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MDs must help to end opioid epidemic

New guidelines warn MDs to prescribe fewer opioid pain relievers. @NightshiftMD assesses the potential impact.

The Canadian Public Health Association says the opioid crisis in this country has led to an epidemic of overdose deaths.  Canada is the world's second highest per-capita consumer of opioid pain relievers, right behind the U.S. That country has taken steps to deal with the crisis. Now, there are hopes that new prescribing guidelines for doctors in Canada will do the same here. 

The 2017 Canadian Guideline for Opioid Therapy and Chronic Noncancer Pain calls on doctors who treat people with chronic pain to restrict the prescribing of opioid drugs like Percocet, OxyContin, Dilaudid and morphine.  The guidelines recommend that doctors prescribe non-drug treatments and non-opioid drugs as much and as optimally as possible before even considering a prescription for opioids. They say that opioids should only be prescribed after other treatments are tried and only after other treatments are given a fair trial.

The guideline also sets dosage limits.  It recommends a maximum dose of 90 mg of morphine per day, but suggest going no higher than 50 mg a day. 

The guideline addresses the problem of opioid abuse in several ways. One is by restricting the prescribing of opioids to patients who have not responded to a thorough trial of other treatments.  By establishing a maximum dose of 50 to 90 mg a day, the guidelines also remove the temptation for doctors to keep upping the dose, a factor implicated in rates of addiction and overdose deaths. It so happens that the dosage limit is also one of the key recommendations in the guidelines by the U.S. Centers for Disease Control.  

In addition, the new guideline suggests that doctors avoid prescribing opioids to patients with a prior history of alcohol or drug abuse or active mental health disorder.  These two high risk groups have driven epidemic rates of opioid addiction and death.

For patients already receiving high doses of opioids, the guideline recommends that doctors encourage patients to taper down to the lowest dose that's effective at relieving pain.  If the patient remains comfortable, the doctor should encourage the patient to get off opioids entirely.  The authors acknowledge that some patients may have a big increase in pain or decrease in function as the dose is tapered; should that happen, they recommend hitting the 'pause' button on cutting the dose.

For the new guideline to reduce the opioid epidemic, doctors must know and follow the new rules. There's evidence that previous guidelines weren't followed by doctors, which is why the authors of the new rules are applying for federal funding to disseminate them to prescribers.  

If we want to look to the future, the U.S. is ahead of Canada at trying to reduce opioid abuse.  States and the federal government have far more data than Canada on patterns of prescription opioid abuse. They were the first to create drug-monitoring programs and have been much more effective at prosecuting unscrupulous doctors. The result in the U.S. has been some stemming of the supply of opioid pain relievers, but progress there has been slow.  Meanwhile, in that country, some users have turned instead to heroin, which is cheap and plentiful. In 2014 more Americans sought treatment for heroin than for any other drug, and heroin deaths are on the rise. I could see the same thing happening here.

A Commentary published alongside the guideline says that reducing the willingness of doctors to prescribe opioids addresses issues like addiction and overdose deaths. But it doesn't deal with the fact that an estimated 15 to 19 per cent of Canadians have chronic pain lasting more than three months and affecting their quality of life.  

The Commentary says that there are numerous barriers to treatment of people with disabling chronic pain. These include lack of timely access to safe, effective and affordable treatments.  Comprehensive pain clinics have unconscionably long wait lists.  Patients are often treated with a rushed visit and little empathy. The provinces don't pay doctors enough money to spend the time doing a proper assessment.

The authors of the Commentary say the updated guidelines will not address the opioid crisis without a national pain strategy that addresses these and other issues.  On that issues, I am inclined to agree.

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