There is no simple or quick fix to our society’s opioid crisis
Early one morning, while leaving my downtown Toronto home, I heard the quiet crying of a young woman lying in the alleyway. I saw a tourniquet and needle on the ground, her valuables scattered in disarray. I stopped and offered to take her to a centre where she could get help.
Tragically, this is an all-too-common occurrence across the country. Scenarios like this will only increase if we restrict opioid prescribing for chronic pain. We have an opioid abuse problem in Canada, but we must be careful about how we address it.
Politicians are under significant pressure to make quick decisions about this issue and see the solution in restricting prescription opioids. Changing healthcare policy based on the false premise that a restriction of opioid prescribing will immediately benefit our society, save lives, and solve the “opioid crisis” is misguided.
A blurring of two issues has occurred. The death rate associated with illegal drug use is not related to the risk of overdose among chronic pain patients who are using an opioid long-term under the care of a qualified pain physician. Publications on the increase in opioid-related deaths in Ontario lack data on other substances ingested (e.g., alcohol and benzodiazepines) and whether or not the person had a history of mental health problems.
Prior to prescribing an opioid, every physician should inquire about a patient’s history of mental health problems, abuse, addiction and their living situation. The relevant information may not preclude an opioid prescription, but, in some cases, would certainly trigger a modification of prescribing practices and referral for other nonpharmacological interventions.
Although four-out-of-five heroin users admit their path started with a “prescription” opioid, this does not mean she or he was prescribed the opioid. They likely acquired it from an individual to whom it had been prescribed or they purchased it illegally.
The Toronto General Hospital Transitional Pain Service is at the forefront of managing pain and coexisting opioid misuse and addiction. The multidisciplinary program combines the worlds of pain medicine and addiction to help people with their pain while optimizing opioid use.
We recognize that people with chronic pain not only use prescription opioids to relieve pain; some also may misuse them to avoid withdrawal symptoms that develop with long-term use at high doses or to manage other unpleasant symptoms. However, the public is entitled to know there are many people who function extremely well on their opioid-based medications.
Pain specialists provide safe and effective care to thousands of Canadians with chronic pain who enjoy productive and fulfilling lives given the pain control they obtain from opioid medication. Earlier this year, the Centers for Disease Control (CDC) published guidelines for prescribing opioids for chronic pain, highlighting the importance of integrating nonopioidbased pain medications with non-pharmacologic treatments for chronic noncancer pain.
Since 2014, the Transitional Pain Service has provided such a tailored approach to patients before and after major surgery by combining psychological interventions, nonopioid medications, acupuncture, and physical therapy all with an emphasis on weaning off opioids as soon as possible and within reason. Moving forward, provincial funding plans for pain programs should be focused on supporting services that emphasize functional recovery and psychological health as much as medical well-being.
Restricting medication is not a solution. We need to drive change locally, provin- cially and nationally.
“Low-hanging fruit” to target for effective change in the prescriber world includes:
Eliminating fentanyl patches for all but cancer and palliative care patients. Creating tamper-resistant solutions. Targeting areas of health care where opioids are often mismanaged, which includes postsurgical pain, inflammatory bowel disease, multiple arthritic conditions, pediatric/adolescent conditions such as sickle cell disease, emergency departments, and so on. Improving physician education. Advocating for more psychological services.
Proposing an overnight change that restricts opioid prescribing indiscriminately will lead to a worsening of the illicit drug epidemic in this province. People with chronic pain who presently obtain their opioids through prescription and have never resorted to illicit use may be forced into illegal channels if placed into acute withdrawal.
The circumstances of the young woman described above will become increasingly common in neighbourhoods across our province. There is no quick fix to our society’s opioid crisis; a concerted effort is required from government, law enforcement, industry, and pain management and addiction experts who are on the front line. Dr. Hance Clarke is the director of pain services and medical director of the Pain Research Unit at Toronto General Hospital. He is an assistant professor at the University of Toronto. Dr. Joel Katz is a professor and Canada Research Chair in health psychology at York University. He is research director of the Pain Research Unit at Toronto General Hospital.