British Columbia's physician regulatory college has unveiled the first mandatory standards in Canada for prescribing opioids, formally acknowledging the role played by doctors in creating the country's epidemic of painkiller abuse.
The College of Physicians and Surgeons of B.C. adopted the new standards in response to "inappropriate" prescribing by doctors and a spike in the number of fatal overdoses linked to illicit fentanyl, deputy registrar Ailve McNestry said in an interview.
"The confluence of those two things has given us the impetus to go forward," Dr. McNestry said.
The standards are modelled on new national guidelines in the United States for prescribing painkillers. The U.S. guidelines, published in March by the Centers for Disease Control and Prevention (CDC), urge doctors to first try non-drug approaches to treat chronic pain, and to prescribe opioids sparingly by starting patients with low doses and providing only a few days' supply.
The B.C. move comes after a Globe and Mail investigation found that Ottawa and the provinces failed to take adequate steps to stop doctors from indiscriminately prescribing highly addictive opioids to treat chronic pain.
The B.C. college has gone further than the CDC by making its standards legally enforceable. In doing so, the college is taking aim at practices developed two decades ago, when doctors began prescribing opioids to relieve moderate to severe pain as pharmaceutical companies promoted their benefits.
Doctors have a "collective ethical responsibility" to mitigate their contribution to the problem of prescription drug misuse, particularly the "over-prescribing of opioids," say the new standards announced on Wednesday.
The standards are in stark contrast to the Canadian prescribing guidelines, which have not been revised since 2010, leaving them out of date with current research on the risks associated with taking painkillers. The maximum dose recommended in the Canadian guidelines is 200 morphine milligram equivalents a day – four times the amount highlighted by the CDC and the B.C. college.
The Michael G. DeGroote National Pain Centre at McMaster University in Hamilton is overseeing the revision of the Canadian guidelines, which are scheduled for release in January.
Physician regulatory colleges in Nova Scotia and New Brunswick have endorsed the CDC guidelines. A spokeswoman for the Ontario college said on Wednesday that it advises doctors to follow the Canadian guidelines.
Dr. McNestry stressed that the college is not telling doctors they can never prescribe opioids. Rather, she said, the college is telling them they must be hesitant about starting patients on painkillers, to keep the doses low and to not combine opioids with other drugs.
"These are very simple pieces of advice that really haven't been heeded in the last two decades," she said.
Jason Busse, an assistant professor in McMaster University's department of anesthesia and co-lead of the group working on updating the Canadian prescribing guidelines, said his concern is that the college's standards on daily maximum doses do not provide guidance for doctors whose patients already exceed those thresholds. "Those patients could be compelled to seek drugs from other sources," he said.
The college published the new standards two months after provincial health officer Perry Kendall declared a public health emergency over the number of opioid deaths in British Columbia. At current rates, Dr. Kendall estimates that the province could see 600 to 800 fatalities this year, a dramatic increase from the 474 recorded in 2015.
Medical experts praised the college for showing leadership in coming up with safer ways to prescribe opioids.
"This is exactly the sort of thing a college should be doing," said David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto.
Edmonton physician Hakique Virani said the B.C. college is making an "explicit admission" about the role played by doctors in the opioid epidemic. "They're saying people are dying – and make no mistake, we have contributed to this problem," he said.
Benedikt Fischer, a senior scientist at Toronto's Centre for Addiction and Mental Health, said colleges in other provinces should follow B.C.'s lead to "help reduce the extensive opioid-related health toll."
Canada consumes more prescription opioids on a per-capita basis than any other country in the world, a recent United Nations report says.
In 2015, doctors wrote 53 opioid prescriptions for every 100 people in Canada, according to figures compiled for The Globe and Mail by IMS Brogan, which tracks pharmaceutical sales.