War on drugs has become war on pain sufferers

Prescribed opiates rarely hit streets, writes Barry Ulmer.

The College of Physicians and Surgeons of Alberta is happy lately, at least according to the medical regulator’s new registrar. Dr. Scott McLeod wrote in these pages last week that doctors contributed to Alberta’s “opioid crisis” by over-prescribing, and now they’re going to help fix it. “We need to prescribe opioids more appropriately,” he wrote, “and that means less. Already, prescriptions for Albertans in pain are way down, and that’s terrific.”

Terrific for whom?

Many of Alberta’s doctors feel terrified, not terrific. Under the college’s watchful eye, most no longer dare to prescribe their patients effective pain relief. The consequences are predictable: their patients aren’t feeling terrific either. Instead, they’re back to the misery they left long ago before opiates became the latest whipping boy in the U.S., and now Canada’s interminable and ill-informed “war on drugs.”

This time, the war on drugs has become a war on pain patients. How about a war on pain for a change? Taking stable pain patients off opiate analgesics or reducing them to doses too low to work has caused them pointless suffering and even death — by suicide, or by overdosing on the street drugs they’re forced to buy to top up the small bit of legal analgesia they’re now allowed. For doctors, it’s led to “a climate of fear” around prescribing. In November, three Ontario physicians published an open letter in the Canadian Medical Association Journal confirming all this and saying it has to stop. I know doctors who cheered. Is anyone surprised?

While doctors are indeed prescribing less, Alberta’s opiate overdoses are still going up — from 2016 to 2017 by a whopping 40 per cent. The trend is Canada-wide: less prescribing, more overdose deaths. That’s because prescribing is one thing and street-dealing quite another. Canada’s doctors haven’t contributed to street deaths. Patients haven’t been doctorshopping, nor have they been faking pain to get

There is a lot of recent evidence that medical use doesn’t cause addiction.

prescriptions or selling their medications to dealers and addicts.

Prescribed drugs rarely make it to the streets. The single study we have on Canadian “diversion” rates, from 2012, says data is too “fragmented, unsystematic, and insufficient” to inform evidence-based policy. (A 2015 update says more of the same.)

But there is a lot of recent evidence that medical use doesn’t cause addiction. An analysis of 17 studies involving 88,235 patients and published in the medical journal Addiction concludes there’s little risk of addiction for people using opiates for pain. A study from the Journal of the American Medical Association cited last May in the Canadian Journal of Pain found that of 39,140 Ontario surgical patients, only 0.4 per cent were on an opiate a year after surgery, and then likely for ongoing pain.

Likewise, a study by the American College of Surgeons found that of 7,302 patients recovering from major trauma, nearly half filled an opiate prescription after discharge, though only 0.9 per cent still used an opiate a year later.

These studies put the addiction rate from medical exposure at 0.4 to 0.9 per cent — infinitesimal. But that hasn’t stopped Canada’s colleges from demanding that doctors make their pain patients sign “contracts” and agree to urine testing (and, by some reports, even blood testing) as if they’re criminals or at least addicts, all the while they tell patients unhappy about their pain care to complain to the college, which caused it.

Last October, Alberta’s pharmacies joined the war on pain patients by playing doctor and subjecting patients filling opiate prescriptions to up to an hour of “counselling,” even people who’ve used their medications for decades and know their effects far better than pharmacists do. Picking up refills gets you pulled out of line and “counselled” too. No other customers have their privacy violated in this way.

For several years now, Canada’s medical regulators have been chasing the wrong fix for street deaths. By “deprescribing,” doctors are scapegoating their pain patients for something patients have nothing to do with. We wouldn’t kick a dog when it’s down, but in Alberta, as in the rest of Canada, people in pain are now fair game.