Safe(r) Narcotic Prescribing (as in Just for Canadian Doctors Spring 2016)

 

Safe(er) Narcotic Prescribing

 

There is no denying that there is a problem with the use and misuse of prescription medications, viz. narcotics, stimulants and sedatives, principally benzodiazepines. I will deal just with the opioids in this essay, though much that I suggest will be relevant to all.  There is an abundance of literature concerning this subject but I could find little useful current statistical information.  Frequent reference is made, however, to the fact that Canada has the second highest narcotic use per patient in the world.  Second only to the USA.

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 suffering untreated pain, and that narcotics were safe, available and should be used to relieve non-cancer pain.  It did not take long for it to become apparent that in fact these medications, though effective, were easily prone to abuses. The lively promotion by the pharmaceutical companies must have been a factor too.  In 2007 the US branch of Purdue Pharmaceuticals were fined in excess of $600 million for ‘misbranding’ Oxycontin.   It was actively detailed in physician’s offices across North America.

The result is that there has been an escalation in the abuse of these drugs which is like a runaway train which is accelerating downhill. The safe way to regain control of this train is to skillfully and carefully apply the brakes.  Trying to stop it immediately will inevitably lead to derailment and disaster.

The subject is dealt with excellently by the National Advisory Council on Prescription Drug Misuse in their paper First Do No Harm: Responding to Canada’s Prescription Drug Crisis.  I have posted a link to this on my webpage at www.drpeng.ca .

My impression of this document is that it sets a realistic goal of 10 years to satisfactorily put things 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 overtaxed, and the Royal College of Physicians will need to significantly increase certification of pain care specialists from its current twenty a year.

Helpful instructions are available in the document Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-cancer Pain.  (The link for this is also on my webpage.)  This paper has a number of useful appendices.  I found it realistic, readable and replete with practical advice.

The difficulties of putting the situation right is adding to the emotional stress of primary care physicians. Mixed feelings will be experienced.  Guilt for allowing the situation to get out of hand, the will to practice good safe medicine and the difficulty of persuading drug dependent patients that, for their safety, they will need to significantly modify their medications.

I suggest that focused support groups be created to meet regularly to offer mutual support.  Good ideas could be shared, difficulties ventilated and problems discussed.  Divisions of Family Practice will be invaluable in coordinating these.

Provincial colleges run courses offering pain management/opioid prescribing CME. These courses are excellent, practical and well attended, but have a waiting list.  I suggest that a one-on-one in-office non-judgmental peer assessment and mentoring would offer useful patient-orientated problem solving.  A repeat visit or two by the mentor will probably be needed as the physician acquires and uses the new skills.  A physician should be able to request this sort of help with an assurance of temporary immunity from college discipline.

On a broader basis both the federal and provincial governments need to be lobbied for many more drug treatment programmes, especially residential. The chronic underfunding of mental health needs also to be addressed as well as the lamentable paucity 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, for example fentanyl related deaths have increased in BC seven-fold in two years — 13 in 2012 and 90 in 2014.

 

 

 

 

 

 

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