Trevor’s Take On: Opioids and Referral Consultation

Dina Baras Messenger, Trevor's Take On 3 Comments

Opioids

Recently, Associate Minister of Health Brandy Payne announced financial support for the application by a group in Edmonton to establish safe consumption services for drug users. Informed by the success of Insite in Vancouver, a proposal to provide this form of harm reduction also received unanimous support from the Council of the College of Physicians & Surgeons of Alberta in September. This is truly an evidence-based public health initiative, and I applaud Minister Payne and our Chief Medical Officer of Health, Dr. Karen Grimsrud, for their leadership.

Just a couple of days earlier, the CPSA hosted a forum on opioids in Edmonton where, with our partners, we identified 5 key goals to address the opioid crisis.

  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

The entire event was recorded and a webcast of the proceedings is available on our website. I encourage you to watch the forum and look forward to hearing your feedback on our draft Standard of Practice on Safe Prescribing.

Referral Consultation Standard of Practice

Dr. Michael Caffaro has become the point person for feedback and response to the implications of this revised Standard of Practice. Mike is responding to the comments on our blog, and I encourage you to read the back and forth.

I am surprised that we are now getting such pushback when the consultation – completed between April and June – resulted in so little feedback. As we want our standards to strike an appropriate balance between serving patient needs and setting reasonable expectations, we make a concerted effort to solicit input on draft documents. For the Referral Consultation standard, we included the following:

  • A specific request to section heads at the AMA, asking for their feedback.
  • A mass email to all members
  • Two Messenger articles (April and June)
  • Posts on Twitter
  • Notices in the AMA’s MD Scope and the Alberta College of Family Physicians web news.

I point this out because the revised standard is now approved. Short of another revision, and the process that accompanies any standard revision, this is (as of January 1, 2017) the Standard of Practice. Only College Council can change it, and that process takes time.

Two messages from this experience are worth stating:

  1. Members who don’t want to find themselves saying “Holy Cow, look what the CPSA has done” may want to pay attention to the draft standards and draft revisions when they come out.
  2. The revised referral/consultation standard will become operative January 1, 2017. That means Alberta physicians have less than 2 months to look at their referral and consultation processes and ensure compliance with the new standard.

Annual Fee

This is the time of year we begin notifying members of the need to renew one’s practice permit and complete the Registration Information Form (the RIF). We’ve been working hard to reorder and simplify the RIF, and to include only that information which we need for our work.

On that front you will find that we no longer ask whether you have had a civil lawsuit launched against you or whether a finding was made against you (or a settlement made). After a two year trial, we found the information not valuable and a significant drain on resources . Our Professional Conduct staff found little value from the information gleaned from such reporting, and the work of following up, asking questions and seeking further information was significant, and disproportionate to the usefulness of the information.

As to the annual fee, it will remain at $1960, as it has for the past five years. However, we are no longer collecting $150 per year for a building fund. That means that the entire annual fee of $1960 will go to College operations.

Side Comments

Two items of a certain age came to my attention recently.

The first is that of so-called “Conversion Therapy”, psychological treatment or spiritual counseling designed to change a person’s sexual orientation from homosexual or bisexual to heterosexual (so says Wikipedia). I’d heard of this as a young physician in the days when any gender identity other than heterosexual was considered deviant; I’ve never heard of it being practised by medical professionals in Alberta.recent article

It was brought to my attention by a recent article published in the Journal of Medical Regulation and by an inquiry from our Ministry of Health. The Ministry official was concerned that such therapy might be offered in Alberta by physicians and, if so, wondered what stance the CPSA would take.

I assured the official that I was not aware (and have never been aware) of physicians in Alberta offering or promoting such treatment, and assured the official that the College would consider the offering or promotion of such an approach to be improper, unethical, unscientific and unprofessional. In short, we would take action against a physician who we found to be offering or promoting such practice.

The second item is that of female genital mutilation (FGM), sometimes known as ritual cutting. While the exact practice varies, it generally involves removal of the clitoris and portions of the labia, resulting in a tiny vaginal introitus, and is usually performed on girls prior to puberty.

The specific question put to me was this: Should physicians who see children who’ve been subjected to this procedure be reporting suspected child abuse to appropriate authorities?

The relevant legislation (the Child, Youth and Family Enhancement Act) says that a child is in need of intervention if there are reasonable and probable grounds to believe that the survival, security or development of the child is endangered because…(2(h)) the guardian of the child has subjected the child or is unable or unwilling to protect the child from unusual treatment or punishment.

In our society, allowing – or subjecting a child to – a mutilating procedure like FGM is clearly and obviously unacceptable. As the child’s welfare supersedes any cultural justification for such practice, two conclusions come to mind: the first is that physicians who see a girl who’s been subjected to such a procedure should report to child welfare; and the second is that no physician should be complicit in such practices. What I mean by the latter statement is that no physician should perform such procedures, irrespective of cultural norms in other societies, and no physician should be complicit in allowing such procedures to go ahead (if, for example, the physician is consulted by the parents about having the procedure performed, either by the physician or an unregulated person). And, finally, in compliance with the relevant legislation, physicians should report to Child Welfare any child who has been subjected to such abuse.

I welcome your comments

Trevor Theman

3 Comments on Trevor’s Take On: Opioids and Referral Consultation

Trevor Theman said : Subscribe Nov 09, 2016 at 4:21 PM

Thank you for your comments and concerns Mr. Sandercock.

I recognize there are patients who are well-managed on opioids for treatment of their chronic pain, and I (and the College) have no intention or desire to interfere with good care and good patient outcomes.

We are concerned, however, about the the very high use of opioids in Alberta (and Canada) and about prescribing practices that may put patients at risk.

We are also promoting access to evidence-informed pain treatment for patients, which ideally will include a multi-disciplinary approach that incorporates both drug and non-drug treatments and approaches. 

I encourage you and others to view the webcast of our opioid forum on our website.

Trevor Theman

 

    Wlodzimierz Zakrzewsku said : Subscribe Nov 10, 2016 at 5:03 PM

    Thank you for addressing a sad issue of child sexual mutilation.

      Gregory E Sandercock said : Subscribe Nov 07, 2016 at 6:28 PM

      I presently receive Rx for OxyNeo and 20 mg Oxycontin.  I have severe arthritis in my lower back, both knees but more on the left knee, both shoulders, my neck, and my hands and wrists are getting worse too.  I'm 57 years old.  about 3 or 4 years ago, my thyroid died and I gained close to 130 lbs in very little time. I also have trouble with my Esophagus  I work a full time job and my employer is very supportive of me in-spite of my lack of mobility.  

      I see my family Dr. and a pain management Dr. at Healthpoint. While I have I daily dosage, I take my medication responsibly and work. 

      If I don't have medication, I would have to go on disability. I would stop being a productive member of society. 

      I am more than well aware of the issues.  For one thing, I worked for AADAC in the Opiate Dependency Clinic until 2004 when AADAC change the program.  I have training in Addictions studies and Mental Health from Grant MacEwan and U of A Extension Center. 

      Please allow me to keep working.  If truly fear that I will not be able to work if I do not have enough medication to cope with the pain issues I have.  As an older man, my job is pretty much all I have.   It is sad but I contribute to society.  I am not a criminal.

      The antidotal innuendo the  Edmonton Police Service is sharing on TV makes it sound like all patience that need medication to help them cope with physical limitations they experience is not fair to those of us that follow the rules and the laws. 

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