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.

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Wayne

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… Read more »

Dr. Karen Mazurek, Deputy Registrar

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… Read more »

RicardoH

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… Read more »

RUKHSANA AMEEN

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

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… Read more »

Habenom

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… Read more »

ron

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… Read more »

Res Steven

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… Read more »

Wayne

 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… Read more »

Dr. Karen Mazurek, Deputy Registrar

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

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… Read more »

Dr. Karen Mazurek, Deputy Registrar

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… Read more »

Hubert Kammerer MD

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… Read more »

Info@CPSA.ca

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 (http://www.cpsa.ca) for those in your area accepting new patients. Search using key words that describe your condition for a more specific list.… Read more »

Jahn

What happens when your general practitioner retires and has been giving you the same medication for 7 years. And you look for a DR And that doctor and many other doctors will not prescribe those drugs to you? What does a person do?

Khaled Rajab

Chronic pain is complex issue especially  when  there  are mental health comorbidity  like anxiety depression, insomnia or addiction  as I appreciate the CDC , the Canadian  guidelines  for chronic non cancers pain , which gives more insight for family physicians to follow , and in order to follow these recommendations  , so should be paired with other modalities of treatment to be available to those patients , like psychologists CBT  for pain , physiotherapy  , mental health counseling for anxiety  depression and insomnia , more access to addiction clinic  as I see it , it is not only the family… Read more »

Rick Zabrodski

My 35 years of practice in ER, family med, and occupational medicine has taught me that acute pain is an healthy response to inflammation/injury, and chronic pain  while occasionally related to a pain generator such as hip OA, is  more often a much more complex issue related to CNS sensitization, better viewed as a chronic illness, what I call “the dark side” of neuroplasticity.  It is not a character flaw.  The challenge has been providing treatment with both hands tied behind my back. Drugs never fixed anybody with chronic pain.  Unfortunately, while I can order a 600 dollar CT scan… Read more »

Sonya Regehr

Well said! I work on a reserve where I deal with patient expressions of pain frequently. There are just so many barriers to the multidisciplinary care they require.

Patrick

As a new doctor in Alberta who has come from Ireland there is a marked difference in prescribing opioids here. It certainly does appear more prevalent. Unfortunately as a doctor I think it is doctors that are largely responsible for this problem. Patients have expectations of a pain free existence which is just not realistic for many people. I think we must inform people that opioids really are more harmful than beneficial except in certain circumstances where all other options have been exhausted. In my own cohort of patients I seem to have inherited problems that may have been avoidable.… Read more »

Owen Schwartz

My suggestions are to look for the non physical roots of pain as well. Much pain is rooted in fear and a feeling of helplessness.

Psychotherapeutic support ought to be a mainstay for all chronic pain

Everyone would benefit immensely by learning meditation and breath techniques which ought to be a cornerstone of Rx. Forinstance detachment as taught in Mindfulness is an essential skill

 

Kate Bisby

As a doc who works in addictions, I would just like to high-light that gabapentin and muscle relaxants are readily abused (with a street value), and as such, should be monitored for early fills, doctor shopping, etc…

Dr. AH

I believe we need to advocate for adjuvant and non-pharmacotherapy treatments for pain to be covered by low-income benefit plans.  There also needs to be more fundamental discussions with patients and in our society about expectations around chronic pain and addressing underlying mental/emotional/social stressors.  We do have a responsibility as healthcare providers to treat people holistically and not put them at risk for further harm with reflexive prescribing, but then we need to have alternatives that we can offer. 

Neil Heard

Indomethacin or diclofenac suppositories appear to be quite helpful for post op pain, renal and biliary colic ( assuming renal function to be normal). Over and above the cited problems of  diversion, potential overdose and  addiction, one is concerned about impairment, whether or not marijuana and/or alcohol and other substances are added to the mix, for the duration of any prescription. This raises the possibility that prescribers may need to consider alerting the licensing authority to suspend the drivers license if it cannot be verified that a prescription will not impair the user and put the patient and/or public at risk.… Read more »

Lloyd T. Clarke

I have worked as a family and ER doctor in a rural community adjacent to a large First Nation Reservation for 20yrs. The resources available for people who are addicted to narcotics is paltry. The ability of a family doc to help a patient who wants to quit is hampered by distance to resources, and timely access among other things. While the creation of Suboxone clinics has mitigated some of the problems it is only reaching a small part of the problem. I would like to see what is intended to be done on the part of development of resources and… Read more »

locum

I have been a locum in many rural locations and I am often dismayed at how easily opioids are prescribed.  Sometimes a patient has to insist that he does not want opioids.  Furthermore, I have been criticized by rural MDs and nurses for not rushing to give patients opioids.  I really think that opioid guidelines are needed, especially in rural areas, where the prescribing habits of some MDs is a significant problem.

anthony Russell

Chronic pain syndromes are normally centrally mediated problems-if we exclude those few with ,for example,inoperable o/a of the hip.Even there pain “sensitisation” frequently develops.Thus a  psychologic approach, if necessary with psychotropic Rx is required.Frankly it’s not news that opiods dont work.Calling so many of these syndromes “injuries” when there is no evidence of any damage merely adds to the problem.

Noel Hershfield

I saw many patientx with chronic abdominal pain NYD.At least twenty percent had abdominal wall pain,diagnosed by a careful exam in the office.I actually wrote a paper about it.Many of the others I saw had very few significant investigations before being labeled with chronic pain NYD.Before I saw them many consulted chiropractors,massage therapists,and other so called alternative practitioners,some with success.I used all the strategies to treat them.Many were depressed and responded to antidepressants.I attended a meeting in Washington on chronic pain.They used everything to try and control pain,including nerve blocks,psychotherapy,excercise,education about the adverse effects     Of narcotics,before treating with… Read more »

PalliativeMD

I have not seen many proposals to deal with diversion. The Palliative Blue Cross program in AB punishes patients (with more dispensing fees) when opioids are dispensed at shorter intervals, and encourages three month dispensing.  So when the dose or drug or route changes a few weeks later, another three months’ worth are dispensed. Pharmacies in AB are not required to take back the medications, leaving families in possession of very large quantities of opioids, often injectables, which is a risk to them if it becomes known. It is also an unnecessary financial drain on the Palliative Blue Cross program… Read more »

Jeremy Reed

Acetaminophen, NSAIDS, Lyrica/Gabapentin, maybe medical THC, depo-medrol injections, TCA’s, a pain specialist if needed for expert dosing and maybe focal injections of roots/ganglia, possibly physiotherapy, possibly psychiatry and/or psychology, and most importantly – SPEND SOME TIME WITH YOUR PATIENTS.  Find out what NSAIDS they’ve tried and what worked and what didn’t.  Do they take their NSAID with food always??  Are they on a PPI/H2?  Encourage them to get going – get moving.  Get back to life as much as possible.  Reassure them that getting out with their kids and playing catch may hurt a little, but it will not harm.… Read more »

Kristine

I live with Chronic Migraine. On average I have 12 per month. 25-50% of the time I require 2 Percocet to abort my Migraine when my Triptan and NSAID is not effective. I need access to this medication because it will allow me to not have to go to the ER where I am instantly labeled a ‘drug seeker’ or ‘drug abuser’. I will do ANYTHING to avoid the psychological and recently physical abuse I receive at the hands of so called health care professionals. I am very careful with my medication, I only use it when it is necessary.… Read more »

Dr. Karen Mazurek, Deputy Registrar

Thank you for sharing your concern, Kristine. I want to reassure you that nothing the College is doing or recommending will prohibit patients from continuing to receive the prescriptions they currently receive from their physicians. The prescribing guidelines are intended to provide support and education for physicians to help make the best decisions with their patients. To be sure you are getting the best care, my advice is to continue to keep a close relationship with a single prescribing physician and a single pharmacy to be sure your providers understand your medical history.

David Woolliscroft

I refer to your comment on 22 Nov to Kristine. While it is absolutely true the college is not preventing prescribing but please be honest and realistic in your answers. The media, government and the CPSA are putting the blame on physicians. The draft proposal is more enforcement, more harassment, more time and work which will fall to GP’s .Undoubtably we have a duty to do as much as possible to prescribe in a professional manner, in truth so called safe prescribing is a nonsense. Any drug is potentially unsafe that is why we have to prescribe them! Somehow we… Read more »

Dr. Karen Mazurek, Deputy Registrar

David, thank you for commenting. You raise some very good points. I want to be clear that we are not blaming doctors for the opioid crisis. What we are saying is that the medical profession contributed to the problem, we are not responsible for the entire problem. It’s our collective responsibility as a profession and that responsibility includes the College. Yes we need more resources focused on providing more support and less stigma around opioid dependence, and on sharing more options for treating long-term chronic pain. Hosting Alberta’s recent Opioid Prescribing Forum, and this blog, help the College engage decision… Read more »

Barry Ulmer

We appreciated the invitation to participate in this forum, but were disappointed in the overall content. It did not really shed much light on the situation as it relates to people with pain. The content seemed directly related to addiction problems and the illicit drug trade on the street. The charts outlined by the Medical Examiner and Chief Coroner were interesting as they certainly confirmed we have an illicit substance abuse problem, but not one that has been caused by prescribing. The intent of the “College” to promote a standard of care based on the Centers for Disease Control (CDC)… Read more »

Dr. Karen Mazurek, Deputy Registrar

Thank you, Barry, for providing the patient’s voice. I hear your concern, and the patient fear you raise. Let me first say that the College does not and will not limit physicians from prescribing opioids beyond recommended guidelines for legitimate patients with chronic pain. The College heard very clearly from our recent consultation and forum participants that there are legitimate chronic pain patients who need opioids — patients who are benefiting from opioid treatment with improved pain relief and better function, and who are taking their medication responsibly under a physician’s care. As the College works to address irresponsible prescribing… Read more »

Dianne Millette

Thanks to CPSA for inviting Physiotherapy Alberta to be part of the forum.  It was an informative discussion and has given us cause to consider how physiotherapists can further contribute to better management of chronic pain patients.  However, public physiotherapy funding for chronic pain patients is almost non-existent.  There is very limited funding in the proposed provincial standardized model for ambulatory physiotherapy for low-income patients that could apply but many patients must rely upon private pay or extended health benefits.  These funding sources may not be a viable option for many chronic pain patients.  Discussion about publicly funded but privately… Read more »