More drug-treatment programs badly needed

I agree with the Sunday editorial in the Times Colonist (“Don’t overuse heavy narcotics,” Dec. 18) but I feel that there is additional information needed for some aspects of this subject.

How did this situation come about? Twenty or so years ago, there was a well-intentioned, but sadly misguided, philosophy that too many patients were unnecessarily suffering pain, and that narcotics were safe, available and should be used, albeit carefully, to relieve non-cancer pain.

It did not take long for it to become apparent that in fact these medications, though effective, were alarmingly prone to abuses.

The lively promotion by the pharmaceutical companies must have been a factor, too. In 2007, the U.S. branch of Purdue Pharmaceuticals was fined more than $600 million for “misbranding” Oxycontin. It was actively detailed in physicians’ offices across North America.

So when a situation goes wrong, there are two ways of dealing with it. Ignore it and hope that nobody else will notice your errors, or recognize that there is a problem, accept responsibility and deal with it head-on.

Physicians, and their regulatory bodies (the B.C. College of Physicians and Surgeons), have addressed this problem aggressively since it was brought to their attention, mostly by the coroner.

I am in a privileged position where I professionally meet physicians (mostly family physicians) throughout the province, and I have yet to meet a single physician who is not up to date with, and wholeheartedly applying, the latest relevant standards and guidelines from the college.

The difficulties of putting the situation right is causing emotional stress to primary-care physicians. Mixed feelings are experienced: guilt for allowing the situation to get out of hand, the will to practise good, safe and empathic medicine, and the difficulty of persuading drug-dependent patients that, for their safety, they must significantly modify their medications — while ensuring no one is left with untreated intolerable pain.

Some physicians might be anxious concerning the concept of “unexpected consequences.” It is reported that drug-dependent patients are alleging they need to go to the street for illicit (and potentially lethal) drugs since the curtailing of prescriptions.

I want to emphasize that fentanyl is not an analgesic prescribed by, or available from, family physicians. Family physicians very occasionally prescribe a long-acting patch, almost exclusively for cancer patients; otherwise, it is restricted to minor surgical procedures as a single dose. Codeine, oxycodone and hydromorphone are prescribed and too easily have led to opiate dependency — to put it more accurately, opiate addiction.

So what to do about it? An aggressive and yet practical report by the National Advisory Council on Prescription Drug Misuse in their paper First Do No Harm: Responding to Canada’s Prescription Drug Crisis will guide and advise physicians, pharmacists, other health professionals, bureaucrats and politicians alike. (It is readable, and readily found by Googling “First Do No Harm: Responding.”)

My impression of this document is that it sets a realistic goal of 10 years to satisfactorily put things entirely right. The authors suggest that it is going to require input (both dollars and expertise) from the federal government, provinces, public-health and primary-care physicians.

A large part of the burden, in fact, is landing on primary-care practitioners. Unfortunately, they are sorely lacking support. Pain clinics are already overextended, and the Royal College of Physicians and Surgeons of Canada will need to significantly increase certification of pain-care specialists, for the entire nation, from its current 20 a year.

Both federal and provincial governments need to be lobbied for many more drug-treatment programs, especially residential. The chronic underfunding of mental health needs also to be addressed (and, hopefully, not impeded by provincial self-interests) as well as the lamentable scarcity of pain-treatment clinics.

The cost of dealing with this situation is going to be great, but doing nothing is estimated at a cost $8.2 billion per annum ($262 for every Canadian), not to mention the lives lost. Dr. Chris Pengilly of Saanich is a semi-retired family physician.