Chronic pain versus opioid crisis: A medical dilemma

People suffering from chronic pain are at risk of becoming collateral damage in the battle against opioid addiction and abuse.

New national guidelines for prescribing opioid painkillers, or fear of the consequences of exceeding the doses recommended in the guidelines, has some doctors denying pain sufferers the medicine they need.

One of the authors of the guidelines says if that is happening it is due to misinterpretation of the guidelines. Meanwhile, pain management advocates say the guidelines belong in a comprehensive provincial or national pain management strategy, but neither exists. Nova Scotia Liberals promised a pain management strategy before the 2013 election but once elected refused to engage the issue. There is a twoyear wait to get into Nova Scotia’s pain management clinic and, surprisingly, almost 20 per cent of the Canadian population suffers from chronic pain.

Nova Scotia, like the rest of the country, is fully engaged in a battle against illicit opioid use, abuse, addiction and overdose. A component of the effort attempts to strike at the source, so new guidelines have been adopted for doctors prescribing opioids.

Here the medical community diverges.

Some doctors say the proper, prescribed use of opioids as a painkiller is not related to the illicit use of the drug. Indeed, less than one-half of one per cent of people who take opioids for pain become addicted.

They dispute the extent, if not the existence of, any connection between prescribed medication and the street-level opioid problem. Most street drugs, they say, are synthetic opioids produced in foreign labs.

Other health professionals, focused on opioid abuse, believe there is a direct connection between prescription and addiction levels and that more prescribed drugs increase their availability on the street.

For chronic pain sufferers in need of opioid-based pain relief, the problem is threefold.

First, and most damaging, is physicians cutting back doses or refusing to provide prescriptions. Doctors fear sanctions if they are found to be overprescribing and are intimidated by letters or phone calls from the provincial drug monitoring board asking them to explain their prescriptions.

Second, chronic pain sufferers have become stigmatized and grouped with drug addicts, but they do not “get high” from their medications.

And third, people with opioid prescriptions may be considered a source of street-level drugs, but that is a rare and usually inadvertent occurrence.

These health professionals say people will die because of what one expert calls “the current harsh regulatory climate.”

Mary Lynch, a Dalhousie Medical School professor with more than 25 years pain management experience, said when pain sufferers are unable to legally obtain their medication, not only does their pain worsen and their quality of life deteriorate, but their risk of depression and suicide increases. Two of her patients committed suicide in the past year.

People might also turn to the illegal market and unwittingly buy highly potent synthetic opioids that might kill them.

“The media and others continue to cite rising deaths due to opioids, without clarifying that a large percentage of the current deaths are related to illicit highly potent fentanyl and other synthetic opioids coming across our borders from China,” Lynch wrote in a recent paper in the Canadian Journal of Pain.

Chronic pain sufferer Terry Bremner, an advocate for improved access to pain management, says he’s heard recently from several people unable to get their medication and who are on the verge of suicide.

“We are not arguing that opioids have not been overprescribed. We acknowledge that the lack of education of physicians regarding pain assessment and management, and the lack of access to appropriate nonpharmacological treatments, continue to contribute to cases of overprescribing,” said Lynch.

Gus Grant, CEO of the College of Physicians and Surgeons of Nova Scotia, chairs the provincial drug monitoring board and helped write the national guidelines.

He said doctors who are contacted by the board and asked to explain prescription practices may “feel a cold wind” but, he added, dealing with that is part of their professional responsibility, and the guidelines were painstakingly prepared in response to a national opioid addiction health crisis.

Grant understands the emotion inherent in the issue, and the fear people would experience if they were denied medications they needed.

But the guidelines are flexible. No one is to be cut off medication, no patient is to be destabilized and, in cases where tapering to a lower dose is not an option, the guidelines suggest alternatives.

Sunday marked the first day of National Pain Awareness Week in Canada. This year chronic pain sufferers are worried about the unintended consequences of a well-intended national opioid harm-reduction effort.

TOMORROW: Has the pendulum swung too far?