Proposed new national standards for prescribing opioids cap the maximum daily dose at one-quarter the amount in Canada's existing outdated guidelines but stop short of addressing alternative means of pain control, sources say.
The Michael G. DeGroote National Pain Centre at McMaster University will unveil the draft blueprint on Monday, as part of an effort to reverse one of the deadliest drug epidemics in Canadian history. The Pain Centre received funding from Health Canada to draft the standards. A Globe and Mail investigation found that Ottawa and the provinces had failed to take adequate steps to stop doctors from indiscriminately prescribing highly addictive opioids to treat chronic pain.
The proposed new guidelines come 10 months after the United States published its own standards, urging 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 Canadian guidelines have not been updated since 2010, leaving them out of step with current research on the risks associated with taking painkillers.
But medical experts said Canada cannot turn the tide on the epidemic just by addressing practices developed two decades ago, when doctors began prescribing painkillers to relieve moderate to severe pain as pharmaceutical companies promoted their benefits. As well as reducing the supply of prescription opioids, the experts said, Canada must reduce demand and provide more treatment programs for people addicted to the drugs.
The current Canadian guidelines consider the equivalent of 200 milligrams of morphine a day a "watchful dose" – the threshold at which doctors should more closely monitor patients. This is four times the amount recommended in the U.S. guidelines, published last March by the Centers for Disease Control and Prevention. The U.S. guidelines urge doctors to weigh the benefits and risks carefully when increasing a patient's dose to more than the equivalent of 50 milligrams of morphine a day, and to avoid increasing dosages to more than 90 milligrams. They also recommend that doctors first try ibuprofen and aspirin to treat pain, and that opioid treatment for short-term pain usually last for three days, and rarely longer than seven.
The new Canadian guidelines propose the same 50 and 90 milligram thresholds as those in the United States, according to sources who had input into the guidelines. But, unlike the American guidelines, Canada's do not address prevention measures such as treating patients with acute pain – which is typically defined as pain lasting less than three months and is often the entry point for initially taking opioids – and advising doctors to try to avoid prescribing opioids altogether.
"It's ridiculous that it has taken this long to come up with a revision," said Meldon Kahan, medical director of the substance use service program at Women's College Hospital in Toronto and a member of the advisory panel in 2010.
The 2010 guidelines were "forward thinking" at the time, said Dr. Abhimanyu Sud, who teaches physicians a course on prescribing opioids at the University of Toronto's faculty of medicine. Prior to then, he said, the prevailing view was that there should be no daily cap on doses.
The updated guidelines take aim at the roots of Canada's epidemic of addiction and overdose deaths: the overprescribing of a drug whose risks are substantial and benefits uncertain. In 2015, doctors wrote one opioid prescription for every two Canadians, according to figures compiled for The Globe and Mail by IMS Brogan, which tracks pharmaceutical sales. Canada ranks as the world's second-biggest consumer of prescription opioids.
Without more treatment programs, people addicted to opioids could turn to the illicit market if their doctors respond to the guidelines by abruptly cutting off or reducing their prescriptions, said Hakique Virani, an Edmonton-based public-health and addiction-medicine specialist. In the illicit market, demand is being met with "the most dangerous opioid supply we have ever seen," he said.
"If some irresponsible practice of medicine got us into this mess," Dr. Virani added, "it is not going to be another irresponsible practice of medicine that gets us out of it."
The opioid epidemic includes two distinct but interrelated trends: overdose deaths involving prescription painkillers and a recent surge in fatal overdoses from illicit opioids, including bootleg fentanyl manufactured in China and smuggled into Canada, and carfentanil, a powerful drug used to tranquillize elephants and other large animals.
British Columbia has been hardest hit, with a record 914 overdose deaths in 2016 from illicit opioids and another 50 to 80 deaths from prescription painkillers. In response to the crisis, the College of Physicians and Surgeons of B.C. last June introduced the first mandatory standards in Canada for prescribing opioids. The standards are modelled on the guidelines of the U.S. Centers for Disease Control. Colleges in Nova Scotia and New Brunswick have also endorsed the CDC standards.
Dr. Kahan said that in order to bring about effective change, every physician regulatory college in Canada should take the guidelines on prescribing opioids and "translate" them into standards of practice for doctors. "They provide an important intellectual starting point so everyone is on the same page in terms of the evidence, but they have to be implemented with an action plan," Dr. Kahan said.