Safe prescribing (1)

I and every doctor in British Columbia received the new College of Physicians and Surgeons of BC professional standards on safe prescribing last week to address the public health emergency related to opioid overdoses. This is a new professional standard to assist physicians with the challenging task of prescribing opioids, benzodiazepines, and other medications. This was adopted to “direct appropriate prescribing of potentially harmful drugs,” and “these professional standards are not discretionary and must be adhered to.” We are all directed to document discussions with our patients about the benefit of pharmacologic and non-opioid therapies for the treatment of chronic pain.

The College accepts aggressive pharmacotherapy in the context of active cancer, palliative, and end-of-life care. But it frowns on continuing to prescribe opioids to patients with chronic noncancer pain who, usually, after everything else has been tried and failed, need narcotics as an add-on or replacement (usually due to adverse events) for other modes of treatment.

We are to advise our patients that long-term opioid therapy is not indicated for certain medical conditions, including headaches, headache disorders, and axial low back pain, but if we are at the point of prescribing opioids to a patient in chronic pain then usually everything else has failed.

I have patients with chronic headaches where neurologists have prescribed narcotics because nothing else works. I have patients who have had benzodiazepines added to their narcotic regimen by neurologists and pain clinics so that they can get some sleep. Patients who are nonsurgical candidates for chronic back pain often suffer until opioids are prescribed.

When did it become gospel that patients with a history of addictions or those with psychiatric illness or young people, whoever that applies to, can’t suffer severe pain? I attended a medical conference years ago when a well-respected clinical pharmacologist asked, “Would you rather have a patient in chronic pain suffer, be bedridden, and/or housebound, and not be on narcotics, or be adequately treated and be a productive member of society working, enjoying his/her quality of life, and paying taxes, albeit needing narcotics to do so?” I thought about what he said and changed my whole attitude on treating chronic noncancer pain and have never regretted it.

Yes, patients become dependent on narcotics, but there is a difference between dependence and addiction. We have patients who are dependent on antihypertensive medications, on thyroid medications, on diabetic medications, and the list goes on. We also have patients dependent on narcotics and if that’s what it takes for them to have some quality of life and function normally, or as close to normally as possible, then I am all in favor of prescribing narcotics.

I have no problems with the College’s new standards, but what do they recommend I treat my chronic pain patients with? Many cannot tolerate nonsteroidal antiinflammatory drugs (NSAIDs). (It is said more people die from NSAIDS in Canada than all of the traffic accidents combined.) NSAIDS are contraindicated in so many situations—chronic kidney disease, heart problems, gastrointestinal bleeds, etc. Tylenol is minimally effective, if at all, in patients with anything more than mild pain, especially in the geriatric population.

We send our difficult patients to pain clinics, and after a prolonged wait for usually minimal benefit, rarely, if ever, do they suggest to taper or stop opioids.

Studies have shown it to be safe to drive, etc., in those with steady-state narcotic administration. I will gladly stop prescribing opioids for chronic pain, but tell me what should I prescribe?

My prescribing habits can easily be monitored through PharmaNet and the duplicate prescription program. Those who are prescribing out of range can be audited and disciplined if they can’t justify their prescribing, but leave the rest of us alone to care as best we can for our patients in pain.

Not all patients are con artists or junkies. Not all doctors are inappropriate prescribers. We care about our patients and hate to see them suffer but our options are limited.

I have yet to have a specialist in pain, surgery, physiatry, internal medicine, etc., suggest I stop narcotic prescribing for appropriate indications, and I have been practising for a long time.

Give me readily accessible, workable alternatives to narcotics when all else fails or leave me alone!
—Stephen M. Shore, MD, CCFP
Langley