countries besides the US as examples. Well, in many European countries, there are other medication options for maintenance.  First, the single entity methadone may work better for some than the LD version. This is used in Germany. There are other evidence based approaches that are shown to work for people who don't do well with methadone, or Subutex. Things such as long acting, oral morphine formulations like MS Contin.  There are many patients that are just as stable on that medication as some are on methadone, or Subutex. Countries like Switzerland and Holland have injectable heroin programs for long term opiate addicts that don't respond to other treatments.

                  How about adding some of these evidence based approaches? The research in Vancouver showed they work and save lives.  My concern is, there may be patients out there who, may have  been stable on opiate medications for years, are not abusing them, and if they are forcefully tapered, they may end up on the street looking for pain relief. I'm sure it's not unheard of.  These patients need other options

                    Dr. Karen Mazurek, Deputy Registrar said : Subscribe Feb 23, 2017 at 10:26 AM

                    Thank you for your comment. I agree that we need to avoid the unintended consequence of chronic pain patients turning to illicit opioids. The CPSA has been very clear in our messaging to physicians and the public that opioids should not be abruptly discontinued or rapidly tapered. Your point regarding options for opioid dependence treatment is well taken.

                      William Petty said : Subscribe Feb 07, 2017 at 12:25 PM

                      My doctor arbitrarily reduce my opiod  dose by 10 %, and advised me he will continue 10 % reductions on a monthly basis, with a final goal of 30% permanent reduction. I was given no choice in the matter.

                      I  am already experiencing extreme discomfort, to the point where I am now in serious pain for over 50% of my day and sleep in my chair because it is too paiful to raise my legs onto the bed. I have no wish to participate in this program and feel very strongly that I should have been given a choice.

                      I'm wondering if I must resort to legal action ?

                        Dr. Karen Mazurek, Deputy Registrar said : Subscribe Feb 09, 2017 at 11:00 AM

                        Thank you for your feedback, William. Current best practice recommendations support that there are a number of scenarios that, to ensure patient safety, a taper of opioid medication is appropriate. While a decrease of 10% of the original dose per week is in keeping with best practice guidelines, every patient is different. The best course of action is to talk to your physician about your symptoms. You may require a slower taper and/or an adjustment of non-opioid medications and non-pharmacological therapy to manage your symptoms as the opioid is gradually reduced. I hope that advice helps you and others who may be in a similar situation.

                          Hubert Kammerer MD said : Subscribe Dec 11, 2016 at 2:16 PM

                          Physicians have to take some responsibility for the position we presently find ourself in, with regards to opioids. We have actively contributed to the pool of addicted patients some of whom are now overdosing on Fentanyl and other opioids in ever increasing numbers. 

                          I remember years ago, attending lectures sponsored by the pharmaceutical industry where "pain specialists" would tell us that opioids were safe and effective in non-cancer pain and the likelihood of someone in pain becoming addicted was low. We were told that chronic non-cancer pain is greatly under treated and we were letting our patients suffer unnecessarily by not using opioids more liberally. 

                          We swallowed this garbage and have contributed to the problem we now have. Canada has one of the highest prescribing rates of opioids for non-cancer pain in the world only second to the United States. Europe has much lower prescribing and usage rates. The difference is not that we have different patient populations or pain syndromes, as there is no evidence of that. The difference is the prominent role of the North American pharmaceutical industry had in sponsoring conferences and seminars and paying mouth pieces to disseminate the propaganda that increased the industry's profit margin.

                          Fortunately this is now being recognized as a conflict of interest and is not as prevalent as it previously has been but the damage is done.

                          I applaud the CPSA and Trevor Theman for taking this issue on and trying to put some evidence and rational into opioid prescribing. We have to start being part of the solution and not keep contributing to the problem.

                          The solution may be three fold.

                          1. Reduce the pool of addicted patients by rational and evidence based opioid prescribing which CPSA is now advocating. The evidence is not perfect but will improve with time as we learn more. Our prescribing practices need to start trending toward what is normal in other advanced countries, other than the United States where the pharmaceutical industry still has great sway. Use of non opioid and non addicting treatments for treating chronic non-cancer pain is part of this strategy.
                          2. Promote and fund harm reduction strategies to try to reduce the number of deaths we are now seeing and
                          3. Increase the access to opioid treatment programs.

                           

                           

                            Info@CPSA.ca said : Subscribe Dec 07, 2016 at 11:49 AM

                            Thank you for your question, Jahn. Discuss your concerns about your medications with your new physician, understanding that our knowledge of medications and medical conditions is constantly changing and becoming better. It is important to reevaluate care regularly and it may be necessary to make changes that will bring about the safest and most effective patient care based on a current assessment of your clinical needs.

                            Anyone looking for a new family physician in Alberta can search our website (www.cpsa.ca) for those in your area accepting new patients. Search using key words that describe your condition for a more specific list.

                            Designing Quality Team

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