ROAD TO ADDICTION
New guidelines for opioids
It’s tough love time for prescription opioid users.
Doctors are being compelled to dramatically dial back patients who have long managed their pain with large doses of opioids and to stop prescribing them to patients who haven’t tried alternatives.
The measures are among 10 recommended guidelines aimed at controlling the rising and alarming use of opioids in Canada, which has the second highest prescribing rate in the world and the highest rate when measured in daily doses.
“From an opioid epidemic substance abuse standpoint, it’s an excellent thing,” Windsor addictions physician Dr. Peter Farago said of the new guidelines published May 8 in the Canadian Medical Association Journal.
They won’t cure Farago’s opioid addicted patients, but they will stem the supply to those who could become addicted and typically fall into one of two categories.
The first is someone in their 50s who has worked for decades at arduous factory jobs, developing chronic, painful injuries that a doctor treated by writing a prescription. The patient developed a tolerance, and two pills a day turned into four, which turned into eight, and 15 years down the road they’re taking an enormous dosage. “And I’ve got a new addictions patient,” Farago said.
The second type of patient has become an addict largely due to the availability of opiates hitting the street. “You’ve got 20-yearold kids using them at parties. Six months of putting Percocet up your nose, I’ve now got a new patient: a 20-year-old kid without chronic pain,” said Farago.
Many addicts get hooked after using opioids for legitimate reasons, said Dr. Robert Drake, a family doctor and local coroner who is called to a great number of fatal overdoses. “They get prescribed drugs for painful conditions that are temporary.”
Doctors are regularly faced with patients complaining of pain and some won’t prescribe opioids at all, he said. “And there are others handing it out like confetti.”
The recently published guidelines are for people suffering chronic, non-cancer pain, which affects an estimated 15-19 per cent of Canadians. For people who are still suffering despite trying alternatives, the guidelines suggest putting them on a trial of opioids.
They are just the latest measures taken in recent years to address the opioid addiction epidemic. Up until recently, doctors were advised to keep patients on less than 200 morphine equivalent milligrams a day of opioids. The new guidelines recommend a daily limit of 90 mg and suggest a limit of 50 mg for new prescriptions.
“I’ve got many, many patients we’re treating for chronic pain and we’re bringing them down. Everyone’s going to be below 90,” said Farago, who believes lower dosages will result in fewer prescription drugs making it to the street.
“We’ve made a policy decision overall, and unfortunately you’re going to have some fallout with that, but I think overall in the end when the dust settles this will be a positive thing for Ontario.”
Farago said the shockingly high rates of prescription opioid abuse were years in the making and derived directly from doctors’ pens.
“I’m not necessarily blaming physicians, but a big part of it is physician awareness, physician education,” said Farago, who works in Windsor and Michigan, where he notices much of the opiate abuse involves illicit drugs like heroin. In Windsor, people are abusing prescription drugs like fentanyl, oxycodone, hydromorphone and morphine. Whether these drugs are bought on the street or at a pharmacy, the road to addiction began with a prescription, he said.
When family doctor Dr. Jeff Cohen started practising medicine several decades ago, nobody prescribed opiates. “Basically, we were telling our patients to suffer silently,” he said.
But then there was a shift in thinking as palliative care took hold as a medical field and doctors began accepting that they should be treating pain. Who were they to judge a patient’s pain level? That, and marketing campaigns by pharmaceutical firms for such popular opioids as OxyContin, led to much more drug abuse and related deaths. People were being prescribed enormous doses without any benefit.
“For the last 15 years, everybody’s been preaching at us that we’re not treating chronic non-cancer pain adequately and the message was: ‘You’re not giving them enough. You should be giving them more,’ ” said chronic pain specialist Dr. Curtis Fedoruk, a former emergency department physician who used to believe giving opiates for chronic pain was inappropriate.
He said doctors bought into the trend and now society is feeling the effects.
“Some blame the drug companies,” he said.
“But no drug company has ever told a doctor to give more than 100 milligram morphine equivalents a day.”
For the last 15 years, everybody’s been preaching at us that we’re not treating chronic noncancer pain adequately and the message was: ‘You’re not giving them enough. You should be giving them more.’
Many of the patients Fedoruk now sees have had their dosages built up over time due to increasing tolerance, to the point they’re on very high doses. In January, the Ontario government responded to the opioid epidemic by delisting the most powerful ones — more than 200 morphine equivalent milligrams per day — from its provincial drug plans.
“I’ve had people come in as high as 1,500 milligrams per day from other doctors,” Fedoruk said. “Unbelievable.”
Others come from family doctors and are taking up to 900 mg per day. Suddenly some of these doctors lost their licences or their ability to prescribe narcotics, and their patients were left “high and dry.”
“They’re still in pain. They also probably have opiate tolerance and addiction. What do you do with these people?” Fedoruk said.
The guidelines state that when a patient takes less than 20 morphine equivalent milligrams a day, the risk of addiction is 5.5 per cent and the risk of fatal overdose is 0.1 per cent. But the overdose risk goes up as the dosage rises. In a study of Ontarians receiving social assistance, one out of every 550 patients prescribed opioids died of opioid-related causes within a median of 2.6 years. Of those taking at least 200 morphine equivalent milligrams a day, the death rate was one in 32.
Fedoruk said reducing dosages is a continuing challenge.
“I’ve had to basically tell patients the rules of the game have changed, the government isn’t going to allow this to continue, status quo is not acceptable,” he said. “You’ve got to come down, you’ve got to go to detox, you’ve got to go on methadone (one of two synthetic opioids used to treat opioid addiction), or you can fire me.”
Fedoruk, who practises in Tecumseh, is so busy that patients — many of them gainfully employed and with families — have to wait six months to get in to see him.
“There has always been an opioid crisis, but now they’re cutting down on it, we’ve really got an opioid crisis. I mean, we had an armed robbery at our pharmacy right next door,” he said.
There are alternatives, such as yoga, cognitive behaviour therapy and physical therapy. But they all require money and effort on the part of patients, said Cohen, the family doctor. “Not everyone’s motivated, so the easy route is to take a pill.”
In the past, those dependent on opioids got them from doctors known not to ask many questions, but those opportunities have narrowed as the government clamped down and developed a cross-referencing system.
Many local doctors have been either cutting their patients back, cutting them off or referring them to chronic pain specialists or addiction specialists.
Caught in the middle are patients like Rose Serecin, who manages a downtown Windsor apartment building despite the “horrible” pain she suffers as a result of losing her bladder and large bowel in the 1980s. She has two big bags outside her body to collect her waste. “But I function well. I’m just usually in pain,” the 48-year-old said.
In the last year, she said, as the crackdown on opioid prescribing descended, her family doctor sent her to a pain specialist who told her the government required her dosage to be cut down.
“I’ve lost 70 per cent of the pain medication that was allowing me to function,” she said, describing how her pain was “just throbbing,” but she had to wait several hours to take her next pill. Alternatives to opioids, like medical marijuana, haven’t provided her the relief she needs, she said.
“I don’t take drugs to feel funny, I just want the pain gone, to feel comfortable.”