College should collaborate to curb abuse
Doctors aren’t the enemy, Owen Williamson writes.
If your only tool is regulation, everyone appears under-regulated. At least that’s the impression one would gain from reading Dr. Ailve McNestry’s opinion in The Vancouver Sun on Feb. 22.
McNestry, a deputy registrar and spokeswoman for the College of Physicians and Surgeons of B.C., described a B.C. man with a complex history of chronic pain and mentalhealth disorders as a doctor-shopping abuser of painkillers and other addictive drugs.
Apparently McNestry intends to use the man’s situation to convince all of B.C.’s 12,000 physicians that the college “isn’t tilting at windmills” — attacking imaginary enemies — in its attempt to curb over-prescription of addictive medications.
Canada has been a world leader in the development of evidence-informed medical practice. Physicians are taught to integrate the best available research evidence, clinical expertise and patient values and circumstances.
The anecdote cited by McNestry indicates the health system may have failed the man described. It also indicates a benefit a physician might realize by accessing PharmaNet, the database that records every prescription dispensed in B.C.
Compelling though anecdotes may be, physicians prefer to seek guidance from wellconducted scientific studies. We can’t place the anecdote into a context that informs the discussion of this complex topic without accurate information about the number and proportion of people who “doctor-shop” for opioids.
In May 2016, the college asserted that physicians contributed to the crisis of illicit-fentanyl overdose deaths through the over-prescription of opioids. We knew then that the physicians of B.C. prescribe fewer opioids at higher doses than physicians in the other Canadian provinces, with the exception of Quebec and P.E.I. Even now, we don’t understand why B.C. has the greatest number of illicit overdose deaths. If 150 to 200 of the 12,000 physicians practising in B.C. are ordered by the college to attend safe-prescribing courses each year, unsafe prescribing doesn’t seem to be a pervasive problem.
The college could have obtained informative data on prescriptions for opioid doses greater than the maximum daily dose (equivalent to 90 milligrams of morphine) recommended by U.S. and draft Canadian guidelines by accessing the PharmaNet database. In its haste to respond to the illicit fentanyl crisis by introducing its legally enforceable “Safe Prescribing of Drugs with Potential for Misuse and Abuse” policy, however, it appears the college was too busy to check PharmaNet records. It’s ironic that McNestry now calls for physicians who are too busy to check PharmaNet records to “take a look at the broader job market.”
It’s clear the college policy failed to arrest illicit-fentanyl overdose deaths. It’s also clear that patients who were legally prescribed opioids for back pain, headaches and fibromyalgia have suffered increased pain and disability after being withdrawn from medications in accordance with the college policy.
At the National Opioid Summit in November 2016, the college committed that by March 2017 it would form a Prescription Monitoring Oversight Committee to receive PharmaNet data and do detailed analyses to identify prescribing that may be unsafe. However, it can’t determine prescribing that is unsafe in an individual — that requires clinical expertise.
Rather than seeing physicians as imaginary enemies, the college should, in its public health role, collaborate with experts in the management of chronic pain and patient representative groups, to ensure that patients not only have access to safe care, but also effective and affordable care.
Dr. Heidi Oetter, the registrar and CEO of the college, recognizes the barriers that restrict physician access to PharmaNet and has conceded “technology that is not effectively implemented or easy to use at the point of care rarely delivers the system improvements promised.”
Oetter wrote to physicians in late 2016 about the need for medical regulators to build greater public trust and confidence in regulatory systems and the need to make more information available about the work they do. To do this, the college must operate within its mandate, observe its core values and develop evidence-informed health policy. Failure to do so undermines the credibility of the college as a regulator, and harms those it seeks to protect.
Tough talk by McNestry, without regard to the best available evidence, clinical expertise and patient values and circumstances, will only confirm the college is “tilting at windmills.”