Alberta’s opioid policy changes threaten physician autonomy

Bonnie Larson is an assistant clinical professor of family medicine at the University of Calgary with certification in addictions medicine. Alana Luft, MD, CCFP, is a family physician and clinical lecturer at the University of Calgary.

The relationship between a patient and their family physician is unique.

Family doctors are entrusted with detailed knowledge of many facets of their patients’ lives and are gamely in it for the long haul. Their doctor being unconditionally there for them, over a lifetime, is what grants even the most guarded or traumatized patient a safe place from which they can address their deepest health concerns. Many come to rely on their family physician not only for health issues but also for support in building a foundation of stability for themselves, their families and future generations.

Family doctor advocacy goes far beyond the prescription pad: We champion the most important determinants of health, such as income and education; smooth over tensions with employers and insurance companies; vouch for patients with the justice and legal systems; and accompany them through the most difficult parts of life, including death and grief. We devote years to initiating, building and maintaining a therapeutic alliance that can withstand life’s surprises and uncertainties.

The value of this relationship is contingent on a physician’s freedom to build a customized therapy plan with each patient. We were therefore dismayed to hear the Alberta government’s recent announcement about new legislation that restricts family physicians’ ability to provide certain treatments to patients with severe opioid use disorder.

The unprecedented Community Protection and Opioid Stewardship Standards were implemented without debate in the legislature or adequate consultation with family doctors.

The new law requires family physicians to relinquish therapeutic alliances with their most complex and vulnerable patients. It limits treatment to specific, often inaccessible facilities and insists on punitive models of care that include archaic indignities to patients, such as being watched while urinating and having to open their mouths to prove they have swallowed their medications.

Such service models are far from patient-centred, trauma-informed, inclusive and culturally safe. The moral distress for physicians who are forced to comply with the new standards – with only a three-month grace period – is significant. Not only is the model of care in opposition to the recommended and evidence-based standard, it also places their dear patients – for whom they would go to the Earth’s end – at high risk of disability and death from drug poisoning.

In Canada, the medical profession is self-regulated. That means there is a body or “college” in each province that, through a process of consultation and consensus building within the profession, establishes rules and guidelines. These standards prioritize the safety of patients above all else and are held to account by science and peer review. Straying from the college standards puts a doctor’s medical licence at risk.

Self-regulation is critical in the medical profession because it is the foundation for autonomous decision-making.

Although the colleges that regulate doctors are meant to be arm’s-length and are, theoretically, independent of government, they exist only because they are provincially legislated to exist. Therefore, they can also be legislated to cease to exist. In that case, politicians rather than physicians would ultimately be making everyone’s health care decisions. This threat underpins the reluctance of medical colleges – or any licensing body that receives its mandate from government – to fight back against government interference.

Such interference is exactly – under cover of a leadership drama created by the governing party itself – what the Alberta government has done with this policy.

It is not only Alberta that places an already-weakened health care system at risk of further devastation by deliberately undermining physician autonomy. As we see a shift across Canada toward similar types of governments – which call themselves conservative yet interfere with privacy, professional autonomy, education and access to data in the manner of big bureaucracies – other provinces may follow suit.

No matter how one feels about party politics or substance use, the stakes are high. The implications of restricting the ability of physicians and patients to decide together on the best course of treatment deeply affect, and go well beyond, the care of people who use drugs.

Although these particular “standards” involve a highly stigmatized and emotionally charged issue, that should not obscure the risk they pose to a person’s right to access non-coercive health care. It also threatens physicians’ autonomy to make medical decisions without bias or interference and sets the stage for the dissolution of any number of professional governing bodies, to be replaced by the tentacles of an ever-growing and increasingly controlling government.

Family doctors are known to tangle with anyone who tries to interfere with the hard-won, delicate and beautiful bond we forge with our patients. This is the norm in family medicine. Protecting the doctor-patient relationship does not make us partisan or radical activists. We are simply doing the job that has been entrusted to us by our patients and society.

Ultimately, we all want our loved ones to receive unbiased, evidence-based, effective care from compassionate caregivers who are unencumbered by political ideology. Therefore, all doctors, and all patients, should reject this law and the people who made it.