‘Overlooked’ patients amid the opioid crisis
Many feel abandoned as they find it difficult to get the pain relief they need
NEVER
BEFORE has more attention been paid to chronic pain sufferers with long-term and high-dose opioid prescriptions.
Last week alone, Health Quality Ontario asked for patient feedback as it finds ways to evaluate opioid prescribing for chronic pain.
The College of Physicians and Surgeons of Ontario updated its prescribing policy, created a web portal to provide public information and sent a message to patients living with non-cancer pain.
And the Canadian Institutes of Health Research declared national standards led by McMaster University to be “unbiased” and “scientifically rigorous” despite concerns about financial conflict of interest.
Yet many feel abandoned as they find it increasingly difficult to get the pain relief they need in the midst of a deadly overdose epidemic.
“I do have a heart for people who are addicted and we have to do something, but what about me?” said one west Mountain patient who does not want to be identified for fear his house will be targeted by drug thieves.
“Legitimate opioid users have been overlooked by the public and by the policy-makers.”
The former logistics manager takes 90 mg per day to cope with chronic pain from a past spinal surgery.
The dose is higher than what is recommended in the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain published in May.
“One of the things I was quite surprised about was how quickly the new standards cascaded down,” he said. “My (family) doctor has been honest with me, saying that as the new guidelines come down, she is basically told to lower what she is prescribing to people.”
His story is all too familiar to the guideline’s lead author Jason Busse, an associate professor in the department of anesthesia at McMaster.
“I have heard from some patients
“I was told to reduce so I did. It’s terrible. It’s very, very hard.” PATIENT PRESCRIBED OPIOIDS FOR CHRONIC PAIN
that this may be occurring,” Busse said.
“This should be a discussion that happens between the patient and their physician to determine if they are comfortable with a course of tapering.”
The guideline does recommend lowering long-term doses that are 90 mg or higher but it makes it clear the decision ultimately rests with the patient.
“We have limited evidence for this recommendation,” Busse said.
“Because of this, it’s reasonable for one patient, informed by their physician of the benefits and risks and the associated uncertainty, to choose to try to lower their dose, but another given the same information might choose to leave well enough alone …
“It depends on the patient’s values and preferences.”
The standards also acknowledge there are risks to decreasing the dose, including opioid withdrawal.
“Some patients may have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction,” Busse said.
“Tapering may be paused or potentially abandoned in such patients.”
But the west Mountain man says he felt pressured to reduce his dose by about 50 per cent. So far, he’s down to 60 mg a day with the help of medical marijuana.
“I was told to reduce so I did,” he said. “It’s terrible. It’s very, very hard.”
He feels like he’s lost the balance that kept the pain in check for the last five years on opioids.
As well, the marijuana costs more than $1,000 a month but isn’t covered by drug plans like the MS Contin he takes.
“Marijuana is helpful for pain that is three to five out of 10,” he said. “But when you get sharp nerve impingement pain that is seven or eight or nine out of 10, it’s not going to help at all. The only thing you can do is take pain meds.”
He’s frustrated and feels he’s no longer getting the treatment he needs.
“I’m not abusing the medication,” he said. “I’m taking it as prescribed. I find it unfortunate that outside circumstances are impacting what I’m able to get.”
There are similar stories across Ontario, says Michael Parkinson, who works with the Waterloo Region Crime Prevention Council and the Municipal Drug Strategy Coordinators Network of Ontario.
“Laws and policies are blunt instruments and … don’t serve everybody,” he said.
“The other deficit would be really providing physicians and pharmacists with the tools they need to improve successful tapering of patients.”
It’s significant because there can be deadly consequences if chronic pain patients have to seek relief from illicit drugs.
“The fear in Ontario was that many folks would end up turning to the black market when they were cut off by their physician or were not successfully tapered,” Parkinson said.
“As we know, the black market has never been more toxic and dangerous with the bootleg fentanyls.”
More than 7,200 people have died in Ontario from opioid-related poisoning since 2000, Parkinson said.
While prescribing is levelling off, overdose deaths continued to increase in 2016.
“What has developed really late in the day is a general recognition that opioid prescribing should fall in line with the clinical evidence and a general recognition we need to dial back opioid prescribing given the range of adverse effects known to occur,” Parkinson said.
But many patients don’t have the backing of the multidisciplinary teams the guideline strongly recommends to support long-termopioid patients as they try to lower their doses.
“In Canada right now it is certainly not the case that everybody has ready access to multidisciplinary tapering support teams,” Busse said.
“We did recognize there is a resource element that is relevant to that recommendation.”
The west Mountain man says the worsening epidemic has left the public and health-care workers automatically associating opioids with danger.
“Opioids have caused a lot of hurt, but they’ve also done a lot of good,” he said.
“I’m one of the ones that most people don’t know about …
“Policies need to strike a balance between helping those who are vulnerable but not impeding other people who are benefiting.”
Legitimate opioid users have been overlooked. WEST MOUNTAIN PATIENT