Opioid prescribing: The profession and the patients we serve and support

Let’s consider a patient named Jack—an active 26-year-old male who developed a dependency on opioids after suffering a lower-back injury that caused him acute, then chronic, severe lower-back pain. With there being no medically identifiable reason for his pain, he was treated with opioids prescribed by his GP, as well as ER and walk-in clinic doctors—prescriptions that were renewed and refilled regularly. Over time Jack became dependent on the prescriptions, requiring them to function on a daily basis and suffering terrible withdrawal symptoms without them. His increased reliance caused him to turn to illicit drugs—something he was embarrassed to confess to his doctors even though he wanted help—but he feared the street drugs could be laced with fentanyl or that he could accidentally overdose and die.

In the first 7 months of 2016 there were 433 deaths from drug overdoses in BC—an increase of more than 70% from the same period in 2015, and enough to spark BC to be the first province to declare a public health emergency. I want to express some personal views on this topic—views that I suspect will be provocative but that I’m sharing in the hope that they encourage an open discussion.

While these deaths may seem beyond the reach and scope of our own practices, as a profession we must acknowledge how many of these patients have arrived in their desperate circumstances—not unlike Jack—and that we are in the midst of a major public health crisis. Accordingly, as opiate prescribers, we have a significant responsibility and role to play in helping end this crisis.

As a province, BC dispenses on prescription twice the amount of opioids per capita compared with Quebec, the lowest dispensing Canadian province. In the late spring, on the heels of the declared opioid crisis, the College of Physicians and Surgeons of BC swiftly introduced its new standards, Safe Prescribing of Drugs with Potential for Misuse/Diversion, which all doctors were urgently required to familiarize themselves with. While the method and manner in which the College launched this initiative has been questioned by many within the profession, this is without doubt an urgent call for action and attention to address our provincial and national prescription opioid crisis and epidemic.

There’s a great deal physicians can do to support patients and the profession in this crisis. As professionals who have an obligation to provide the very best care to our patients, I believe there are a number of steps we can take now to ensure this occurs. Some examples include increasing efforts to improve and enhance identification of patients at risk for opioid addiction and enacting strategies within our own prescribing habits for improved and safer prescribing practices, among others.

The new College standards make BC doctors the first in Canada to be legally bound by strict opioid and narcotic prescribing practices, and include requirements such as talking frankly with patients about alternatives to opioids—clearly communicating that these medications aren’t pain killers but pain reducers and not stand-alone long-term solutions. This doesn’t mean we should shy away from prescribing opioids in a safe and appropriate manner when clinically necessary. We offer great value to society by continuing to support and treat patients who are experiencing acute and chronic pain-related conditions. But it’s time to reconsider the landscape surrounding how we prescribe these potentially highly addictive substances. The bottom line when prescribing is patient safety—ensuring the potential risk or harm to patients is fully realized, discussed, and mitigated.

Not all patients who are prescribed opioids are or will become addicts, but we need to screen for and listen to those who are indeed addicted to opioids; suspend any judgments we have that label them as drug seekers; and recognize that their addiction is a medical condition no different than diabetes, hypertension, or chronic kidney disease. We need to offer long-term, evidence-based solutions.

We should take a collaborative approach to support the seamless integration of professional tools and resources such as PharmaNet into physicians’ practices, but in a way that isn’t cumbersome to physicians or staff—in a way that allows for ease of use and prescriber efficiency while ensuring patient safety.

Physicians, the Ministry of Health, the College, other stakeholders, and patients all have a role to play, and as partners in health care, together we can make a difference. For doctors, the health and safety of our patients is of utmost importance. We must do everything in our power as a profession to help support and protect our patients—most of whom are often unknowingly vulnerable—by eliminating the judicious overprescribing of opioids. I ask you all, please talk and engage openly with your patients about the opioid crisis we are facing. I also encourage you to let me know your thoughts on this topic. E-mail me at president@doctorsofbc.ca, and I will share some of the feedback I receive on my President’s Blog. Let’s start the conversation.
—Alan Ruddiman, MBBCh, Dip PEMP, FRRMS
Doctors of BC President