New national standards for prescribing painkillers do not address treating patients with acute pain – the place where opioid addiction often begins – after Health Canada rejected a request to expand the scope.
Canada has little hope of reversing its deadly opioid epidemic if it does not stop the surge of people becoming addicted to the drugs, medical experts said. The way to do that, they said, is by reducing opioid use at the beginning of a case, when a patient is in acute pain.
But the guidelines released on Monday by the Michael G. DeGroote National Pain Centre at McMaster University are silent on how opioids should be prescribed for acute pain, focusing instead on treating chronic pain – typically anything that persists longer than three months.
Many chronic-pain sufferers begin their experience with opioids after an acute-pain episode – they receive painkillers after breaking an arm or undergoing day surgery, without clear instructions on how to get off the drugs as soon as possible.
Jason Busse, an associate professor in McMaster's department of anesthesia and co-lead of the group that drafted the guidelines, said the group asked Health Canada about expanding the mandate to include acute pain, but was told "no." The department provided just more than $600,000 in funding to McMaster to revise the outdated 2010 guidelines for prescribing opioids to treat chronic, non-cancer pain.
Health Canada spokesman Eric Morrissette said in an e-mail response to The Globe and Mail that the department has not received a funding application request to broaden the terms of reference, but "remains open" to discussing ideas to expand the guidelines.
The new guidelines take aim at the roots of Canada's epidemic of addiction and overdose deaths: the oversubscribing of a drug whose risks are substantial and benefits uncertain. As first reported by The Globe, the revised guidelines recommend that doctors restrict a patient's dose to less than the equivalent of 50 milligrams of morphine a day and avoid increasing doses to more than 90 milligrams.
The prescribing caps mark a good step forward in getting doctors to prescribe lower doses of opioids to their chronic-pain patients, said Gary Franklin, medical director of the Washington State Department of Labour and Industries and a clinical expert on the panel. He also noted that the guidelines recommend that doctors try other therapies instead of opioids for chronic-care patients. But in contrast to the prescribing guidelines released in the United States last March, which urge doctors to first try non-drug approaches or to start patients with only a few days' supply of opioids, there is nothing in the Canadian document that addresses prevention.
"If you don't nip this thing in the bud," Dr. Franklin said, "how are you going to prevent your next cohort of Canadian citizens from getting into trouble here?"
Not everyone who worked on the guidelines agrees with Dr. Franklin, a reflection of the fact that clinical experts were drawn from two camps – those opposed to opioids and those in favour of them.
Norman Buckley, the director of McMaster's National Pain Centre, said the new recommendations will "certainly be incorporated into practice" at his specialty clinic, which often sees chronic-pain sufferers who have already come to depend on opioids at doses much higher than those set out in Monday's draft guidelines.
Dr. Buckley, who sat on the steering committee for the new guidelines, said the National Pain Centre regularly receives e-mails from across the country from patients who functioned well on high doses of opioids, but can no longer get as much medication because their doctors have retired or changed their prescribing behaviour.
"We get those calls and we struggle with them a little bit," Dr. Buckley said.
David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre, and also a member of the steering committee, said the guidelines will dramatically improve the care of patients with chronic pain. But with such a contentious issue, he said, "there are bound to be people who are unhappy with one aspect of the guidelines or another."