Medical Assistance in Dying
The suspense around Bill C-14 is over. The Criminal Code has been amended to allow for medical assistance in dying (MAID). Physicians should familiarize themselves with the law and with the College’s MAID Standard of Practice, a new standard just approved by Council in May. Our homepage offers easy navigation to relevant materials from AHS and the College, and a link to the amended Criminal Code.
While proclamation of the federal legislation is a milestone, it is also only a step along the way. Many predict legal challenges to this new law, and the federal government has committed to begin addressing a number of related and difficult issues including the age of consent for MAID (do mature minors qualify?) and the question of advance directives. These are big issues, and resolution will neither be easy nor simple. It makes sense, therefore, for members to gain a good understanding of the current state, recognizing that the final chapter is years away.
Here in Alberta, a small group from AHS, Alberta Health and the regulatory community (pharmacy, nursing and medicine) meets by phone every couple of weeks to share intelligence, discuss issues and brainstorm solutions. After doing this for some months, this degree of cooperation has come to seem routine and natural, when it is anything but routine and natural. It is, however, a great example of what can be accomplished when we work together, and when we don’t care who gets the credit.
Recently I highlighted the new guidelines for opioid use for non-cancer pain published by the US Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm). In comparison, Canada’s national opioid use guideline, the revised version of which should be available in February 2017 (http://nationalpaincentre.mcmaster.ca/opioid/), is most strikingly different in its position on the ‘watchful dose’ of opioids (200 oral morphine equivalents – OME – per day) and in its tone.
Notably, the CDC guidelines state: When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
The second difference is the tone of the messaging. The CDC guideline states: Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
The evidence supporting the guidelines is very similar; how that evidence is framed as clinical guidance is also similar in content, but different in tone. In short, the National Opioid Use Guideline (Canadian) comes across as more permissive – opioids can be used for chronic pain; here is the evidence and here is how opioids can be used rationally and responsibly. In contrast, the CDC guideline (US) is more direct that opioids are not first-line therapy for chronic pain; other therapies are more effective.
The differences may be in recognition of how large the opioid crisis is in the US or may be a reaction to changing times and changing attitudes toward opioid use for chronic pain. The message, regardless, is clear: the medical profession, in good faith and with good intent, had a major role to play in creating the opioid problem in both the US and Canada, and now it must play a major role in both addressing the problem and preventing future opioid-related issues.
The Canadian guidelines are currently under review. Whether they will more closely adhere to the CDC guideline regarding the ‘watchful dose’ is probably less important than the tone of the advice to physicians around the initiation of a trial of opioids for chronic pain.
Why raise this topic again? Because at the CPSA we’re changing our approach to the information we provide to members about their opioid prescribing. While we’ll continue to monitor and assist those members who have patients taking high doses of opioids, multiple types (short and long-acting) of opioids, and combinations of opioids with other drugs (such as benzodiazepines), we will also provide feedback to members who have patients using dosages beyond the watchful dose.
Rather than targeting only high-volume and high-dose prescribers, we’ll be connecting with a much larger cadre of physicians who have patients on opioids. Our goal is to have wider and deeper impact on physician prescribing of opioids (when the use of an opioid is indicated), recognizing that the best outcome for many patients with chronic pain is better treatment with nonpharmacologic therapy.
What can members do now?
- Familiarize yourselves with both the CDC and Canadian guidelines
- Ask whether you have patients receiving opioids beyond the ‘watchful dose’
- Request a copy of your prescribing snapshot from the College – the address is (CCInquiries@cpsa.ab.ca); this will provide you a view of your prescribing of opioids and other drugs of potential abuse
- Consider how you might assist those patients in reducing their dose, seeking addiction treatment or substituting alternate therapies (methadone or buprenorphine)
- Look for opportunities to help patients seeking help for chronic pain to avoid the use of opioids whenever possible
As always, I welcome your feedback. Join the conversation by commenting below or email me at firstname.lastname@example.org,