Continuing education for opioid prescribing should be mandatory: CMA

Canadian physicians should be subject to mandatory continuing medical education in the appropriate prescribing of opioids -- medications whose use has now become almost routine for treating chronic pain, the Canadian Medical Association's annual meeting in Halifax was told Monday.

Dr. Douglas Grant, registrar of the College of Physicians and Surgeons of Nova Scotia, told an educational session on the drugs that excessive prescribing of opioids like oxycodone, fentanyl and hydromorphone for patients with chronic, non-cancer pain has become "an enormous problem."

"With respect to opioids, there's been in my view a general loss of awareness, a growing casual attitude about the risk of these medicines," Grant said.

As doctors have become increasingly comfortable with prescribing opioids over the last two decades or so, he believes they've become less aware and concerned about their potential dangers, including the increasingly common risk of overdose death.

At the same time, there's been a shift in patients expecting to be not only treated for pain, but to be pain-free, he said.

"That's created a positive feedback loop which I think has led to the present rates of high prescribing," said Grant, noting that Canada has the second-highest per capita usage of prescription opioids in the world, after the United States.

"I really think we're at a point now where we have to consider mandatory CME (continuing medical education) about prescribing."

Doctors must have a number of continuing education credits each year to be considered medically competent and to remain in good standing with their professional colleges.

"So the question we have to ask ourselves is: how do we get the toothpaste back in the tube?"

Grant doesn't believe excessive opioid prescribing arises from "malignant" doctors who are knowingly contributing to the widespread legitimate and illicit use of the drugs, but from physicians who take too casual an approach to prescribing the potent painkillers.

"What I frequently see is undisciplined, unstructured and arbitrary use of these medications," he said, pulling no punches in his address to delegate-colleagues attending the session.

"Most of the time, this approach is employed by well-intentioned but weak-willed and underinformed physicians who have lost control of the patient-doctor relationship."

Regulators like his Nova Scotia college can help physicians by pointing out how their prescribing practices stack up against those of other doctors in their province, based on a prescription monitoring program, he said.

Nova Scotia is one of the few jurisdictions in Canada with such a program, which allows doctors to check on a patient's real-time medication history.

Dr. Mary Lynch, a professor of anesthesia, psychiatry and pharmacology at Dalhousie University in Halifax, said opioids are an essential tool in managing pain, especially for those with cancer or for acute pain from injury or diseases that cause tissue damage such as rheumatoid arthritis.

Using the drugs to get acute pain under control is also crucial for preventing patients from going on to develop chronic pain and to promote healing, she said.

But in the case of chronic pain, Lynch said patients can often benefit from a comprehensive treatment plan that also includes physiotherapy and other non-pharmacological interventions.

However, not all patients have access to such programs, leading doctors to rely on opioids to alleviate their suffering and improve their quality of life.

Lynch said up until about 2010, the use of opioids in Canada and the U.S. had been increasing, but she suggests their use has been falling as awareness of the drugs' risks has increased among physicians and the public.

There are now reports of patients being unable to access the medications when they legitimately need them, she said. "Now we may need to be concerned that the pendulum has maybe swung too far the other away."

Lynch, who's also director of research at the Pain Management Unit at the QEII Health Sciences Centre, would like to see a national opioid strategy in Canada.

But she said it's important when developing policies to remember there's a specific sub-population of people who use the drugs to get high or who have become addicted to the narcotics.

"There is massive ignorance about the complexities of addiction, there is inadequate access to care for addiction for many people. There is massive ignorance about the assessment and treatment of pain. We are not teaching it in our medical schools adequately," she said.

"So the solution is to get better care for pain and better care for addiction -- not to demonize a drug or a class of drugs and try to identify simplistic solutions like increasing the regulation of those drugs, which is what two consecutive health ministers have wanted to do."