Have Canadian Doctors Lost Their Moral Compass?
By Marvin Ross
Sadly, the answer is yes when compared to their US counterparts. But let me explain.
In 2016, the US Center for Disease Control published its guidelines on the prescribing of opioid pain medication for those with chronic non-cancer pain. That report called for limiting the maximum amount of pain medication to 90 mg of morphine equivalent per day (MME) and the tapering of patients on higher doses.
A large part of the reason for this guideline was that it was erroneously believed that over prescribing was the cause of all the over dose deaths being seen throughout the US which was not the case. Nor was it correct to suggest that doctors’ prescriptions for opiates to their patients turned them into addicts. Dr Sally Satel, an addiction specialist at a Washington methadone clinic, lecturer at the Yale University School of Medicine and resident scholar at the American Enterprise Institute has disproved this as have many other experts. Writing in Politico, she pointed out that various large scale studies have only found addiction or misuse resulting from opiate prescriptions ranging from 0.12% to less than 8% of those prescribed.
Because of these guidelines, US doctors felt compelled to force their pain patients to reduce their doses unilaterally in a practice called forced tapering. Needless to say, the results were a disaster. Patients who were on stable and high doses of of opiates for years with no problems, had their doses reduced thus resulting in a return of severe pain. Reports of suicides among pain patients due to their pain were common as Satel pointed out in her article in Politico.
Both Dr Satel and Dr Stefan Kertesz, an addiction and pain specialist at the University of Alabama, described the plight of legitimate pain patients in an article in Slate Magazine. They wrote that the crackdown on opiates was leaving pain patients in very untenable situations and they provided a number of heart wrenching examples of what was happening to many of them.
Following on the US lead, Health Canada released a similar guideline in 2017 which they funded via McMaster University in Hamilton, Ontario. That guideline also severely limited pain medications for those with chronic pain and doctors found themselves under attack by their regulatory agencies. As a result, Canadian doctors also began force tapering their patients with equally disastrous effects — return of pain for those who had been stable for years, suicides, and pain patients seeking out drug dealers to make up for what their doctors would no longer prescribe.
Pain patients have been reported seeking out street dealers for what they could no longer get from their doctors. This has happened all over the country as in this case in Ottawa and this in British Columbia where a 60 year old was forced to seek out drug dealers. Syndicated Canadian talk show host, Roy Green, has been devoting considerable air time to this problem and had to announce that a pain patient who had been on his show and who was not being properly medicated, had passed away in excruciating pain.
While the plight of pain patients on both sides of the border has been similar, there is one huge difference. American doctors have been speaking out on behalf of their patients. Last Fall, the American Medical Association issued a report demanding that the use of the CDC Guidelines stop. This was followed by a pain management task force that issued a report recommending that pain be treated not as a one size fits all but as the complex issue that it is. Then, in March of this year, 300 American physicians demanded that the CDC re-evaluate its guidelines and that it clarifies the rules on tapering.
Likely as a result of these criticisms the CDC made public in early April, a letter it wrote February 28 stating that its opioid guidelines were never intended to limit opiates for patients with chronic pain. Then CDC Director Dr Robert Redfield stated that his agency “is working diligently to evaluate the impact of the Guideline and clarify its recommendations to help reduce unintended harms.” And the FDA issued a warning to doctors about the dangers of forcing patients off opiates and of tapering too quickly.
In contrast, very little has happened in Canada to help alleviate the plight of chronic pain patients. There has been no petition by doctors on behalf of their patients although a few individual doctors have spoken out. Because of patient outcries in British Columbia, the college of physicians and Surgeons in that province changed their rules and now forbid doctors from refusing to prescribe opiates or from taking on patients who required them.
When it comes to tapering, their new guideline states that “the merits of tapering to the lowest effective dose must be emphasized. Such tapers must be slow to minimize patient discomfort. Patients attempting a taper need supportive counselling and frequent follow-up. The College recognizes that these attempts may not always be successful; however, the option must not be abandoned.” Read, no matter how troublesome this attempt is for your patients, keep at it.
Patients are still tapered even if they have been on high doses for years with no problems.
Two examples of what doctors are getting away with in Ontario are these. The first is a 77 year old former member of the Canadian military and a retired police detective who has been on long term opiates for 20 years but who is being forced to reduce to less and less medication. He described his plight on the Roy Green show and the failure of the Ontario College of Physicians and Surgeons to offer him any help. This is the interview where he describes his current feelings as more frightening than when a homicide suspect held a gun to the back of his head.
Or that of a young woman who was born with cancer of the lower spine, endured powerful chemo as a child and had numerous surgeries. She was doing reasonably well until her doctors began forcing her to reduce her meds and she complained to a callous College of Physicians and Surgeons.
I have spoken to some senior physicians on behalf of various pain patients who either cannot find a doctor because they need opiates or are being severely tapered and they have tried to help but to no avail. None of them have bothered to deal with this problem systemically as have their US counterparts. The doctors who drafted the Canadian Guidelines did respond to an article I wrote in the Canadian Medical Association Journal criticizing what is happening to pain patients. They all said that they were concerned as well with forced tapering and that they speak out about it when they can.
That is wonderful but they have not issued a formal statement nor has their institution issued a formal public statement like the CDC did. In essence, they are quiet and allowing the current situation to continue. And they are allowing the abuse of pain patients to continue.
Health Canada, which has the same powers at the US Food and Drug Administration, has also said nothing.
Canadian pain patients continue to suffer.