Safe prescribing of opioids and sedatives: It’s about primary prevention

Issue: BCMJ, vol. 60 , No. 10 , December 2018 , Pages 504-505 Special Feature

The current opioid crisis has two important dimensions: first, a drastic increase in opioid prescribing over the past 30 years, and second, a fatal combination of opioid addiction coupled with the contamination of the illicit drug supply leading to thousands of deaths due to fentanyl poisoning. The College’s “Safe prescribing of opioids and sedatives” practice standard aims to effect positive change by targeting the first dimension of the crisis.


Prescribing opioids for pain has not always been as controversial as it is today. In the 1980s and ’90s, the harms of prescribing opioid medications for noncancer pain were not fully recognized. We now know that when it comes to treating noncancer pain, opioids are overvalued, and their highly addictive properties can pose huge risks to patients.

Regulatory bodies recognize that the unfolding opioid crisis is complex; there are no easy solutions. The College of Physicians and Surgeons of BC and other regulatory bodies in the province and across the country have dedicated themselves to addressing this extraordinary threat by adopting a broader view and targeting their efforts closer to the upstream source of this unprecedented health crisis that has claimed the lives of thousands.

The opioid crisis has (at least) two important dimensions: the first is the drastic increase in opioid prescribing over the past 30 years and the adverse outcomes that attach to that; the second is the fatal combination of rampant opioid addiction coupled with the contamination of the illicit drug supply leading to thousands of deaths due to fentanyl poisoning. This is an important distinction. The connection between these two facets is complex and is not settled in science. The College stands with researchers, clinicians, patients, and families in the growing recognition that opioids themselves are potentially harmful, and that they expose people to risks of addiction—an increasingly fatal disease.

The College’s “Safe prescribing of opioids and sedatives” practice standard,[1] published this year, strives to effect positive change by targeting the first dimension of the crisis. For years, the College has participated in or led initiatives to address physicians’ roles in the rise of opioid consumption for noncancer pain. In 2010, the College contributed to the development of the National Opioid Use Guideline Group’s “Canadian guideline for safe and effective use of opioids for chronic noncancer pain.” In 2012 the College published its “Prescribing principles” guideline for BC physicians. In 2016 the College Board endorsed the US Centers for Disease Control and Prevention’s “CDC guideline for prescribing opioids for chronic pain—United States, 2016,”[2] and in the same year the “Prescribing principles” guideline was significantly revised and renamed “Safe prescribing of drugs with potential for misuse/diversion.”

After extensive consultations with members of the public, representatives from patient support groups, physicians, key health partners, and the Ministry of Health, an updated standard, “Safe prescribing of opioids and sedatives,”[1] was published in June 2018.

Changes made to the updated standard include the following:

  • With the publication of the “2017 Canadian guideline for opioids for chronic non-cancer pain,”[3] the clinical guidelines were removed and it is now a standard only. (Best practice musts and must nots.)
  • Language was strengthened to ensure that patients with complex care needs, or patients who are on or seeking opioids and sedatives, are not discriminated against or abandoned.
  • Greater clarity was provided about dosage, tapering, and discontinuing opioids and sedatives. Minimal standards around pharmacovigilance and stewardship of prescribed opioids and sedatives were set out.
  • Stimulant medications were removed from the standard. It now addresses safe prescribing of opioids and sedatives only.
  • The standard now clearly acknowledges that different diagnoses (sleep apnea, heart failure, etc.) will result in unique risks for patients.
  • The standard continues to promote collaborative decision making between the patient and physician when possible, while allowing for circumstances when a collaborative decision may not be possible.
  • Emphasis was added that problems from excessive prescribing, and the requirement to document discussions with patients about safe storage and disposal, apply across the entire spectrum of prescribing (both short- and long-term care, and for acute and chronic indications).
  • While it was stated in previous versions, the new version of the standard more explicitly states that it does not apply to the treatment of substance use disorder, or to the treatment of cancer pain or pain at the end of life.

Despite what has been incorrectly suggested, the College has never set limits or absolutes on prescribing. Physicians are expected to use their professional judgment when prescribing opioids or sedatives. The “Safe prescribing of opioids and sedatives” standard has, as its principal objective, primary prevention of opioid addiction, overdose, and other harms from the use of such medications. In achieving this objective, the College expects physicians to consistently employ the most basic and fundamental best practices to ensure good patient care. The College directs physicians to initiate these medications after completing proper patient assessments, hold and document discussions with patients about the risks of the medications, take full histories and learn about what other drugs patients are taking (illicit and prescription), review patients’ PharmaNet profiles, schedule follow-up visits, advise patients not to mix opioids with alcohol and other substances, and taper safely. The College expects physicians to prescribe with deliberate thought and care toward the patient, and to consider the long-term impact these drugs may have on patients’ lives.

The College also recognizes that prescribing is complex. Even the most seasoned physicians find prescribing challenging. To assist, the College works collaboratively with physicians through the Prescription Review Program[4] to ensure prescribing patterns are consistent with the standard and aligned with the “2017 Canadian guideline for opioids for chronic non-cancer pain.” The Prescription Review Program is not punitive, and the College does not wish to deter physicians from prescribing opioids and sedatives responsibly. The College takes a collegial, educational, and remedial approach in its Prescription Review Program to enhance safe prescribing, and provides a Prescribers Course along with other educational offerings. Physicians will not have their licences suspended or taken away for doing their best under difficult circumstances.

Video on safely prescribing opioids and sedatives

A short video from the College providing an overview of “Safe prescribing of opioids and sedatives” is available at www.youtube.com/watch?v=8Qc_2j3w90o.

Acknowledgment

The College would like to thank all physicians and patients who participated in the multiphased consultation that led to the latest version of “Safe prescribing of opioids and sedatives.”

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This article has been peer reviewed.


References

1.    College of Physicians and Surgeons of British Columbia. Practice standard: Safe prescribing of opioids and sedatives, 2018. Accessed 17 October 2018. www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf.

2.    Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65:1-49. Accessed 30 October 2018. www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm.

3.    Busse J (ed.). The 2017 Canadian guideline for opioids for chronic non-cancer pain. Hamilton, ON: National Pain Centre; 2017. Accessed 30 October 2018. http://nationalpaincentre.mcmaster.ca/documents/Opioid%20GL%20for%20CMAJ_01may2017.pdf.

4.    College of Physicians and Surgeons of British Columbia. Prescription review program. Vancouver: College of Physicians and Surgeons of British Columbia; 2018. Accessed 17 October 2018. www.cpsbc.ca/programs/drug-programs/prp.

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Dr Unger is the deputy registrar, Health Monitoring Department and Drug Programs at the College of Physicians and Surgeons of BC. Dr Unger received his medical degree from the University of Saskatchewan, and holds a master’s of science in bioethics from Albany Medical School in New York. Prior to joining the College, he practised as a family physician in BC focusing on vulnerable populations living with HIV/AIDS and addiction, and also served as director of ethics at Providence Health Care.

David Unger, MD. Safe prescribing of opioids and sedatives: It’s about primary prevention. BCMJ, Vol. 60, No. 10, December, 2018, Page(s) 504-505 - Special Feature.



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