Does Canada Need ‘Enforceable’ Opioid Guidelines?

By Pat Anson, Editor

Canada should adopt nationwide “enforceable guidelines” to limit the prescribing of opioid pain medication and doctors should be sanctioned if they fail to follow them, according to a new commentary in the Canadian Medical Association Journal.

The head of the Chronic Pain Association of Canada called the proposed guidelines “another sad effort to punish people with pain.”

Like the United States, Canada has been hit by a wave of opioid overdoses – deaths increasingly attributed to heroin and illicit fentanyl, not pain medication. According to one estimate, over 1,000 Canadians have died so far this year from fentanyl overdoses.

But, like its neighbor to the south, Canada has been trying to fix the opioid problem by restricting access to pain medication.

“This crisis is only getting worse, and Canada urgently needs to implement effective measures aiming at and addressing the underlying drivers of the opioid epidemic,” writes lead author Benedikt Fischer, PhD, of the Centre for Addiction and Mental Health at the University of Toronto.

Fischer and his two co-authors specialize in addiction, mental health and epidemiology, not in pain management.

“Evidence of the therapeutic effectiveness of prescription opioids for pain is rather limited. Data show some benefits for treatment of acute pain, but evidence to support using opioids to treat long-term chronic pain is weak and insufficient,” they wrote.

Only in passing do Fischer and his colleagues even mention the rising number of deaths in Canada being blamed on illicit fentanyl – a synthetic opioid 50 to 100 times more potent than morphine.   

They propose several measures similar to the opioid prescribing guidelines released by the U.S. Centers for Disease Control and Prevention:

  • Prescribe opioids in “the lowest possible dose and for the shortest possible duration”
  • Establish prescription drug monitoring systems across Canada
  • Develop a “national surveillance system” for opioid-related overdoses and emergency room visits
  • Expand access to opioid addiction treatment

One key difference from the so-called “voluntary” guidelines of the CDC is a recommendation that Canada adopt “enforceable guidelines” that would allow for opioids to be prescribed only as “an exceptional treatment” and only when there is “good scientific evidence” for their use.

The guidelines would be similar to professional medical standards recently adopted in British Columbia and Nova Scotia, which make physicians in those provinces liable for professional, civil or even criminal sanctions if they don’t follow them.

Critics say the guidelines are having a chilling effect on both patients and prescribers.

Limiting prescriptions of opioids will do absolutely nothing to stop this problem and just the notice of intent has already made the problem for pain sufferers worse,” said Barry Ulmer, executive director of the Chronic Pain Association of Canada.

“They are forcing patients on high doses to come off their medications, stopping family doctors from actually working with patients who have been in their care for years, and even giving names of patients on high doses to the police as potential dealers. One doctor had his practice visited by police with 3 names of patients and took their files for investigation.”

Like the United States, Ulmer says the debate over opioids in Canada is being led by addiction treatment specialists, not by pain management physicians.

As an example, he cites this month’s National Opioid Conference in Ottawa, which is being hosted by Canada’s Minister of Health. The invited keynote speaker is David Juurlink, MD, an academic toxicologist at Sunnybrook Health Sciences Centre in Toronto, who is also a board member of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group that played an influential role in drafting the CDC guidelines.

“It is not a conference on opioids, but an addiction conference or more probably an effort to restrict opioids or just prohibit them,” said Ulmer. “It is clear what direction they are going in when they invite Juurlink to be the keynote speaker and have not invited some of the preeminent doctors who are experts in the use of opioids. Tantamount to medical malpractice. They don’t want to talk about the illicit problem because that destroys their whole argument.”

Health Canada is currently conducting a review of Canada’s opioid prescribing guidelines, which have not been updated since 2010. The Centre for Addiction and Mental Health in Toronto – Canada’s largest addiction treatment hospital -- released a report today urging Health Canada to pull all high-dose opioid medications off the market, according to The Globe and Mail.