Important information regarding opioid prescribing

College of Physicians and Surgeons of Alberta CPSA, Medical Matters, Messenger 26 Comments


There has been recent media activity in Alberta about concerns from chronic pain patients and access to opioids. The messaging has stated that CPSA prevents or discourages physicians from prescribing opioids. We have also heard that some physicians have stopped prescribing opioids or have refused to treat patients with chronic pain, because they are afraid of losing their licence to practise medicine. Unfortunately these two situations are putting people’s lives at risk. As a profession, we all have a responsibility to work together to protect chronic pain patients and CPSA is here to support you.

We understand that many physicians feel poorly equipped to manage patients with complex chronic pain, particularly when our understanding of the role of opioids is constantly evolving. In times of change, messages are often conflicting or confusing, and it’s easy to feel ill-informed in providing care to pain patients. Our physician community needs to continue developing and sharing the best practices around opioid prescribing, and supporting one another in learning about and implementing those changes. Each of you are focused on providing the best patient care you can, and CPSA is here to support you.

As physicians in Alberta, we are all accountable for prescribing opioids appropriately. The MD Snapshot – Prescribing reports we provide are intended as an education tool to help you prescribe safely. I’ve heard these reports have caused fear in some physicians—this is not our intent. CPSA is here to work collaboratively with the Alberta College of Family Physicians (ACFP) to support you in the appropriate care and prescribing of all medications, including opioids, for chronic pain patients. It’s important to reiterate:

  • It is never appropriate to abandon a patient on long-term opioid therapy, or abruptly cut off or threaten to cut off the patient’s medication. Safely reducing long-term opioid medication requires expertise and support. Links to specialized clinics and resources for physicians are available on the CPSA website.
  • It is never appropriate to refuse to accept a patient because they have complex medical needs or use opioids. All Albertans deserve access to the care they need and physicians must treat all patients equally regardless of their medical condition.
  • Patients taking prescribed opioids should not be stigmatized. There are some medical conditions where opioid use is an appropriate treatment. Also, any person taking an opioid medication can develop dependence over time. This is a known risk of the medication, and is not the fault of the patient.

CPSA recently spoke with Dr. Cathy Scrimshaw, the lead of ACFP’s Collaborative Mentorship Network for Chronic Pain and Addiction, about the complexities of providing care for patients who use opioids for chronic pain. When helping patients effectively manage their pain, Dr. Scrimshaw suggests drawing on the strong relationships family physicians have with their patients.

“Talk to your patients with an open mind,” Dr. Scrimshaw recommends. “Reassure them that you don’t want to take away their medication today. Review their history to see if all avenues for pain management have been explored and whether their current medication may be causing problems. If you have concerns, tell them why and ask if they would consider tapering, or maybe trying a new treatment. Give them some resources to review. Then ask them to come back to discuss next steps.

“Chronic pain is complex but ultimately, it’s just like treating any chronic illness and there are resources available for physicians who need help supporting their patients.”

Read more about Dr. Scrimshaw and her work.

I would like to personally thank all physicians who are already providing excellent health care to your patients and commend you for your hard work and dedication. We value the exceptional work physicians are doing for Albertans. The ACFP and CPSA are here to support you and ensure you have access to any resources or information required to best care for your patients. You can reach out to ACFP at mentorship@acfp.ca or 780-488-2395 or CPSA at CC.Inquiries@cpsa.ab.caor 780-969-4935 for any further questions or concerns.

I also encourage you to check out the University of Calgary’s new course, Wise Prescribing and De-prescribing: Opioid Skills for the Frontline Clinician, that was developed in partnership with CPSA and AHS. There are free, self-learning online modules as well as small group workshops that will be held throughout the year.

Dr. Scott McLeod, MD, MPH, MPA, CCFP, FCFP
CPSA Registrar

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James Currie

Thank you for the clarification, and your article published in the Calgary Herald.
Although I am consistently in the high 90th percentile for opioid prescriptions I have never felt threatened by the College. (I work at AHS Chronic Pain Centre in Calgary). The Snapshots provide useful feedback, although in my case I know of all the patients already. The place for opioids in Chronic Pain is controversial, but I have no doubt that there is a group of patients who do well on this therapy, and consequently remain functional in daily life.
Thank you.

Scott McLeod

Thanks James.

I appreciate your perspective on this. In fact your experience is actually the most common response we hear when we ask for feedback. Most physicians actually aren’t fearful of the MD Snapshot. They see it as an opportunity to reflect on their practice and identify ways to improve the care they provide. That is what it was intended to be. Last, but certainly not least, thank you for providing care to those suffering with chronic pain.

Scott

Kept private

I am not a physician but work with physicians, I am some one who has seen first hand the way the College does not provide any guidance whatsoever with respect to prescribing narcotics or dealing with situations that can arise when dealing with some narcotic patients. I personally have called the college to get advise and have been transferred around and finally no one has called me back. I have had patients threaten, and follow through, submitting a complaint, because the physician has moved them to short carry, requested a urine test or are dismissed from the practice due to… Read more »

Scott McLeod

Thank you for writing in and sharing your concerns. You have brought up several things here that concern me and I would love to learn more from you and your experiences. We consider ourselves to be a learning organization and therefore we want to learn from people’s experiences and improve how we do our work. I can assure you that we are not on a witch hunt, but if that is how our work is being perceived then we must address that. If you would be willing to share more detailed information with us please let me know and I… Read more »

Private

Thanks for this. My question is very simply , why does most physicians feel threatened. Why did most prescribing doctors in Alberta develop the same concerns at the same time that led to this current situation where patients are impacted and physicians feels that their licenses are threatened. I am afraid that the CPSA’s response currently seems like damage control which many of us predicted more than a year ago. Most responses here have been from Chronic pain specialists and very few from regular family physicians . I am a practicing family doctor who also works in the acute care… Read more »

Ricardo Hamdan

Thank you Dr. McLeod, THANK YOU. I am a man in my 50’s with a partial spinal cord injury and sometimes the pain makes me cryI saw my GP yesterday and I actually wrote a letter to the Editor of the Edm Journal yesterday too. I went from having a prescription which I never exceeded to nothing. I had to beg and got 10 tablets a month (and they were prescribed like an incredibly generous gesture on the part of the physician). If my pain level gets to the point where I need to take one of those tablets during… Read more »

Scott McLeod

Dear Mr Hamdan, Thank you for sharing your story with me. The experience you describe above is exactly what we are trying to address by starting this discussion. We have never told doctors to do what you describe, but we know that some have decided to do it anyways and that must stop. I would encourage you to share the information we have provided over the past week with your doctor so that they are well aware that as their regulator we have stated that it is never appropriate to abandon a patient on long-term opioid therapy, it is never… Read more »

L. Pederson

This is a gtreat start! I had a doctor toss files in front of me saying these are from cpsa asking why? I am NOT going to jeapordize my job! This was for mild o.5 mgms clonazapam! On it for 40 yrs! Yes tried to taper and anxiety took over- I do NOT take pain meds but found this helped me take slow deep breaths and mentally try to deal with pain. Lifes events added stress- tried reducing A anxiety – had heart attack! Cardiologist when I sdid heart always races without clonazapam – i was told see a shrink!… Read more »

Ricardo Hamdan

“To me many of these physicians are making chronic pain suffers suicidal as they can no longer stand the pain!
Many make you feel unworthy!”

Thank you for bringing up this extremely vital issue. Any human being who loses hope immediately loses the will to live. As pain sufferers hitting our heads against a wall that we know should not be there, losing hope has become for many of us not a matter of “if” but a matter of “when”

Scott McLeod

Thank you so much for taking the time to submit your comments. It’s unfortunate that pain patients have been put in these difficult positions and it has certainly never been our intent for anyone to be treated in such a judgmental way that you describe above. Thankfully for every doctor that acts that way we have many more that want to help and are much better representatives of the medical profession. If you feel you’re not receiving the care you need I would recommend that you seek out a family physician who is interested in providing you the care you… Read more »

Tracy Fossum

On behalf of the HELP ALBERTA’S PAIN (HELP_AB) TEAM, and chronic pain patients of Alberta, I would like to thank you for this statement, Dr. McLeod. I think this may be one of the most pertinent and bold statements in the ongoing discussions about pain management in our province. Recognition of the struggles that both pain patients and doctors are facing is vital to our success. We understand that chronic pain is challenging for many physicians, but we must not lose sight of the fact that patient lives are on the line. The time has come to openly discuss the… Read more »

Scott McLeod

Thank you Tracy. I wish I could say this will turn around quickly, but its going to take a great deal of time and work moving forward. The good thing is that more people and organizations are having the conversation. Hopefully by working together and understanding each other better we can find some solutions to this very complex problem.

Scott

Sheilagh Peters

I’m heartened by the CPSA starting to act, working in conjunction with help_ab, and understanding that something has gone wrong, along the way that’s hurt chronic pain patients (CPPs),and lead them, doctors and the medical establishment to this point. That the CPSA appears to be listening to what help_ab is presenting them to understand what is being said, and not just to respond gives me some hope that things might change for chronic pain patients. I do pray it doesn’t happen too late for some. I, personally, and many that I know, all CPPs, are hoping for some form of… Read more »

Ernie Schuster

Thanks for this Scott, I would like to add that I have run into physicians who refuse to have triplicate prescriptions in principle. It is in my view unprofessional to purposely choose to not be able to prescribe opioids even when truly indicated such as in palliative care.

Scott McLeod

Hi Ernie. I agree with you, In fact one of our staff was looking for a new doctor recently and was told by a family doctor that she would not prescribe opioids. This must change, but what I also recognize is that there is a great deal of fear and uncertainty out there that needs to be addressed. There are so many false messages floating around that some doctors just don’t know what to do. Thankfully, as a result of the great work being done by organizations like ACFP and the physician learning program, there is help. Instead of refusing… Read more »

Sheilagh Peters

As a chronic pain patient, one who has been on 120mg of morphine/day and was functioning well on it, then when the md snapshot came into play, I was on “the list”. I was reduced to 60mg/day of long acting morphine and a maximum of 20 mg/day of short acting morphine for breakthrough pain. I’m no longer functioning successfully and I’m still reading “we don’t want to take their medication away today.” This tells me, as a patient who IS being adversely affected by the reduction, that while not “today” the intention IS still to reduce my opioids to 0mg/day.… Read more »

Scott McLeod

Hi Sheilagh, Thank you for taking the time to read our message and for sharing your thoughts and personal experience with us. We recognize that chronic pain patients need to receive good care from physicians who understand the complexities of treating pain, and offer support and appropriate doses of medication to improve quality of life. Today we submitted an editorial to the media that stated “We understand that chronic pain is a very complex issue and there are patients who need opioids to be able to live their lives.” The CPSA does not promote the rapid tapering or abrupt cessation… Read more »

Jamie Irvine

Scott Thank you for this editorial. As a chronic pain physician who does prescribe opioids for chronic non-cancer pain. Majority of my practice is maintaining long term opioid patient (70%) as per standard of care for family physicians who will not take over the prescription once stabilized. I would prefer my time being spent seeing new patients and providing clinical advice on opioid management to the family physicians. I have seen so many patients getting pain medication off the street because their family doctor has discontinued use. An extremely dangerous and irresponsible practice on the part of the physician because… Read more »

Sheilagh Peters

Thank you, Jamie Irvine. I’ve written the CPSA 2 letters asking that my dose of opioid medication be allowed to go back up to where I was before I got reduced. So far no response, I’m hoping for one on my letter here, and for written reassurance that taking all chronic pain patients off opioid medication is not their (short sighted in my opinion) ultimate goal. Family physicians shouldn’t be feeling they must reduce a pain med dose arrived at by years of work in a pain clinic, and pain clinics should be given leniency to prescribe a dose they… Read more »

Scott McLeod

Hi Sheilagh, Thank you so very much for this. We absolutely do not want all chronic pain patients to stop all opioids. That would be completely inappropriate. What we want is for there to be a recognition that opioids are not as safe as what people once thought they were, but that is no different than many other medications that are used in medicine. A recent report form the Medical Examiner showed that 110 Albertans died in 2017 as a result of prescription opioids. That just means that opioids are not without risk, but if used appropriately they can be… Read more »

Scott McLeod

Hi Jamie, Thanks for taking the time to write in. I really do appreciate it. We’re at a very challenging time at the moment where doctors, especially family doctors, are struggling to understand what the right thing to do is and chronic pain patients have been put in the middle of it all. For years we’ve been told that opioids are safe and now the evidence shows that they are not as safe as we once believed. Our MD Snapshot, which is intended to be a self reflective and learning opportunity for doctors, has had the unintended consequence of a… Read more »

Chris Evans

Really well said Scott. Your three points are right on the money, and unfortunately all three of these things are happening to chronic pain patients all over Canada for a variety of reasons. One is the opioid crisis, which by in large has nothing to do with physician’s prescribing habits, but rather with the importation, or home grown “cooking” of illicit substances that often aren’t what they are billed to be. We, as physicians, need to support patients with chronic pain, and not let fear cause us to let them down. Bravo on your excellent and timely editorial!

Scott McLeod

Hi Chris. Thanks for taking the time to comment. This is an incredibly important topic that we need to have more discussion around.

Chris Evans

I totally agree, and you are catalyzing that discussion. Thank you.

Chris Evans

I completely agree. I look forward to further discourse around this topic. Thanks again for your willingness to challenge the status quo.

Andrew Cave

Thank you Scott Sheilagh and Chris for this well balanced approach.
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