War on drugs hurts pa­tients, doc­tors

Strict rules on pre­scrib­ing aren’t fix­ing opi­oid cri­sis, writes Dr. Ellen N. Thomp­son.

Ottawa Citizen - - FRONT PAGE - Dr. Ellen N. Thomp­son is an anes­the­si­ol­o­gist and chronic pain physi­cian — as well as pa­tient ad­vo­cate — who hopes to re­tire, soon.

Na­tional pain aware­ness week has just started. It is likely, how­ever, that the on­go­ing opi­oid cri­sis will over­shadow aware­ness of the chronic prob­lem of pain. The war on drugs and the war on pain have be­come con­flated in the on­go­ing opi­oid cri­sis.

The tragedy of hun­dreds, even thou­sands, of drug over­dose deaths has un­der­stand­ably taken prece­dence in the news me­dia. Gov­ern­ments have re­sponded to the cri­sis, but some of the ac­tions taken are highly un­likely to solve the prob­lem of over­doses and need­less deaths; mean­while, they will make life very dif­fi­cult for in­di­vid­u­als with chronic pain and for the physi­cians look­ing after them.

Key facts need to be re­mem­bered. The “War on Drugs” was de­clared by then-U.S. pres­i­dent Richard Nixon in 1971, sev­eral decades be­fore in­di­vid­u­als with chronic pain start­ing re­ceiv­ing pre­scrip­tions for opi­oids. From about 2000 on, pre­scribed opi­oids be­came pop­u­lar with drug ad­dicts and drug abusers, who gained ac­cess to sup­plies of OxyCon­tin us­ing a va­ri­ety of meth­ods, in­clud­ing phar­macy breakins. Many physi­cians pre­scrib­ing opi­oids were de­ceived by such peo­ple, and a few were care­less in their pre­scrib­ing.

By spring 2012, the for­mu­la­tion of OxyCon­tin had been changed into tablets that were not as eas­ily abused, in that they could not be crushed and snorted or in­jected. The street value of th­ese tablets plum­meted and the num­ber of break-ins into phar­ma­cies dropped.

This sit­u­a­tion rep­re­sented a business op­por­tu­nity for crim­i­nal or­ga­ni­za­tions im­port­ing boot­leg/il­licit drugs from China and else­where. Il­licit tablets made to look like the old OxyCon­tin flooded the streets. They con­tain fen­tanyl in var­i­ous quan­ti­ties and even some car­fen­tanil, a very deadly syn­thetic opi­oid also known a “the ele­phant drug” (it was ini­tially de­signed to tran­quil­ize large an­i­mals). A Cit­i­zen ar­ti­cle in May 2017 de­scribed this in de­tail. But On­tario of­fi­cials seemed un­aware of it.

At the na­tional “opi­oid sum­mit” held in Ot­tawa a year ago, min­is­ters of health from Bri­tish Columbia and Al­berta de­scribed the im­pact of boot­leg fen­tanyl in their ju­ris­dic­tions. Dr. David Wil­liams, On­tario chief med­i­cal of­fi­cer of health, gave a talk later that day stat­ing that in On­tario pre­scribed opi­oids were the real prob­lem. This in­for­ma­tion was in­ac­cu­rate, and un­for­tu­nately re­sulted in an un­prece­dented crack­down by the On­tario Col­lege of Physi­cians and Sur­geons on 84 On­tario pain physi­cians found to have been pre­scrib­ing higher doses of opi­oids than the much-re­duced limit now adopted by the col­lege.

Some of th­ese 84 were world lead­ers and highly re­spected physi­cians. Cer­tainly a re­view of prac­tices, and re­me­di­a­tion where in­di­cated, would have been con­struc­tive. In­stead, the dra­co­nian mea­sures taken have been enor­mously costly both for in­di­vid­ual physi­cians and for the pro­fes­sion as a whole. They will do noth­ing to stop the over­dose deaths and will not curb the opi­oid epi­demic. And th­ese ac­tions have al­ready had a very neg­a­tive im­pact on chronic pain pa­tients.

For ex­am­ple, a 57-year-old man who had been able to re­turn to a de­mand­ing phys­i­cal job by us­ing a reg­u­lar daily dose of oxy­codone long-term, with no dose es­ca­la­tion and no aber­rant be­hav­iours, was told he would have to go down to half the ef­fec­tive dose, to com­ply with the col­lege’s new di­rec­tive. This may not work for him.

There have been re­ports of des­per­ate pa­tients trapped un­der the new, tougher pre­scrib­ing poli­cies, and even re­ports of a few sui­cides. So far, there are no con­firmed re­quests for med­i­cal as­sis­tance in dy­ing by those who can no longer es­cape the pain, as they once could have.

Mean­while, the facts re­main: One in five Cana­di­ans suf­fers from chronic pain — 20 per cent of the pop­u­la­tion. Half of th­ese, that is 10 per cent of all, have pain of such sever­ity that they can­not work, play or sleep much. The cost to so­ci­ety of chronic pain equals that of can­cer, heart dis­ease and AIDS/HIV com­bined.

We had made good in­roads with th­ese prob­lems, and proper opi­oid pre­scrib­ing has been part of the so­lu­tion. Th­ese gains are now in jeop­ardy.

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