Physicians need to own our part of the opioids crisis. We prescribe opioid painkillers (codeine, oxycodone, hydromorphone, etc.) too freely, which fuels the supply of – and demand for – opioids and other drugs, both legal and illegal.
Opioids are less effective and have higher addiction risk than we thought; we have to use them more carefully. But we have to change for the right reasons, and that starts with getting the evidence right.
How big a role do prescribed drugs play in the overall drug problem?
In the U.S., 12.7% of illicit drug users started on prescription pain relievers (National Survey on Drug Use and Health (NSDUH) 2014). I know of no exact Canadian equivalent but our rate is likely lower, perhaps around 10%. The U.S. consumes far more prescription opioids per capita than we do – around 50,000 standard doses per million people vs. 30,000 (International Narcotics Control Board 2015). We’re the world’s second-largest consumer, but a distant second. There is also far more misuse in the U.S.: 1.4% of Americans report using opioids in the past month in a way other than as prescribed (NSDUH 2015), compared to 0.3% of Canadians (age 15 and over) in the past year (Canadian Tobacco, Alcohol and Drugs Survey 2015).
What about fentanyl?
Alberta Health recently released data that gives us some important new insights. Prescription opioids were officially listed as a contributing cause of death in 5% of the 343 fentanyl overdose deaths in 2016. About half the people who died had been prescribed an opioid in the year before their death; of those, 7% had been prescribed a high dose – over 90 Oral Morphine Equivalents (OME) per day, the threshold for extra caution in the current U.S. guideline and the new draft Canadian guideline.
While the direct role of opioid prescribing in fentanyl overdose deaths looks small, there is a larger indirect role that is deeply worrying (bearing in mind that these measures are estimates from a fraction of the cases where medical history could be determined). Of those who had received an opioid prescription in their final year of life, 37% had prescriptions from multiple prescribers, 55% had a prescription for codeine, and 56% had a benzodiazepine (a tranquilizer used to treat anxiety, insomnia, etc.) prescribed as well as an opioid (Alberta Health, Opioids and Substances of Misuse, 2016 Q4).
These are high-risk practices and the fentanyl data underscores the urgent need for us to do better. But the larger reason we need to change is simply that it’s good medicine.
New Prescribing Standard of Practice
That’s the essence of the new Standard of Practice on prescribing approved recently by the CPSA Council. (Read it for yourself here: http://www.cpsa.ca/standardspractice/prescribing-drugs-misuse-diversion/.)
The new Standard took effect April 1, 2017. The message to doctors is simple: Use opioids in accord with sound clinical practice and relevant guidance, including the guideline from CDC in the U.S. and the similar new draft Canadian guideline from McMaster University, expected to be finalized soon. First and foremost, avoid making new addicts: use therapies other than opioids, especially for acute (short-term) treatment; when you do use opioids, prescribe the lowest effective dose for a short duration, typically just a few days’ worth for acute pain; and watch closely to make sure short-term therapy stays short-term.
Our new Standard requires doctors to check the patient’s record in the Pharmaceutical Information Network or a valid alternate source before prescribing an opioid, and at regular intervals for patients on long-term opioids. This is the first time we’ve been so specific about clinical practice, and it’s important. For now the requirement applies only to opioids and other high-risk drugs, but the larger message is that competent practice requires more use of information to make decisions and coordinate with other physicians, pharmacists and other colleagues, and with the broader health system. As a doctor you have to know what medications your patient is taking, not just what you prescribe.
Will the new Standard prevent the next fentanyl overdose? No, but it will help. More importantly, it reaffirms our commitment to evidence-based care for every patient, and it helps define what that means for every doctor. And I want to emphasize it applies to all doctors, not just those in primary care. We need hospital-based specialists, especially surgeons and Emergency doctors, to be more careful with opioids, and make sure the patient’s primary care provider knows if a patient has been started on them.
It’s important to be clear that the numerical thresholds in the guidelines are not rigid cutoffs; the numbers themselves are not our main concern. A doctor prescribing grossly higher amounts – say, in the thousands of OMEs per day – is going to hear from us directly. For the majority of doctors and patients, our concern is simply that patients get good care, including careful management of the risks of opioid therapy – not meeting numerical limits. We never want a patient abandoned or arbitrarily taken off opioids, or “tapered” to a lower dose without careful management.
The new Standard is where we’re going. What’s happening with opioid prescribing today? There is some good news: prescribing of opioids in Alberta has stopped increasing and is starting to come down. The graph shows that per-capita prescribing of all five of the main opioid painkillers is flat or down over the past two years. In total they’re down about 3%.
This doesn’t mean the crisis is over; we still have a big problem. We don’t have good current data to compare provinces but historically Albertans have been among the top per-capita consumers of prescription opioids. The difference appears to be all or mostly in our use of codeine, so it’s good that codeine prescribing is coming down. But we’re still using these drugs far too freely: 4,500 Alberta physicians have at least one patient receiving over 200 OME/day – the maximum suggested in the previous Canadian guideline, and more than double the threshold in the current U.S. and Canadian ones; 2,600 doctors have a patient receiving over 400 OME/day. Some of those patients are getting high doses appropriately as part of cancer treatment or palliative care; but over 60,000 patients last year received opioid prescriptions from 3 or more prescribers, and 8,000 patients received 3 or more different opioids (Triplicate Prescription Program Atlas 2015). Those situations are high-risk by definition: they raise the concern that patients’ total doses may not be properly monitored.
A broader strategy
Our new Standard of Practice is a step forward, but we need changes far beyond prescribing:
- We need to step up our commitment to harm reduction, including “rescue” interventions like naloxone, and safe drug consumption sites (which our Council has expressly supported).
- Family physicians need to manage more patients with opioid use disorder and other addictions; to do that confidently, they need education and training.
- All primary care providers need more access for their patients to publicly funded physiotherapy, psychology, and other resources to manage pain, to supplement services provided by Alberta Health Services.
- There are limits on what primary care providers can do; we urgently need more specialized chronic pain and addiction services.
- Insurers can help by providing more coverage of less-addictive non-opioid painkillers.
- We need to educate patients and the public about the risks of opioids. Opioids are over-used in part because patients demand them.
- We need better data on prescribing rates, abuse and addiction, and overdoses, for Alberta and for all provinces, so they can be compared.
As a regulator we’re doing our part and we’ll do more. The Alberta Government has taken good initiatives, including making naloxone more available and improving data collection and reporting. The bigger challenge is to recognize that drug overdoses are an addiction crisis. Fentanyl is frightening but we had too many opioid overdose deaths before fentanyl and we still do. We need to move beyond rescue interventions to a focus on the mental health problems and other issues that drive addiction.
– Dr. Trevor Theman, Registrar, College of Physicians & Surgeons of Alberta (CPSA). *Edited version published in the Globe and Mail April 7, 2017.