Back to Opioids: the dual tragedy continues – PART I

Over a year ago I wrote a column about the “Opioid Public Health Crisis” in Ontario. Opioids are a class of medications that are a natural derivatives of morphine and that can be also synthesized in the lab. They are the most potent medications available for the treatment of most types of severe pain, but they are also associated with several adverse events, including abuse and addiction.

In early 2009 a scathing newspaper report was published providing data that showed a high incidence of opioid abuse by some people whose medical care was funded by the Ontario government.  Lawmakers reacted and the Ministry of Health created the Narcotics Advisory Panel to start looking into the problem (I serve in this panel myself). Since then “water has ran under the bridge” but slowly, while the banks of the “opioid river” continue to swell up and overflow. On one hand abuse, overprescribing and diversion (selling the drugs for profit) continue, while on the other hand hundreds of legitimate patients are cut off their pain medications or refused the drugs despite a real and valid need.

Let me give you an idea of the magnitude of the problem through stories I live every day. I will start provide accounts from overuse/ overprescribing aspect first.

Many patients on high dose opioids will gravitate to my clinic (based on an academic hospital and handling difficult chronic pain cases) as doctors now have become more aware that certain prescribing practices have gotten out of control. Consuming daily doses of morphine over 100-200 mg have been shown to be associated with overdoses and deaths. My record patient was a 41-year-old man with bad bowel disease who had undergone 13 surgeries since the age of 19. His medications had been prescribed and continuously increased by his family doctor. He was referred to me by his gastroenterologist, who was very concerned about this man’s opioid consumption. This man was taking (HOLD your breath) 180 opioid pills A DAY plus a very powerful opioid patch (sticking on the skin every two days), for a total of 9,360 mg of morphine per day (this is 50 times higher than the dose the Canadian Guidelines for safe and effective use of opioids considers risky).

This translated to his consuming 5,400 tablets of a very potent opioid per month in addition to 15 patches, costing the Ontario taxpayers 41,750.00$ a year! I nearly fell off my seat and told the man that he needed to be hospitalized to get off these megadoses safely. The man insisted that it was time to reduce his intake as his wife had just delivered his first child, a baby son, who became “the light of his life”. He came to my office of his own volition holding his newborn baby.  He begged me to give him guidance and show him how reduce the pills on his own safely because he could not wait to be admitted since the waiting lists to gain entry to a proper facility are so long. I did, and months later he was able to dramatically reduce his medications while functioning well at home.

While he was the most prolific consumer of opioids we have ever seen in in the 30 years I have been running my clinic, similar stories are part of my daily life. Only few days ago, I saw a 39-year-old man who had a bad ankle fracture 2 years ago and had 3 surgeries. He came to the office barely putting weight on this leg, leaning heavily on crutches, as he insisted that he was in terrific pain (despite his medications). His doctor had put him on the equivalent of 2,300 mg of morphine daily and had also prescribed medical marijuana for him (to the tune of 5-8 fat joints daily).

What the doctor missed is that this patient had abused opioids and other substances before his surgery, so he was at very high risk for further abuse and possibly diversion. The worse thing is that he came holding his last 4 pills as his doctor had advised him that “from now on the pain clinic would be taking over his opioids”! I told the patient in no uncertain terms that I was not taking over his prescription and that he would have to return to his prescribing physician.  I promised to call the physician immediately to counsel him on how to reduce the patient’s medications safely because they level of opioids he was currently consuming was unacceptably high).

The patient became very angry, jumped off my examination bed and I noted that he was was able to speedwalk right out of my office on the very same ankle he had been unable to place weight on just moments before. He left to go straight to his doctor’s office while making threatening comments. I called his physician immediately and advised him that the patient was on his way to his office and that he had no alternative but to continue prescribing him the medications while reducing them slowly and safely until the patient brought down his opioid consumption to a reasonable level or until a consultation had been obtained with an addiction specialist.

This is called tapering. I provided him with a numerical formula and instructions how to do this and the physician was able to comply. Unfortunately, this is not the first time we see this as some physicians frequently drop their patients like hot potatoes on my doorstep, refusing to prescribe further opioids.  Once they get concerned about college regulations or other reasons, some physicians will do this despite the fact that they were the ones who had been prescribing the opioids for a long time.

In one case 2 members of the same family (father and son) arrived at my clinic from Sudbury without an appointment because their doctor (who initiated and prescribed their opioids for years) had written to them saying that he no longer wanted them at his practice.  They came to me because he had given them a 3 month supply of medications and they were running out of pills.

The other thing we often see is older physicians retiring or closing their practices (particularly in Northern Ontario). The new doctors who take over refuse to continue prescribing high dose opioids to their new patients, leaving them stranded. The proper approach is to accept these patients but start tapering their medication down to a reasonable and safe level (if they still need them), to discontinue them or to refer them for methadone or buprenorphine treatment (the latter control cravings). Abrupt cessation of these powerful drugs is very dangerous because patients go in withdrawal and in some cases will desperately resort back to opioids from different sources after the withdrawl.  They will take the same amount they had used before and overdose because opioids were out of their system for a while and they have lost some of their tolerance to them.

The crisis we face with opioids does not finish there. What about our aboriginal communities, some of which are very isolated, where at times half of the population is hooked on opioids that arrive to the communities illegally in large quantities via air or boat)? Opiod abuse and misuse is the “symptom of a disease, not the disease itself” as the Honourable Health Minister of Ontario Deb Matthews told me personally on September 15, 2010, when she presented Bill 101 to the Legislation in an effort to curtail opioid abuse. The “disease” relates to poor pain management and lack of resources to treat addiction. You just do not cut the drugs and solve your problem if you do not provide addiction services and social support systems. In our aboriginal communities alcohol was highly abused years ago just to be replaced by certain prescription opioids. As prescription opioids are been curtailed, heroin is making a comeback.

What about our kids who take these pills from grandma’s cupboard to get high at parties? The Ontario government has launched a campaign to educate highschool students as one study has shown that up to 20% of all teenagers have tried prescription opioids.

What about the older persons who break their leg or something else, sent out of the hospital on opioids (even in small doses), but overdose, because at the same time they are on other pills that suppress the nervous system including medications to calm the nerves of induce sleep (such as drugs of the family of valium etc)?

What about patients who appear in emergencies with a blocked bowel (called “narcotic bowel syndrome”) due to prescribed opioids  beause constipation is the most common side effect of these drugs?

What about those on sizeable doses of opioids who still operate their cars or in some situations heavy machinery and trucks that run on our roads? Many of them are safe but some are not (and we do not know WHO is safe to drive on our roads as the Ministry of Transportation lacks any guidelines for physicians with regards to what to do with such patients).

What about little towns which have never had sex trade workers and in a matter of a few years have become littered with women exchanging sex for prescription opioids?

What about pharmacy robberies and pharmacists held at gun or knife point by addicts who seek prescription opioids? What about physicians threatened by opioid-seeking addicted patients and are scared to say No?

My bad stories do not end there as there is the exact opposite side of the problem. In my next paper, we will look at the tragic situation of those who need and deserve those drugs but cannot get them.

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario