New opioid guidelines may worsen crisis: expert
New opioid guidelines for doctors may reduce prescriptions, but with an unintended consequence: the risk of more deaths, an expert in treating chronic pain argued at an Ottawa forum Saturday.
Dr. Greg Murphy, who founded the Kingston Orthopaedic and Pain Institute, said that the 2017 guidelines for Canadian doctors who treat chronic pain unrelated to cancer had “created fear” of prescribing among physicians.
The cause of the current crisis, though, Murphy said, is far more complicated than the prescription pad.
For example, Ontario leads Canada when it comes to opioid prescribing, but not opioid addiction or mortality, he said. Furthermore, not prescribing carries its own risks.
“If you cut people down from their opioids that are on them and doing well, then they’re going to self-medicate, they’re going to go to the street; there’s a possibility that we could have a worsening of the epidemic,” Murphy said. “That’s actually what’s been shown in some of the United States, from their states’ records. The opioid prescribing has dropped and the opioid death rate has increased. These are the unintended consequences that I don’t think people have thought about.
“That’s what happens when you make a decision because it’s the easy one. It’s really hard to tackle mental health and addiction, it’s really easy to say doctors are to blame.”
Murphy spoke Saturday at 2017 Ottawa Pain Day, the sixth annual event organized by the Ottawa Pain Physician Network, which drew several hundred people.
He argued opioid guidelines released in 2010 were actually instructive, walking doctors through how to decide whether to use opioids, how to start and maintain patients on the drugs and what to watch for in case of complications.
Illicit opioids are readily available — in Kingston, fentanyl has replaced heroin on the street — and research shows when people are most likely to die of overdoses: When they’ve stopped taking opioids — and again become “opioid naive” — then take them again; when they’re starting or increasing a new dose; when they buy drugs from unknown sources; and when they mix them with other depressants, such as alcohol and benzodiazepine, Murphy said.
“For me, I’m not saying that we don’t have to look at our prescribing. There are people that are not prescribing properly,” Murphy said. “But I don’t think the few people who are out of line are indicative of prescribing patterns in Ontario.”
His advice was doctors should “start low and go slow” and “look critically” at every opioid prescription to make sure the treatment is actually helping a patient. Patients should be prescribed the lowest effective dose. That dose should only be continued if assessments show the patient is less physically disabled by pain, not just that they think they’re feeling better.
He starts treatment by making agreements with patients that it will stop if it’s not effective. He runs urine tests for other drugs and does an addiction screening questionnaire to start the conversation about the risk. Most patients don’t get months of pills at a time and, if Murphy has any doubt about a patient’s use, he will ask them to bring their pills to their next appointment so he can count them.
Most of the doctors who attended the pain session are general practitioners and their key concern is how to prescribe safely, Murphy said.
But amid the suggestion by some that doctors’ prescribing habits are in part to blame for the crisis, some of the safer drugs that are recommended for pain control aren’t covered by the Ontario government, while non-drug help for pain, such as physiotherapy, isn’t covered at all.
With one in five people suffering from chronic pain, family doctors will be called on to help, and they need more tools, Murphy said.