It is well established chronic pain is a major health care problem that is largely ignored in the
health care field and by those making health care policy decisions. People with pain can attest to this as they continue to be stigmatized, marginalized and often simply ignored. The recently released Guidelines for the use of Opioids in Canada re-enforces this and raises another barrier to the treatment and management of pain. These guidelines, which were no doubt influenced by the recent release of the extremely flawed and biased guidelines by the CDC in the United States, written by a small group of anti-opiate crusaders with strong ties to a large drug rehab chain, seem to reflect more attention to people with addictions and not people with pain. We are not opposed to guidelines when they are relevant and appropriate, but feel strongly these are again premature and relate more to addiction medicine then pain medicine. This is obvious when one looks at the official Guideline Panel. Although, which we find audacious, they did not list the backgrounds and ALL affiliations these members have; our early research indicates most have little or no experience on the front lines of pain medicine and are exceedingly intertwined. In addition, publishing the draft recommendations without the guideline’s main text and the supporting evidence provides limited information for anyone to sufficiently evaluate the guidelines. This is much like the recent Opioid Summit in Ottawa where pain physicians were poorly represented. We do believe increasing awareness of the opioid overdose risk is appropriate, but claiming certain unsubstantiated tisks outweigh the benefits of using opioids to treat pain lacks scientific foundation. According to a recent study by Dasgupta et al., of 2,181,372 patients prescribed opioids, 478 deaths were reported (0.022% per year). In addition the CDC Guidelines, which these are based on, are in direct conflict with the National Institutes of Health guidelines put out in 2014. They were based on an extensive literature review by an unbiased expert panel which concluded: “What was particularly striking to the panel was a realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience.” It was also observed the target should be what the patient and their healthcare provider have decided between themselves as a reasonable goal to accomplish. Pain patients feel strongly the authors and policy makers behind these guidelines have missed another golden opportunity to create real change in this area of medicine. They would have impacted pain medicine far more positively if they had used their resources and ability to bring a strong group together to develop forward thinking educational programs and incorporate them into the curricula in our teaching hospitals. This would have a far greater impact on addressing the chronic pain pandemic and that of addictions. By putting forth guidelines like this, at this time, to influence a profession that has little education and understanding about chronic pain is myopic and similar to the last attempt at guidelines will simply encourage more physicians to dump the pain patients they now have. Or is that the goal? Barry D. Ulmer Executive Director The Chronic Pain Association of Canada 11247 11 Avenue NW Edmonton, Alberta T6J 6S3 (780) 482-6727 Review and critique of the 2017 Draft Recommendations for use of Opioids inChronic Non-Cancer Pain8/12/2017
It is well established chronic pain is a major health care problem that is largely ignored in the
health care field and by those making health care policy decisions. People with pain can attest to this as they continue to be stigmatized, marginalized and often simply ignored. These draft guidelines re-enforce these ideas and raise another barrier to the treatment and management of pain. These guidelines, which is appears were influenced by the extremely flawed and biased guidelines by the CDC in the United States, written by a small group of anti-opiate crusaders with strong ties to a large drug rehab chain seem to reflect more attention to people with addictions and not people with pain. We would note that publishing the draft recommendations without the guideline’s main text and the supporting evidence provides limited information for anyone to sufficiently evaluate them. We strongly suggest, before moving forward with them, that you publish a draft of the complete guidelines and then opening it up for comments from readers so they may adequately comprehend the guidelines’ content and adequately provide comments. We would also strongly suggest that if your wish to receive comments leave it at that and don’t ask people to answer your preconceived survey. In addition, it would be helpful to have access to the panel members’ backgrounds and ALL their affiliations. How many of the voting panel were medical doctors with front line pain experience? Our initial research concerning the panel members indicates most have little or no experience on the front lines of pain medicine, but are inextricably intertwined, which leaves the impression that perhaps balance may have been difficult to achieve. We do believe increasing awareness of the opioid overdose risk is appropriate, but claiming certain unsubstantiated risks outweigh the benefits of using opioids to treat pain lacks scientific foundation. According to a recent study by Dasgupta et al., of 2,181,372 patients prescribed opioids, 478 deaths were reported (0.022% per year). In addition the CDC Guidelines, which this Canadian(?) effort appears to be based on, are in direct conflict with the National Institutes of Health Guidelines published in 2014. They were based on an extensive literature review by an unbiased expert panel which concluded: “What was particularly striking to the panel was a realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience.” It was also observed the target should be, what the patient and their healthcare provider have decided between themselves as a reasonable goal to accomplish. We concur. It is also baffling why we would create guidelines to affect a profession which has little education about chronic pain, and little experience or understanding about the treatment and management of pain. Educate them first and then develop guidelines they will actually understand. We are not opposed to guidelines when they are relevant and appropriate, but feel these are premature and don’t reflect the realities of pain medicine. This is obvious when one looks at the official Guideline Panel. As pointed out, based on initial research, almost all have no real experience on the front lines of pain medicine and the close relationships between the majority of the panel, gives the impression of a biased outcome. It is sheer folly to think this process will do anything to solve the present ILLICIT substance misuse problem, which it appears is another false underlying reason for this project. It will simply create another tragic situation for many people with pain. Pain patients feel strongly the authors and policy makers behind these guidelines have missed another golden opportunity to create real change in this area of medicine. They would have impacted pain medicine for more positively if they had used their resources to develop forward thinking educational programs and incorporate them into the curricula in our teaching hospitals. This would have a far greater impact on addressing the chronic pain pandemic and the problem with addictions. By putting forth guidelines like this, at this time, to influence (or control) a profession that has little education and understanding about chronic pain is myopic and similar to the last attempt at guidelines will simply encourage more physicians to dump pain patients they now have. Or is that the real goal? As we have stated it is difficult to sufficiently evaluate the guidelines without the supporting evidence behind them and the background of the official panel members. However we will make the following observations: 1. We take issue with some of the language that has been used. In Recommendation #1 and #2, in the Rationale it sites….”very frequent dependence and frequent addiction” and …”dependence and addiction”. Physiological dependence may be an expected outcome of long term opioid use…but this is not addiction. You appear to refer to this throughout the document along with addiction (more as the addiction aspect as opposed to the physiological aspect of opioid use. This is quite misleading and should be removed. There is a distinction that physical dependence is not the same as addiction. You also make the insinuation, throughout the document, that addiction is almost guaranteed with opioid use. This again is incorrect and should be deleted. 2. In reference to Recommendations #6 and #7 it is recognized there are various limitations to assigning a morphine equivalent daily dose (MEED) cut-off that could adversely affect patient care and create barriers and other challenges in clinical practice. First, there is no universally accepted opioid conversion method and heterogeneity in calculating morphine equivalence among clinicians. Shaw et al evaluated 8 online opioid dose conversion calculators and identified a percent variation of -55% to +242%. Rennick et al, surveyed 319 healthcare professionals (MD/DO, PharmD/RPh, NP) on calculating MEDD for several opioids and found wide variability. The study authors asked participants to calculate MEDD for hydrocodone 80mg, fentanyl 75mg/hour (1800mcg/day), methadone 40 mg, oxycodone 120 mg, and hydromorphone 48 mg. The calculated MEDD for fentanyl, hydrocodone, hydromorphone, methadone, and oxycodone were: 176 (±117) mg, 88 (±42) mg, 192 (±55) mg, 193 (±201) mg, and 173 (±39) mg respectively. In the cases of fentanyl and methadone, the SD in just one direction was greater than your proposed cut-off of 90mg MEDD. All other cases approached or exceeded 90mg MEDD when considering the entire SD range from positive to negative. Assigning a standard MEDD cut-off in absence of a standardized approach to calculate morphine equivalence is not feasible to implement uniformly in clinical practice and will pose challenges to clinicians. It should also be noted that 25 mcg of fentanyl exceeds the 90mg cut-off as well. 3. Recommendation #7 has been labeled as a “strong recommendation”. However, the rationale section discusses findings from an observational study that is deemed “moderate quality evidence”. A strong recommendation requires high quality supporting evidence opposed to moderate quality evidence from an observational study. After reviewing the implications associated with strong recommendations on different stakeholders (as per your charts on Implications), it appears that strong recommendations will be disseminated and adopted throughout healthcare. Therefore, we believe there should be strong supporting evidence based on high quality studies before they are applied “to all or almost all patients” or “adopted as policy in most situation.” To label the recommendation as “strong recommendation” based on moderate quality evidence from observational studies is unscientific, unprofessional, unethical, and quite frankly should be inconceivable to any legitimate scientific panel. In the absence of strong evidence, we believe this recommendation should be deleted or at best totally reconsidered and reviewed by a different panel. 4. The 50mg and 90mg dose recommendations are arbitrary numbers with no evidence supporting them. These again have been plucked from the flawed CDC Guidelines which has a number of contradicting statements within them on the presented evidence and the recommendation strength of its recommendations. For instance, according to the National Guideline Clearinghouse, “Level A rating requires at least two consistent Class 1 studies. However, all 12 of the CDC recommendations provided are based on case studies (level 3 evidence) or expert opinion (level 4 evidence) yet all were assigned a Grade A recommendation. For instance, according to the guidelines providers should implement additional precautions when increasing dosage to ≥50 morphine equivalents (MME/day, and should generally avoid increasing dosage to ≥90 MME/day (recommendation category A, evidence type: 3)”. This recommendation was based on ONE randomized un-blinded study of only 135 patients (94% male; 74% had musculoskeletal pain) who has received 40 MME/day compared to 52 MME/day, yet this recommendation was then generalized to “chronic non cancer pain” and the recommendation “to avoid increasing dosage to ≥90 MME/day” was NOT EVEN EVALUATED by the referenced study. This makes it even more astonishing you would use the CDC Guidelines as the template for these Canadian(?) guidelines. 5. In regard to the last sentence in the rationale for recommendations #6 and #7, “These serious outcomes are very rare in those prescribed less than 50mg MEDD, but increase in those prescribed dose of 50 to 90, and though rare, are very concerning in those prescribed doses over 90”. The guidelines should fairly and accurately define the aforementioned frequencies “rare vs. very rare” and define “serious outcomes”. As mentioned in the large cohort study by Dasgupta et al, out of 2,181,372 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year) Dasgupta et al concluded a dose-dependent opioid overdose risk but did not show evidence of a distinct threshold. Furthermore, rates of overdose deaths were 10-fold higher among patients co- prescribed benzodiazepines and opioids than opioids alone. Zedler et al developed a validated risk assessment tool using a multivariate linear regression model for overdose or serious opioid-induced respiratory depression. The risk assessment tool was first validated in a cohort of U.S. veterans and subsequently validated in the general population. Zedler’s validated risk assessment tool identified variables associated with increased risk for opioid-induced respiratory depression including various medical and psychiatric co-morbidities and presence of concomitant.. Why were these types of tools not spoken of in the draft guidelines? Relying solely on the morphine equivalent dose when developing the guidelines indicates a disturbing bias against the use of opioids perpetuated by the anti-opiate drug rehab group involved in the CDC Guidelines which has led to the present “Pied Piper” movement across Canada and the premature acceptance of their myopic views. It will be confusing to some readers and contradicts with part of the rationale for recommendation #7 that reads “Some patients may gain important benefit over 90mg morphine equivalents, but not on lower doses.” We recommend distinguishing “persistent problematic pain” from “problematic side effects”. There are various reasons a patient may have persistent pain on a 90mg morphine dose that should be considered when making a clinical decision such as pharmacogenetics variability affecting drug metabolism, weight, drug interactions, tolerance, and variable pain pathology. For example, oxycodone is metabolized through CYP3A4 to inactive metabolite noroxycodone and through CYP2D6 and CYP3A4 enzyme expression can yield different serum concentrations and exposure between patients taking the same dose. Additionally, there are more than 100 polymorphisms in the mu-opioid peptide receptor gene (OPMR1) that can increase or decrease analgesic effect from opioids. Therefore, having a MEDD cut-off to taper opioids may be oversimplified, especially when considering variable half-livrs (consider methadone) and partial agonists/antagonists (consider buprenorphine) and opioids mixed with mixed activity (consider tapentadol). None of these three should ever be given a “hard stop” morphine equivalent. With this we must reiterate the National Institute of Health committee conclusion: “What was particularly striking to the panel was the realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her clinical experience.” The target should be what the patient and their healthcare provider have decided between themselves as a reasonable goal to accomplish. Again, we could not concur more. We recommend these guidelines be scrapped totally and strong efforts be incorporated to move toward this goal. Or scrap these guidelines and have them rewritten by real doctors involved in pain medicine and patients. Leave the “Pied Piper” out of it. References: 1. Rennick A, Atkinson TJ, Cimino NM, Strassels SA, McPherson ML. Fudin J. Variability in opioid equivalence calculations. Pain Med. 2015 Sep 9; Epub. 2. Shaw K, Fudin J. Evaluation and comparison of online equianalgesic opioid dose conversion calculators. Pract Pain Manag. 2013;13:61-66 3. Dowell D. Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016 MMWR Recomm Rep 2016;65(No. RR-1):1- 49. Barry D. Ulmer Executive Director The Chronic Pain Association of Canada 11247 11 Avenue NW Edmonton, Alberta T6J 6S3 (780) 482-6727 Honourable Sarah Hoffman
Minister of Health Government of Alberta 423 Legislature Building 10800 – 97 Avenue Edmonton, Alberta T5K 2B6 Dear Minister Hoffman: It was Aldous Huxley who said that fear, “casts out intelligence, casts out goodness, casts out all thought of truth….in the end fear casts out even man’s humanity.” This appears to be even truer today when it comes to the treatment and management of pain in our communities. Over the past several years there has been an ongoing effort by many that has affected every aspect of the field of pain management. The underlying reason for this is the use of strong analgesics or opioids. The attack on these medications has not only changed how physicians look at these medicines, but has overtly changed how they look at people with pain. Many physicians now often will not take on patients with pain, some have moved to exclude their patients from their practice, with others abruptly reducing stable doses a person has been on for many years to ineffective doses, with still others taking their patients completely off their medications causing unnecessary suffering. These physicians suggest people move to a non-pharmacological approach to managing pain, which is fine, but most people have already tried this approach several times and found it ineffective. This simply results in higher costs to, not only the patient, but to our health care system. The sad reality of this is these physicians do this because they fear the wrath of the regulatory body. The recent announcement by the College of Physicians and Surgeons of Alberta (CPSA) indicating they were establishing “tougher rules on opiate prescribing” has only served to intensify this fear. This “standard of care” pronouncement based on the poorly developed guidelines from the U.S. based Centers for Disease Control and Prevention (CDC) is not the solution to the hysteria surrounding the illicit use of illegal substances. We do have a drug problem in this country, but it is not a prescription medicine problem. What we find disturbing is that the body which is supposedly there to protect patients has taken this step based on poor evidence. As in every guideline developed so far on prescribing opioids the evidence they present is of the “low to very low quality” and involve some skewed data, in addition to being based on more consensus and personal views of those involved in the writing of the guidelines. A recent review, published in the Journal of Pain and Palliative Care Pharmacotherapy, indicated that some policies restricting opioid prescriptions with the thought of curbing overdose deaths may be harming those who need them the most: pain patients. The report “Negative outcomes of unbalanced opioid policy supported by clinicians, politicians and the media” suggested the opioid epidemic, some refer to, has been misrepresented by some politicians and the media. The proposed “standard of care” by the CPSA would fit into that statement. The CPSA is basing their standards and dosage requirements on the flawed guidelines issued by the CDC. Those guidelines were written by a small group of individuals heavily involved in the addiction field, with little or no experience in the field of pain medicine and with close ties to a large addiction Rehab organization. With the exception of one alleged pain doctor who works for a large law firm suing pharmaceutical companies who manufacture opioids. As one group of medical professional critics pointed out the Guidelines are “Neat, Plausible and Generally Wrong”. Their article and many others have enumerated a profound lack of balance, science and medical evidence behind the guidelines. It is bewildering why the CPSA would, it seems, in a kneejerk reaction move forward with such a misguided program. Other research shows the CDC actually manipulated the data it used as a basis for its guidelines. In fact, in its recent Morbidity and Mortality Weekly Report (MMWR) they said “the rise in opioid overdoses had little to do with prescription painkillers. Instead the real culprits behind the spike were heroin and illegally manufactured fentanyl.” The 2016 National Drug Threat Assessment report verifies this. This actually started in 2011, but because regulators, law enforcement, media-hype and politicians were so intent on blaming doctors for the problem we now find ourselves in the present situation of ILLICIT substance overdose deaths, and people with pain suffering far more than need-be. Another review of the CDC Guidelines found a number of contradicting statements based on the presented evidence and the recommendation strength. According to the National Guideline Clearinghouse, “Level A rating requires at least two consistent Class 1 studies. However, all 12 recommendations provided are based on case series (level 3 evidence) or expert opinion (level 4 evidence) yet were assigned a Grade A recommendation. For instance, according to the guidelines providers should implement additional precautions when increasing dosage to ≥50 morphine equivalents (MME/day, and should generally avoid increasing dosage to ≥90 MME/day (recommendation category A, evidence type: 3)”. This recommendation was based on ONE randomized un-blinded study of only 135 patients (94% male; 74% had musculoskeletal pain) who received 40 MME/day compared to 52 MME/day, yet the recommendation was generalized to “chronic non cancer pain” and the recommendation “to avoid increasing dosage to ≥90 MME/day” was not even evaluated by the referenced study.. (Really scientific, right!) We believe that increasing awareness of the opioid overdose risk is appropriate, but claiming certain unsubstantiated risks out weigh the benefits of using opioids to treat pain lacks scientific foundation. According to a recent study by Dasgupta et al, of 2,182,372 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Based on this it is astonishing the CPSA would use the CDC Guidelines as the template for their program. It poignantly points out the lack of knowledge they have concerning this subject, and how misguided they are. To assign a cut-off of morphine 90mg per day, is oversimplified and will create challenges in practice. The guidelines recommend a standardized MME, or a “morphine maximum dose” sometimes abbreviated MMD, but does not recommend a standardized method for calculating morphine equivalence. There is a wide variability among opioid conversions including, but not limited to online dosing calculators. Rinnick, A and others that include nationally renowned pain experts, compared equianalgesic conversion estimates as calculated by practicing clinicians, by surveying 411 healthcare professionals; 129 physicians, 213 pharmacists, and 69 nurse practitioners. After adjusting for statistical inclusion, 319 participants were incorporated in the final analysis. Participants were asked to provide the morphine equivalent for hydrocodone 80mg, fentanyl 75mg/hour (1800mcg/day), methadone 40 mg, oxycodone 120 mg, and hydromorphone 48 mg. They were also asked to provide the resource used in their calculation. MME for fentanyl, hydrocodone, hydromorphone, methadone, and oxycodone were: 176 (±117) mg, 192 (±55) mg, 193 (±201)mg, and 173 (±39)mg, respectively. The authors stated “A total of 124 (46%) respondents identified using personal knowledge as a resource for their conversion problems, followed by use of an online calculator at 83 (31%), a textbook table at 45 (17%), and a conversion table from a journal at 15 (6%). Considering the Rennick study, it is of particular importance that the standard deviations for fentanyl and methadone “morphine equivalents” will exceed the CDC cut-off by the CDC’s own definition of morphine equivalent. In other words, the CDC guidelines suggest patients should not receive more than a 50 MME and not to exceed 90 MME. But, by Rennick’s findings, a calculation for fentanyl 7.5 mg patch would be up to 117 MME less than and 117 MME more than the 7.5mg (75 mcg/hour) fentanyl dose. What does that mean? Looking at this another way, one clinician’s MME in this case could be 59 MME and another clinician might assign the equivalence of 293 MME, a range spanning 234 mg of morphine equivalent. Just the standard deviation alone is a recipe for death in the untrained professional. Again, this shows the lack of knowledge the CPSA has put forward with what they are proposing. Given the lack of standardization, potential drug interactions, a patient’s physical features such as height and weight, gender, organ function, coupled with patient individualized pharmacokinetics due to polymorphism, we respectfully disagree with utilizing a standard cut-off for morphine dose. We suggest the CPSA give credence to these mathematical and physiological variabilities and employ efforts to mandate education for providers and to approach every conversion for each individual patient slowly and carefully. Stop using the one size fits all approach as that is not correct; each person is an individual. Better still let these decisions be made between the patient and their doctor. It is unfortunate the CPSA has chosen the path they are now on and listened solely to the anti-opioid crusaders instead of listening to people who are suffering. Those with pain are seldom asked and then actually listened to when it comes to their pain. It is unfortunate the media has exacerbated the problem with sensationalistic stories and passed on conjecture, false and semi-truthful stories. Such as 80% of heroin users started on prescription medication, when the reality is: “According to the large, annually repeated and representative National Survey on Drug Use and Health, 75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer. And 90 percent of all addictions—no matter what the substance—start in the adolescent and young adult years.” Young people who misuse prescription opioids are heavy users of alcohol and other substances. This type of substance use, not medical treatment with opioids is by far the greatest risk factor for opioid addiction according to a study by Richard Miech of the University of Michigan and his colleagues. For their research they analyzed data from the nationally representative “Monitoring for the Future” survey, which includes thousands of students. In general, new addictions are uncommon among people who take opioids for pain. Another report from a large study of emergency room visits stated that less than 5 percent of attempted suicides involved pain medication. This was from a data base of more than one billion emergency room visits from 2006 to 2013. We believe that increasing awareness of the opioid overdose risk is certainly appropriate, but claiming unsubstantiated risks outweigh the benefits of using opioids to treat pain lacks scientific foundation. According to a recent study by Dasgupta et al., of 2,182,374 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). We firmly believe there is lack of education and training on opioid prescribing; instead of improving knowledge of healthcare professionals, this CPSA program is placing the burden on patients by reducing opioid access for patients that legitimately require them. Also, by ignoring for years what the real problem was—ILLICIT drugs—they have compounded the problem. Although there is a huge deficit in the education provided on pain management in medical and pharmacy schools, Alberta has a number of well qualified clinicians who should be utilized in creating better educational programs in our teaching hospitals. A study done by Mezei et al., concluded that education for North American medical students is limited, variable and fragmentary. Over 80% of attending physicians rate their education on chronic pain during medical school as “inadequate”. We believe the implementation of this CPSA program will have a drastic negative impact on patients living with pain and their loved ones. This proposed guideline will place restrictions on personalized patient care and prevent clinicians from providing high quality care. We find it quite disturbing the CPSA would move forward with their program based on the very flawed CDC Guidelines, which again are based on expert opinion, not on evidence; especially when the majority of those “experts” are strongly biased, as indicated by their affiliations to anti-opioid advocacy groups. Under this qualification it is equally disturbing they accepted the premise of the CDC Guidelines when in 2014 guidelines on the “role of opioids in the treatment of chronic pain”by the National Institutes of Health and based on an extensive literature review by an unbiased expert panel concluded: “What was particularly striking to the panel was the realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provide to rely on his or her own clinical experience.” It was also observed the target should be what the patient and their healthcare provider have decided between themselves as a reasonable goal to accomplish. We concur with this observation the patient and their doctor should decide what works or does not. Good medicine is a science, based solely on clinical research. Excellent medicine, on the other hand, is a scientifically informed art, understanding the uniqueness of every person and every situation, and utilizing answers to questions that science often lacks the tools to ask. It is surprising the CPSA would not work closely with a number of physicians in this province who have worked extremely hard over the past twenty years to refine their practices and increase their knowledge of the treatment of pain. Many have furthered their education every year with some receiving the Royal College of Physicians and Surgeons specialty certification in Pain Medicine, FRCP ©. The CPSA should be following these physicians instead of reacting to a situation beyond the control of people with pain and their healthcare providers; ILLICIT SUBSTANCES, and following the path of a few academics who have an extreme bias. It is unfortunate that the CPSA has reacted to the most recent tragedies inflicted by the use of ILLICIT FENTANYL, but if they think their program will mitigate the problem they are “dead” wrong. Indeed, as with lessons learned from the Prohibition of alcohol, the consequences are only greater harm. Restricting the legitimate use of opioids drives patients to illicit substances, which are not only potentially contaminated and of unpredictable potency, but they also support crime. Addicts have never had their disease mitigated by the restriction of supply. Criminal suppliers always find the means to meet their demands. If the CPSA thinks the present problem with ILLICIT substances is new they are again wrong. You don’t need to look any further then the Prescription Drug Research Center to understand this has occurred regularly since fentanyl was developed in 1963 at the Janssen Research Laboratory in Belgium. Shortly after the discovery, in 1970, in California a substance being sold on the street as heroin,( called “China White”) was discovered, it was however an actual analog of fentanyl. In the intervening years, clandestinely produced fentanyl analogs have appeared in the street drug trade, with the usually predictable consequences. This has led to where we are today with even more potent illegal substances on the street, with, according to the Drug research Center worse ones on the way. But, when you don’t admit what the real problem is, or try to obfuscate it, you can’t solve it. This proposal concerning the safe prescribing of opioids by imposing more requirements on physician prescribers is a dreadful folly. It is a disservice to people with pain, people addicted and those thrill seekers who feel they cannot be affected by trying these ILLICIT substances. If you want to reduce opioid addiction you have to target the real risk factors: child trauma, mental illness and unemployment. We should be working to create better mental health programs and then funding them adequately. Perhaps some of people on the street would not have been there if we had. Real dollars should be spent on pain research and education within our medical schools. We should work to give proper budgets to our law enforcement agencies so they may really fight the illicit smuggling. But, when you won’t admit what the real problem is you can’t solve it. We must not continue failing the citizens of this province when it comes to treating a condition that affects more people than heart disease, cancer and diabetes combined. Of course, we all want to ensure the safety of society and patients through the proper use of opioids, and try to ensure safety for those who are addicted or misusing them is laudable, but ineffect we are now punishing legitimate users of opioids. Those who are misusing are basically breaking the law, so are they more important than those who follow all the rules. We think not. One of the most important things in medicine is the trust that develops between doctor and patient; a key to getting well. The present approaches to opioid prescribing has broken this basic tenet of medicine and has undermined the trust many people with pain had with their doctor. It has had a profound negative effect on those people and is affecting their health care. March 15, 2017
Opinion Editor The Ottawa Citizen Ottawa, Ontario Dear Sir: September 28, 1980 The Washington Post ran an article written by reporter Janet Cooke. It began: “Jimmy is 8 years old and a third-generation heroin addict, a precocious little boy with sandy hair, velvety brown eyes and needle marks freckling the baby-smooth skin of his thin brown arms.” “Jimmy’s World” won a Pulitzer Prize, which the Post ultimately had to return. Cooke had written pure fiction: no 8 year old heroin addict could be found in Washington’s poorest neighborhoods, despite extensive searches. It appears, in 2016-17 large numbers of media outlets, regulators and policy makers have resurrected the need to recreate that time in the 1980’s. Anyone reading a newspaper or watching television news reports today is exposed to an ongoing hysteria concerning the so-called “epidemic” of deaths due to prescription opioids. This epidemic agenda is not entirely new. And while it makes for sensational news headlines that grab public attention, the use of the term and its accompanying panic-provoking rhetoric might be akin to falsely shouting “fire” in a crowded movie theater, and has led to a “Pied Piper” effect with little fact checking or looking at the whole picture. But, what we should all find disturbing is the blatant use of tragic circumstances, (led by a small group of U.S. addictionologists with close ties to a major drug rehab chain), to promote agendas that harm large numbers of fellow Canadians. The typical dictionary definition of “epidemic” is: “a disease or condition “affecting or tending to affect a disproportionately large number of individuals within a population, community, or region at the same time” (Merriam-Webster online). We do have a problem of substance misuse in this country, but it is not a prescription medicine problem. In recent articles, those who should know better, have blamed doctors for the problem. This is blatantly false. They claim 75% of addictions were the result of doctor prescribing, however according to the well respected and representative National Survey on Drug Use and Health, 75% of all opioid misuse starts with medication that wasn’t prescribed for them—obtained from a friend, family members or dealer. And 90% of all addictions—no matter what the substance—start in the adolescent and young adult years. Young people who misuse prescription opioids are heavy users of alcohol and other substances. This type of substance use, not medical treatment with opioids is by far the greatest risk factor for opioid addiction reports Richard Meich et al of the University of Michigan. Their research analyzed data from the nationally representative “monitoring for the Future” survey, which includes thousands of students. In general, new addictions are uncommon among people who take opioids for pain. According to a recent study by Dasgupta et al, of 2,182,372 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Stories about diversion of pain medication make the news, but the stories of people with persistent pain who thrive and function well in the community while appropriately using medications for pain, does not make the news. This imbalance of coverage contributes to limits in access to medications when prescribers become fearful or refuse to consider prescribing opioids, even when they are medically necessary and improve a person’s function and quality of life. But, don’t get me wrong opioids are not a magic bullet nor do they work for everyone, but they do play a part in a great many lives. It is sad when these ongoing “stories” like “Jimmy’s World”, continue to mischaracterize most of what is actually happening are destroying the lives of hundreds of thousands of Canadians with persistent pain. By reacting the way they have been to the unfortunate tragedies, inflicted by the use of ILLICIT FENTANYL, HEROIN and other substances they have made the problem worse and have actually enabled the illegal drug trade to flourish. Indeed, as with lessons learned from the Prohibition of alcohol, the consequences are only greater harm. Restricting the legitimate use of opioids drives patients to illicit substances, which are not only contaminated and of unpredictable potency, but they also support crime. Addicts have never had their disease mitigated by restriction of supply. Criminal suppliers always find the means to meet their demands. When people speak up about this they are continually bullied or painted as “pawns” of “Big Pharma”. But, I guess this is where the “head in the sand” approach will solve the problem. New knowledge often conflicts with old beliefs that have been held, and old beliefs die hard. Clinicians need to learn when it comes to pain management, “one size does not fit all” and individual assessment is crucial. Limiting legitimate access to medications for people with pain certainly will not solve the problems of addiction, misuse and diversion. We must separate the treatment of the person with persistent pain from the treatment of the person with an addiction disorder. Treatment is quite different for each. Taking pain medications as directed, to treat persistent pain should not be confused with having an addiction disorder. Severely limiting access to pain medications for everyone will not solve the problem of addiction. If you really want to reduce opioid addiction you have to target the real risk factors early on: mental health, unemployment and child trauma. So, to those who blame doctors you must do better and quit obfuscating what the real problem is. It is far more complex than attacking people with persistent pain and forcing them to live their lives in agony. We need better mental health programs, funded properly, better education for our medical doctors and obviously better rehab programs with better follow-up; the revolving door method simply does not work. Barry D. Ulmer Executive Director The Chronic Pain Association of Canada 11247 11 Avenue NW Edmonton, Alberta T6J 6S3 (780) 482-6727 |