Curb prescriptions to combat opioid crisis
Lauren Vogel | CMAJ | Nov.18, 2016
Experts at a federal opioid conference on Nov. 18 urged a variety of measures to slash prescribing of the drugs.
Cut opioid prescriptions and doses to prevent increasing addiction and harm, urged expert panelists at a federal conference on Canada’s opioid crisis.
“If opioids were a new drug … they would almost certainly be pulled,” said Dr. Jason Busse of the Michael G. DeGroote National Pain Centre in Hamilton, Ontario. The benefits of opioids are “statistically significant but clinically small,” and “you’ll get the same level of improvement whether you are prescribed a low or high dose,” he explained.
Meanwhile, “we know that 100% of patients engaged in long-term opioid therapy will develop dependence,” Busse said. As patients develop tolerance, that means “higher doses, higher risk of addiction, higher risk of overdose, higher risk of fatal overdose.”
Busse and other panelists advocated for better prescribing guidelines, stronger monitoring and consequences for overprescribing, as well as efforts to discourage patients from starting or continuing opioids.
Current Canadian and American guidelines on opioid prescribing are “more eminence based than evidence based,” that is, heavily informed by expert opinion rather than hard data, said Busse. For example, the United States Centre for Disease Control recommendations on the benefits of opioids for chronic non-cancer pain “considered a total of zero published studies,” he said. For the updated Canadian guidelines, due to be submitted to a journal by March, “we’re considering 104 published randomized controlled trials.”
“We all have our own opinions regarding opioids for chronic pain but we should not be entitled to our own facts,” said Busse. “We know from studies there is no significant difference in pain relief or functional improvement comparing opioids to a non-steroidal anti-inflammatory or anti-depressant.” Even compared to a placebo, opioids don’t provide a difference in benefit at levels patients consider important, he added.
Dr. Karen Mazurek, deputy registrar at the College of Physicians and Surgeons of Alberta, argued that medical regulators need to hold prescribers accountable for following the opioid guidelines. The college has written a draft standard of practice requiring physicians to do so. “If they can’t they have to provide a good reason and it must be written on the chart,” Mazurek said.
In 2017, the college is also going to run quarterly large-scale audit and feedback interventions. “Monitoring high-risk patients and high-risk prescribers is not enough,” she explained. “We need to make sure those guidelines reach every single physician in this country.” To do that, medical regulators need “real-time data” on opioid prescribing, Mazurek said.
Canada Infoway has received $40 million from the federal government to develop a national electronic prescribing system to replace paper prescriptions, which can be lost, forged or filled at multiple pharmacies, said Michael Green, president and CEO of the agency.
The new e-prescription system will provide a direct link between prescribers and pharmacists, and capture data on “all prescriptions, not just dispensed drugs.” This information will be fed back to provincial and territorial prescription monitoring programs, Green said. Infoway will test the system in Ontario and Alberta by March 2018.
In addition to closer monitoring of prescribing, other panelists urged increased patient education about the risks of opioids. “Professional standards include requirements to communicate the harms and risks of opioid use and this needs to be mandatory,” said Sylvia Hyland of the Institute for Safe Medication Practices Canada. “If patients are well aware of the harms … and they’re aware of the alternative options they’ll be in better position to make informed decisions.”
“We’re working with neighborhood pharmacies to develop specific information to give patients and families, not only when a prescription is filled but when the patient comes back for a refill,” she said.
Dr. Cara Tannenbaum of the Canadian Deprescribing Network noted the success of a similar intervention that involved giving patients information about benzodiazepines, in which one in four discontinued the drug. She also suggested linking opioid prescriptions to the renewal of drivers’ licenses. “In Denmark, the government said we won’t renew your driver’s license if you’re on benzodiazepines … the reduction in benzodiazepines was 66%,” Tannenbaum explained. “It says on the oxycodone label do not operate heavy machinery do not drive while under the influence. Should there be a Canadian policy that holds people accountable?”
Some panelists warned against aggressive measures to slash opioid prescribing, particularly for patients who have been taking the drugs for a long time or in high doses. “This could easily trigger opioid withdrawal and it would not be unforeseen that a number of patients … might feel compelled to seek out opioids from illicit sources,” said Busse. “That decision can be fatal.”
Mazurek said that patients in Alberta “are terrified that their prescriptions are going to be pulled out from under their feet. We cannot let that happen.”
Efforts to reduce opioid prescribing should be paired with increased access to non-drug treatments for pain, she said. The point was reiterated by most other speakers.
“Patients living with chronic pain need alternatives,” said Busse. “Things like mindfulness training, cognitive behavioural therapy … these things show evidence of working but they’re not readily available and for too many patients living with chronic pain they’re simply unaffordable.”
Photo credit: Pureradiancephoto/iStock
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