News

Faced with staggering increases inopioid prescribing, rising rates ofaddiction and criminal activity,

as well as an apparent vacuum innational leadership, provincial collegesof physicians and surgeons are bandingtogether to craft opioid use guidelines.

Draft guidelines have been circu-lated to a national advisory group ofexperts in a bid to achieve consensusand are expected to be finalized inOctober as part of the provincial col-leges’ unprecedented move to createnational clinical practice guidelines.

Canadian doctors prescribe almosttwice as many of the powerful and addic-tive painkillers as they did a decade ago,making Canadians among the world’stop consumers of prescription opioids.

While that likely means better paincontrol for select groups — such as can-cer and palliative care patients — thecolleges are concerned that physiciansare inappropriately prescribing opioidsfor all manner of ailments. Others sug-gest that the colleges also hope to obviaterising concern about physician liability.

Janet Wright, assistant registrar ofthe Colleges of Physicians and Sur-geons of Alberta, says the regulatorycolleges decided to step in because no

one had created national guidelines. “Itis really unusual for regulatory bodiesto produce guidelines and we had lotsof discussion about whether we should.… But there was a void.”

Wright adds that the colleges alsofelt compelled to act because doctorshave identified opioid prescribing as a“tough practice area.” A survey con-

ducted by the College of Physicians andSurgeons of Ontario found that familyphysicians ranked chronic pain manage-ment second only to mental health as achallenging area of clinical practice.

In British Columbia, “we found outthat most doctors don’t really know therules of the road when prescribing forsomeone with chronic noncancer pain,”says Dr. Robert Vroom, deputy regis-trar for the College of Physicians andSurgeons of BC. “Why should we bepunishing our doctors for somethingthey don’t know? This is one of thosebig gaps in their education and wethought we should do something tohelp doctors rather than beat them up.”

The draft clinical practical guidelinesnow being circulated were created by anacademic group at the Institute for Workand Health in Toronto, Ontario, that hadearlier developed a chapter on opioidsfor the Ontario college’s guidelines onchronic noncancer pain, says Dr. AndreaFurlan, evidence-based practice coordi-nator for the Institute. It’s expected theguidelines will eventually be maintained,and regularly updated, by the newMichael G. DeGroote National PainCentre being established at McMasterUniversity in Hamilton, Ontario.

Wright says the colleges jointlyfunded the National Opioid Use Guide-

CMAJ • OCTOBER 13, 2009 • 181(8)© 2009 Canadian Medical Association or its licensors

464

Surveys indicate that one of the mostpuzzling challenges that doctors face isappropriate use of opioids for chronicpain management.

Previously published at www.cmaj.ca

Regulatory colleges to set painkiller guidelines

@20

09 J

up

iter

imag

es C

orp

.

of the Centre for Medicine, Ethics andLaw at McGill University and author ofDeath Talk: The case against euthana-sia and physician-assisted suicide,writes in an email to CMAJ.

Alex Schadenberg, executive direc-tor of the Euthanasia Prevention Coali-tion, likewise argues that the rationaleoffered to support the Quebec Collegeof Physicians’ proposal is lacking. Pro-viding comfort has nothing to do withintentionally ending a life, he says, andphysicians are not charged for improperuse of opioids if a patient dies as aresult of accepted pain-relief practices.

“If we were to go down the routethey are talking about, it would createmore confusion,” says Schadenberg,who believes, if the College’s proposal

became law, doctors would be undermore scrutiny when patients on painmedication die. “Why did they use thathigh amount? Did they use it to kill thepain or kill the patient?”

Also expected to drive the euthana-sia agenda this fall is Bill C-384, a pri-vate member’s bill introduced byFrancine Lalonde, that seeks amend-ments to the Criminal Code to permitthe “right to die with dignity.” The billsurvived first reading and is expected tobe debated in the House of Commonsunless Parliament is dissolved as aresult of a nonconfidence vote in theminority government.

The bill states that medical practi-tioners would not be considered to becommitting homicide when they assist

in the deaths of people who are at least18 years old, have severe “physical ormental pain without prospect of relief”and have “provided a medical practi-tioner, while appearing to be lucid, withtwo written requests more than 10 daysapart expressly stating the person’s freeand informed consent to opt to die.”

Schadenberg forecasts that, as withtwo previous attempts to legalizeeuthanasia, the bill will fail, in partbecause its language is too broad. Healso takes particular issue with thephrase “appearing to be lucid.” That isquite different, he says, from actuallybeing lucid, which in itself can be diffi-cult to assess. — Roger Collier, CMAJ

DOI:10.1503/cmaj.109-3034

line Group to oversee the initiative andstresses that the guidelines are beingdeveloped independently. No pharma-ceutical company or other external fund-ing was accepted in development of theguidelines. “We have been extremelyscrupulous and it is very important forus to have scientifically rigorous andwell-supported guidelines.”

The colleges plan to link up with anumber of partners to disseminate theguidelines, Wright adds. “We want toroll these out in a useful way and mea-sure if they improve practice.”

For example, when doctors startsomeone on opioids, there might be atreatment contract or a screeningprocess to see if the patient is at risk ofaddiction. Alberta may also conductacademic detailing on the guidelines.

Ultimately, it’s hoped the new clini-cal practice guidelines will help toresolve what has become the altogetherproblematic issue of opioid prescribing,which Wright says ranges from goodclinical care to “almost criminality.”

In the past, too many dying peoplelacked good pain management becausemany doctors, nurses, patients and fam-ilies had a fear of opioids, she says. “Soyou want to make sure people get reallygood pain control, but at the other endis the abuse problem.”

Fischer says that increases in pre-scribing — and problems with drugabuse — are in large part driven by pre-scribing for the “bottom of the severityspectrum” of pain. “We dish out [opi-oids] far too readily for trivial problems.”

That has resulted in a phenomenalincrease in consumption. Per capita,Canadians rank third in the world in theuse of prescription opioids — justbehind the United States and Germany,says Benedikt Fischer, a criminologistwith the Centre for Applied Research inAddictions and Mental Health at SimonFraser University in Burnaby, BC.

Moreover, the gap between Cana-dian consumption and the rest of thedeveloped world amounts to “lightyears,” says Fischer, lead author of astudy that indicated prescribed opioidsare now the predominant form of illicitopioid use in Canada. (CMAJ 2006;175 [11]: 1385-7). “The fact is we livein a society where the medical systemgenerously dishes out potent and

potentially addictive substances at arate seven times the rate in the UnitedKingdom and something like 30 timesthe rate in Japan.”

Canadian per capita retail spendingon opioid drugs (adjusted for inflation)more than doubled between 1998 and2007, according to the Canadian RxAltas, 2nd Edition. There’s been alock-step increase in addiction prob-lems among the general population,including street users (Can J PublicHealth 2009; 100[2]:104-8) .

So endemic has opioid use becomethat the International Narcotics ControlBoard stated in its 2008 report that abuseof prescription drugs has replaced heroinabuse as a key concern in Canada, partic-ularly the use of oxycodone (OxyCon-tin), which is twice as addictive as mor-phine. According to the board, andUnited Nations data, Canadian consump-tion of oxycodone increased to about 110mg per capita in 2006 from less than 10mg per capita 10 years earlier.

Many claim there’s been a parallelincrease in addiction and criminalactivity. For example, in a seven-weekperiod, five pharmacies in Sudbury,Ontario, were robbed — two of them atgunpoint — by individuals looking forsupplies of OxyContin, says JamesDesault, a pharmacist who was on Sud-bury’s former OxyContin/ NarcoticAbuse Task Force. There is “substan-tial” money to be made by selling pillson the street and “something needs to bedone before someone gets killed.”

But Fischer warns it would be unwiseto focus on a single drug. “I alwaysstrongly urge people not to reduce this toan oxycodone problem because there isusually a sequence of development —people might start off becoming addictedto codeine and when that is not enoughany more, they escalate.”

He also says that resolving the prob-lem will require more collaborationbetween pain management and addic-tion experts. “These people operate indifferent universes and there needs tobe a lot of cross conversation that is notreally happening.”

An attempt to bridge those two soli-tudes was made in 2006 when HealthCanada convened a national workshopon preventing problematic use of psy-chotropic pharmaceuticals. It eventu-

ally recommended that an independentorganization, similar to ones in Franceand the US, be established to monitorabuse, but nothing has come of that.

Getting a handle on the actualdimension of the problem is made evenmore problematic by the lack of accu-rate information. “We don’t have muchdata and we are sort of puzzle-buildingat the moment,” says Fischer, who ispart of a team that received a CanadianInstitutes of Health Research grant tostudy nonmedical use of opioids in thegeneral and street populations.

Questions about prescription druguse and abuse were added to HealthCanada’s annual Canadian Alcohol andDrug Use Monitoring Survey for thefirst time in 2008. More than 20% ofthe Canadians surveyed reported hav-ing used opioid pain relievers — suchas oxycodone and aspirin (Percodan),meperidine (Demerol® Hydrochloride)and oxycodone — in the prior 12months. Of those, 1.5% reported usingthe drugs to get high. Among thoseaged 15−24, that rose to 4.9%. — AnnSilversides, CMAJ

DOI:10.1503/cmaj.109-3031

CMAJ • OCTOBER 13, 2009 • 181(8)© 2009 Canadian Medical Association or its licensors

465

News