Blame street drugs, not doctors, for opioid emergency, physician insists
Regulator, lobby group urged to alter ‘foolish’ mandatory prescribing rules
Dr. Ian Mitchell wants the head of the College of Physicians and Surgeons of B.C. to resign and apologize for forcing what he calls “ill-founded, foolish” mandatory prescribing standards that make doctors feel like criminals for prescribing narcotics and other potentially addictive medications.
Mitchell, a North Delta family physician, made his demands in letters to both the college, which is the doctors’ regulatory body, and to Doctors of B.C., the organization which lobbies on behalf of physicians.
Mitchell said he, like other doctors who’ve spoken out against the prescribing standards, worry that their careers and reputations could be ruined by college investigations.
The standards require doctors to prescribe opioids only as a last resort, at the lowest doses and for the shortest duration, and to monitor patients for risks or signs of addiction to narcotic painkillers. The college also stipulates narcotics and sedatives should not be taken at the same time.
The rules came into effect in June when B.C. became the first province to threaten doctors with disciplinary action for not following them. The college said it implemented the new standards because of inappropriate prescribing by doctors and fatal overdoses, most of which are linked to the narcotic fentanyl.
“The confluence of those two things gave us the impetus to go forward,” deputy college registrar Dr. Ailve McNestry said.
Canada is second in the world for narcotic consumption, behind the U.S., and B.C. has historically had one of the highest opioid dispensing rates in Canada.
College registrar Dr. Heidi Oetter told doctors attending an opioid information session a few months ago that the college acted because despite decreasing opioid prescriptions in B.C. in recent years, there are still too many patients addicted to such medications including morphine, oxycodone, dilaudid and fentanyl.
Mitchell, a family doctor, doesn’t deny there’s a public health crisis, but claims doctors have nothing to do with the record 555 opioid overdose deaths so far this year because they all involved illicit drugs, not prescription medications.
Current data on deaths from overprescribing is elusive, but a 2014 college report on prescription opioid overdose deaths showed 110 deaths in the Interior Health region alone between 2006 and 2011. The vast majority of cases were accidental (not suicide), involving middle-aged patients with chronic pain.
Nearly half of those who died from such overdoses were also being treated with medications like anti-depressants, sedatives or antipsychotics for mental health issues.
Mitchell said the college used “extraordinary powers” and had no business telling doctors they must not simultaneously prescribe sleeping pills or other sedatives and painkillers. Used together, the drugs depress respiratory functions. But Mitchell said he’s never had a patient die from his prescribing practices.
“Patients need to sleep at night. If they don’t, it messes with their immune systems and they can’t function during the day,” Mitchell said.
“I have patients who need a low-dose sedative and a low-dose narcotic for their pain. But under these standards, I am being made out to be a criminal breaking the law even though I’ve been safely prescribing (the combination) to patients for 40 years.”
He’s asked Doctors of B.C. to discuss his complaint at its next board meeting. Besides the resignation of Oetter and an apology, he wants the standards scrapped. Susan Prins, a spokeswoman for the college, said Mitchell won’t get anywhere. “The college board stands firmly behind the principles contained in its standard on safe prescribing and believes it is written with enough flexibility for physicians to make decisions that are in the best interest of their patients. There has been wide support from the profession, as evidenced by Dr. Alan Ruddiman’s comments,” she said, referring to the president of Doctors of B.C.
I have patients who need a lowdose sedative and a low-dose narcotic … I am being made out to be a criminal … even though I’ve been safely prescribing (the combination) to patients for 40 years.
Ruddiman said that as prescribers of opiates, doctors “have a significant responsibility and role to play in helping to end” the rash of drug overdoses in B.C.
In a recent commentary in the B.C. Medical Journal, he said he’s heard many doctors question the “manner and method” used by the college, yet there’s no doubt there’s a problem.
“This doesn’t mean we should shy away from prescribing opioids in a safe and appropriate manner when clinically necessary ” he said.
“We need to screen for and listen to those who are indeed addicted, suspend any judgments we have that label them as drug-seekers and recognize that their addiction is a medical condition no different than diabetes, hypertension or chronic kidney disease.”
McNestry said she’s heard complaints from doctors offended by the standards because they feel they’ve lost autonomy.
While there have been deaths stemming from prescriptions, no one seems to know how many. Some who’ve died were addicted to both prescribed and illegal drugs, she said. In a recent commentary in The Sun, Vancouver doctor Ian Scott said the medical profession has been complicit in the opioid crisis. But doctors have also been “abetted” by drug companies and governments, Scott wrote.
The Canadian Medical Protective Association, the doctors’ legal defence organization, has notified doctors that opioid prescribing has been a source of legal challenges. From 2010 to 2015, there were 151 cases across Canada alleging patient harm related to such prescriptions. For the most part, litigation and complaints to regulatory colleges or hospitals came from doctors issuing prescriptions to patients for non-cancer pain.