Woman seeks doctor. Must be willing to prescribe opioids
Human rights tribunal case underscores dilemma for family doctors trying to combat opioid crisis
She had been taking opioids for back pain for more than three decades.
The trouble began when she needed a new doctor.
Known only as DT — to protect her privacy — the B.C. woman has lost her bid to file a human rights complaint against three family physicians who refused to bow to her demands that they continue her prescriptions.
'Red flag for opioid dependence'
The case lands at the intersection of two medical issues currently facing British Columbia: a lack of family doctors and an opioid crisis that has claimed the lives of thousands.
The woman claimed the doctors discriminated against her for a disability in that they allegedly refused to take her on as a patient once they learned of her need for opioids.
But in each case, the doctors claimed the woman's insistence on continuing her prescription flew in the face of guidelines aimed at diverting patients away from powerful opiates that should never be prescribed for chronic pain.
The B.C. Human Rights Tribunal decision cites the response of one of the physicians — Dr. D.
"In his opinion, based on his training and experience, if a patient comes in at a first appointment specifically seeking a doctor who will prescribe them strong opioids, it is a red flag for opioid dependence and abuse."
32 years — 'no side-effects'
More than 1,400 people died of illicit drug overdoses in B.C. in 2017 in what the province's chief coroner labelled "the most tragic year ever."
In response, the B.C. College of Physicians and Surgeons has issued a practice standard for the safe prescribing of opioids and sedatives.
As part of its rationale, the college states that "the profession has a collective ethical responsibility to mitigate its contribution to problematic prescription medication use, particularly the over-prescribing of opioids and sedatives."
According to the human rights tribunal decision, DT says she has chronic pain in her lower back caused by two broken vertebrae that were fused with screws inserted.
"She says that she has been taking an opioid prescription for 32 years, with no side-effects," the decision states.
She sought a new family doctor when her old one left the country.
The woman claimed one physician "ushered her out" as soon as he heard she was on opioids. She claimed another told her "he did not want her as a patient."
And yet another said he couldn't take her on "because of the opiate prescription."
'Not in her best medical interest'
But the doctors saw things differently.
The first said the risks far outweigh the benefits of opioid prescriptions for anything but chronic cancer pain.
"(He) says he advised DT that he was unwilling to continue prescribing opiates for her chronic back pain, but that he could take her on as a patient if she was willing to try other treatment options," the decision reads.
The second cited the college's prescription standard and said that DT got upset when he told her that continuing a prescription for depressants along with opiates "was not in her best medical interest."
And the third said that he didn't refuse to take DT on as a patient, but that it was "his medical opinion that the requested opioids were not appropriate for (her) chronic pain."
'Not going to help anybody'
University of B.C. clinical associate professor and addictions expert Dr. Launette Rieb says the case highlights the challenge of weaning patients away from the longstanding use of opiates.
"The big challenge for this patient would be finding a new doctor," she said.
"New doctors are not supposed to cherry pick and say, 'no, I won't deal with you.' But they are also not obliged to prescribe what they consider to be an unhealthy prescription just because the patient wants it and is now dependent."
Rieb says the evidence supporting the use of opioids for chronic pain is very poor. But years of prescriptions have effectively created a dependence in many people.
She travels around the province working to teach family physicians how to get patients off painkillers.
"We have to be careful with a tapering schedule, so if you do try to taper them really fast and they get into a lot of withdrawal and they go to the street, that's not going to help anybody," she said.
"It needs to be done in a slow compassionate way with a lot of hand-holding and support. But it's a lot of work. It's a lot faster to put someone on an opiate than to take them off."
The tribunal ultimately decided that even if DT proved she had a disability, she couldn't prove it was a factor in her treatment:
"If that were the case, any physician's offered treatment would potentially be discriminatory."