Physicians need to own our part of the opioid crisis. Opioids are less effective and more addictive than we thought; we have to use them more carefully.
There is some good news: In Alberta, at least, prescribing of opioids has stopped increasing and is starting to come down. Per-capita prescribing of all five of the main opioid painkillers is flat or down over the past two years. In total, they're down about 3 per cent.
This doesn't mean the crisis is over, as we're still using these drugs far too freely: 4,500 Alberta physicians have at least one patient receiving more than 200 oral morphine equivalents (OME) a day – the maximum suggested in the current Canadian guideline, and more than double the 90-OME threshold in the United States and new draft Canadian ones; 2,600 doctors have a patient receiving more than 400 OME a day. Some of those high doses are appropriate as part of cancer treatment or palliative care; but more than 60,000 patients last year received opioid prescriptions from three or more prescribers, and 8,000 patients received three or more different opioids. Those situations are high risk by definition.
We need to do more – and we are doing more, through a new Standard of Practice that took effect April 1.
The message to doctors is simple: Use opioids in accord with sound clinical practice and relevant guidance, including the United States and draft new Canadian guidelines. First and foremost, avoid making new addicts: Use other therapies, especially for acute (short-term) treatment; when you use opioids, prescribe the smallest effective total amount, typically just a few days' worth for acute pain; and watch closely to make sure short-term therapy stays short-term.
Our new standard requires doctors to check the patient's record in the Pharmaceutical Information Network or a valid alternate source before prescribing an opioid, and at regular intervals for patients on long-term opioids.
This is the first time we've been so specific about clinical practice, and it sends a message: Competent practice requires more use of information to make decisions and co-ordinate with other providers. As a doctor, you have to know what medications your patient is taking, not just what you prescribe.
The dosage thresholds in the guidelines are not rigid cutoffs; the numbers themselves are not our main concern. A doctor prescribing grossly higher amounts – say, in the thousands of OMEs a day – is going to hear from us directly. For the majority of doctors and patients, our concern is simply that patients get good care, including careful management of the risks of opioid therapy – not meeting numerical limits. We never want a patient abandoned or arbitrarily taken off opioids, or "tapered" to a lower dose without careful management.
The opioid crisis requires action far beyond addressing prescribing:
- We need to step up our commitment to harm reduction, including “rescue” interventions such as naloxone, and safe drug consumption sites (which our Council has expressly supported).
- Family physicians need to manage more patients with opioid use disorder and other addictions; to do that confidently, they need education and training.
- All primary care providers need more access for patients to publicly funded physiotherapy, psychology and other resources to manage pain, to supplement services provided by Alberta Health Services.
- We urgently need more specialized chronic-pain and addiction services.
- Insurers can help by providing more coverage of less-addictive non-opioid painkillers.
- We need hospital-based specialists, particularly surgeons and emergency doctors, to be more careful with opioids, and make sure the patient’s primary care provider knows if a patient has been started on them.
- We need to educate patients and the public about the risks of opioids. Opioids are overused in part because patients demand them.
- We need better data on prescribing rates, abuse and addiction, and overdoses, for Alberta and for all provinces, so they can be compared.
Most of all, we need to move beyond rescue interventions to a focus on the mental health problems and other issues that drive addiction.