Physicians need more support to tackle opioid crisis, Dr. Peter Butt says
Physicians need to be supported when they work with new national prescription guidelines designed to curb a crisis in opioid-related deaths, says Saskatoon Health Region addictions consultant Dr. Peter Butt.
“If we’ve prescribed our way into this difficulty we’ve got to be thinking of other modalities to back out of it,” he said.
Dr. Butt says he supports the guidelines, which have been developed by the Canadian Medical Association and other stakeholders.
For them to be effective, he says physicians will need services in place when they try to wean someone down or off opioids. And they’ll need assistance in the area of chronic pain management – in receiving accurate assessments in the first place and in having community supports during follow-up care.
That there is an opioid crisis is beyond dispute, says Dr. Butt, who is on a new provincial task force designed to respond to the issue of opioid and fentanyl overdose.
“There’s no question there’s a crisis in jurisdictions that actually track the data such as B.C. and Ontario,” he said. “They have had more deaths from prescription opioids than motor vehicle crashes so there’s definitely a public health problem, number one, and number two, it’s exacerbated by the presence of fentanyl, a very cheap, potent illicit opioid.
“To a certain degree the pump has been primed by readily available prescription opioids and now it’s a bit of a flood with illicit opioids.”
The prescription guidelines for physicians suggest opioids as a treatment option of last resort for people with chronic, non-cancer pain. The guidelines include:
- Prescription of non-opioid drugs and therapy, rather than opioids, for patients with chronic non-cancer pain.
- A trial of opioids for patients with chronic non-cancer pain only after non-opioid therapy has been tried.
- Avoidance of opioid therapy for patients with substance abuse, a history of substance abuse (including alcohol), or mental illness.
- Restricting therapy to less than 90 mg morphine equivalents daily (MED) for patients beginning opioid therapy, with a maximum prescribed dose of less than 50 mg MED.
- Patients already receiving high-dose opioid therapy (90 mg MED or more) should embark on a gradual tapering of their dose, with multidisciplinary support available to those who experience challenges.
During a period of heavy marketing by drug companies, many physicians came to believe they should prescribe opioids for chronic non-cancer pain as aggressively as they had been prescribing them for acute pain and palliative care, says Dr. Butt.
“Those are entirely different pain entities,” Dr. Butt said. “Acute pain, chronic non-cancer pain and palliative care each have their own unique responses and consigning it to an endless supply of opioids has been part of the educational piece that we need to reverse.”
Implementing the guidelines will take time and patience, he said. One type of non-opioid intervention will not work in all cases, but a combination of reasonable doses in a taper program can have an effect, he said.
“It’s not an all-or-none approach. It’s about being engaged and doing this in a gradual, rational, patient-centred way and for some folks a taper isn’t going to be accomplished,” he said.
It is important that physicians assess people based on functional improvement over time, whether as part of an opioid trial or a taper program. And the key for physicians is time.
“In part it’s because we weren’t supported in taking the time initially that people were prescribed into a situation that you could argue has done more harm than good, when you look at the mortality,” Dr. Butt said.
If people are put into opioid withdrawal and they turn to illicit drugs on the streets, “in the age of fentanyl we may see even more opioid-related deaths,” Dr. Butt said.
People who are receiving opioid therapy at levels far exceeding the guidelines will present the greatest challenge, he said.
“To avoid getting into this situation is going to be the easier piece, backing out of it is not easy and usually it requires very gradual tapers, 10 per cent of the dose every two weeks, maybe even slower,” Dr. Butt said. “At the same time they need to be supported in terms of the non-opioid management, the physical therapy, exercise and so on. Frequently the patients that I see that get motivated to engage in more physical activity, even if it’s gradual, incremental, they do better.
“Part of it, too, is helping them to take charge of pain management rather than being dependent on the opioid in many different ways, helping them to become more self-directed in the way that they manage their life with or around the chronic pain.”
Inadequate chronic pain assessment and lack of support services is the other part of the problem for physicians around the issue of opioids, Dr. Butt said.
Chronic pain management presents a host of complex issues, but it is not an emergency so time can be taken to work with people, time for which physicians need appropriate compensation. Physicians also have to know there are community-based resources available to patients suffering from chronic pain.
“The other piece is the need for more services to support physical therapy, massage, exercise, pharmacy, counselling, concurrent mental health issues that are often there with people with chronic care symptoms, a host of things, and this is where an assessment at a good consultation clinic would help a lot of the family physicians to manage, on an ongoing basis, people who struggle with chronic pain condition.”
The new CMA guidelines will create withdrawal issues for some patients, so Dr. Butt advises physicians to take a slow, deliberate approach. And the province’s doctors should realize they can’t do it alone.
“I think it’s really, really important that physicians are given the support and the services required to adequately treat the situation not only in terms of the management of chronic pain, but also with regard to supporting patients during an opioid taper,” Dr. Butt said.
The provincial task force of which Dr. Butt is a member will develop a multi-pronged, coordinated provincial response to the opioid and fentanyl crisis. The task force will be led by the ministries of Justice and Health, with representatives from other ministries.
“The hope is that the task force will better coordinate services and the provincial response over a number of related strategies,” said Dr. Butt.
He noted there has been improvement with training and providing take-home naloxone kits through Corrections, better information sharing between the Justice Ministry and the College of Physicians and Surgeons of Saskatchewan has addressed the trafficking of prescription drugs, and there has been feedback on the number of opioid overdose deaths from the Coroner’s Office to assess the impact of various policy changes or interventions.
All of these coordinated responses are compelling agencies and their managers “to step up and be more accountable and efficient in their response,” he said.