To resolve the opioid over-prescription crisis, we must start by presenting patients with alternative pain management options, before considering prescribing an opioid.
As clinicians, we are bound by professionalism and our ethical responsibilities to do no harm and to do what we can to address the pain and suffering of our patients. When powerful pain-relieving opioid medications were introduced a few decades ago, they seemed to be a way to do both.
We now know that the marketing of these powerful medications for chronic pain was not based on sound scientific evidence, and that the potential for developing physical dependence, addiction and misuse is significant — and considerably higher than once appreciated. We are now in the midst of a public health crisis with an increasing number of Canadians experiencing overdoses or dying from opioids each year.
A recent report estimates that, in Ontario alone, people filled more than 9 million prescriptions for opioids in 2015-16 — an increase of 450,000 from three years earlier.
As a profession, we hold a responsibility to be part of the solution to this problem and to start to turn the tide. The over-prescription of opioids is a complex issue and there are no simple solutions. A good place to start is in the exam room or at the bedside. Through our conversations with patients, we can discuss alternative options for managing pain, including nonopioid and nondrug alternatives, before considering an opioid prescription. And we should talk about the risks and benefits among the options.
Under the Opioid Wisely campaign, professional bodies representing doctors, pharmacists, dentists and others who are part of the Choosing Wisely Canada campaign are identifying clinical scenarios where scientific evidence shows that an opioid prescription is not warranted, and may do more harm than good.
For example, the College of Family Physicians of Canada says that patients should not continue opioids beyond the immediate period after surgery. This period is typically three days or less, and rarely more than seven days. Another example is the Canadian Association of Hospital Dentists (CAHD). We know that over a third of new opioid prescriptions are written by dentists. The CAHD recommends that opioids (like codeine) should only be prescribed after dental surgery if the pain cannot be managed by safer medications like ibuprofen (Advil) or acetaminophen (Tylenol).
Thinking twice about when patients need an opioid prescription and when they don’t is one important step we can take to deal with the opioid crisis. But in so doing, we must not forget our professional duty to address the pain and suffering of our patients. Recent estimates suggest that about 15 to 20 percent of Canadian adults suffer from chronic pain.
Importantly, patients who are already on high doses of opioids must be carefully assessed and managed. Tapering off of opioids should be carried out over a long time, with caution and supports in place. Taking patients off opioids abruptly can be harmful.
We must spend the time with patients to discuss the options for addressing their pain and not jump to the prescription pad for a quick fix. We now have decades of evidence showing that the quick fix has led to dire long-term consequences for patients and society. There is also an urgent need for greater access to evidence-based, publicly funded options for pain management, including multi-professional teams that are better equipped to address complex situations.
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