My area of interest in the treatment of chronic noncancer pain and the treatment of addiction to opioids over the past 17 years has afforded me some unique perspectives on the BC opioid crisis that I would like to share.
Addiction is a behavioral diagnosis that is made over time when it becomes obvious that a person is unable to control compulsive behaviors with negative consequences associated with the misuse of a substance or behavior (e.g., substance: heroin; behavior: gambling). Taking opioids does not cause the addiction. To be clear: Taking prescription opioids does not cause the addiction. Addiction is behavioral. Not all patients prescribed opioids will exhibit addictive behavior. However, addicts prescribed opioids will get into trouble.
Taking a course of opioids may certainly cause a physical dependence that is manifested by withdrawal. This is something any mammal will exhibit. It’s a physiological response to the prolonged exposure of the body to opioids. Addicts in withdrawal are merely exhibiting what all of us would experience if we were similarly exposed to opioids for a period and had them withdrawn. Being in withdrawal does not make one an addict.
Most physicians are not trained to identify the behavior of addiction or how to respond to it. The College has a duty to address this deficiency in training in all physicians who are permitted to prescribe opioids. The BC government has an obligation to fund this so that something at a grassroots level can be done about this crisis. Identifying aberrant behavior and knowing how to respond to it requires training. Are the College and government of BC listening? This is their responsibility.
In order to identify high-risk patients prior to deciding if an opioid should be prescribed, sufficient time is required to do an in-depth assessment of these complex chronic pain patients. Until there is a fee code with remuneration that adequately reflects the time and effort needed to do this properly the cursory assessments of chronic pain patients will continue to be done and the resultant poor prescribing practices will remain.
Lower-risk opioids such as trama-dol, the buprenorphine patch, or tapent-adol are not covered by the province. This is another reason for the crisis we are having. Having worked in Australia recently as a locum family physician where far fewer opioid prescriptions are written, I soon realized why there is a problem in BC. Tramadol and the buprenorphine patch are covered in Australia, and these safer opioids were the first-line medications that I used to treat patients with chronic pain. When physicians have safer opioid alternatives to prescribe there are far fewer problems. This is something the government of BC is responsible for. If they are to act and do something concrete to quickly and safely change the opioid landscape this is where they need to be focused. This would greatly assist the opioid prescribers. I know this because I have experienced it firsthand.
I believe that the physicians, the College, and the BC government will all have to work together to tackle this problem. It all starts with responsibility being taken so that those with the power to implement change may be guided to do so. This requires leadership from knowledgeable physicians of which there are quite a number in BC and who are very willing to engage. Will the College, in concert with the government, approach them for guidance?
—Paul Harris, BSc, MBBCh, LMCC, CCFP
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