Back to Opioids. The dual tragedy continues. PART II

In Part I of this two part series, I discussed over-prescription and overuse of  opioids in Ontario and other provinces. Now, I am going to discuss the other side of the problem. Under-prescribing or refusal to prescribe these powerful drugs, even when they are needed and can help a patient, is also a daily reality. Unfortunately, this part of the story is not making headlines or it is being sensationalized in media.

In one of my past papers entitled “Long Winding Road,” I reported that prior to seeing me, an 89 year old patient who had been suffering for years from incapacitating leg pain and had visited 40 health providers, including medical doctors, chiropractors, podiatrists, physiotherapists, and more. I managed to make a proper diagnosis and finally treat him with small doses of a special drug to soothe the abnormal nerve activity in his leg, something for his sleep and “baby doses” of liquid morphine with a dropper. Today, as a 94 year old, this man is still very active and enjoying his life and family, and has maintained the same regime of small doses of proper medications. He was one of the very first patients over 65 years of age who we decided to treat with “baby doses” of morphine. Patients like him had significant medical conditions, failed previous treatments, could not be operated on, as they were very fragile, and usually were taking lots of other medications for heart, blood pressure, diabetes and other health problems.

So, what does one do with patients who are experiencing a lot of pain, but have significant or multiple medical problems? We decided to study all of our patients over 65 to determine suitability for the morphine drops as treatment. First we had to convince them that it is ok to try the drug, as most had been scared stiff reading all these stories in the newspapers about abuse and addiction. Once we did convince them, we started them on 1 to 3 drops, 3 to 4 times a day, increasing the dose slowly depending on the effectiveness of pain relief. In May 2012 my team will present the results of our small study to the Canadian Pain Society Annual meeting. We are very happy to report that 85% of those we tried on liquid morphine did quite well, reduced their pain by 38% and maintained (hold your breath) on an average of 23 mg of morphine a day. This is nearly an imperceptible dose as compared with the hundreds and thousands of mg of morphine I reported earlier in those who take excessive doses of the drug inappropriately.

The elderly are a vastly undertreated segment of our society. As I have written numerous times before, chronic pain from joint and nerve conditions can only increase as we get older. Most of us will get by with over the counter drugs or no drugs at all. But for some, strong pain killers in small to moderate doses make the difference from being bed-ridden, to going shopping, gardening, or participating in family functions.

In the past, I have also reported that other cases about people in long term care facilities who are not able to communicate properly, are in serious pain and are poorly and inadequately treated. Studies have shown that small doses of proper analgesia in patients with dementia helps to reduce agitation and somewhat improves cognitive function, which is otherwise impaired when the brain is preoccupied with fighting pain.

My clinic faces a serious problem with legitimate patients with significant biomedical conditions and in dire need of appropriate small or modest doses of opioids, who are refused these drugs by their family physicians. As the noise about the abuse and misuse of opioids has increased, the Ontario Ministry of Health makes attempts to curtail inappropriate use by setting up monitoring systems and controls, and regulatory bodies take notice of physicians’ practices, physicians go exactly to the “other side of fence.” They just refuse outright to prescribe these drugs, even when the patient needs them and shows no risks factors for abuse.

In a past paper, I have reported on a young competitive male athlete who suffers from a very bad leg. After many surgeries and infections, he is on mini-doses of a strong opioid, but his physician outright refuses to prescribe it.

I chair the patient organization, ACTION Ontario, which is run by a number of activist patients of mine. Many of them are using small or modest doses of opioids, which they (and I) control tightly, in combination with other drugs. It is this appropriate treatment, together with self-management techniques and other non-drug treatments, that keep my patients going and has turned them into productive members of society.

Proper analgesia keeps many of my other patients in the work force and provides them with meaningful pain relief and increased quality of life (more often than not, combined with other drugs or modalities). One example is the young man whose arm was crushed by a machine at the work place, and has now returned to work after retraining that was made possible only because his pain is better controlled.  Or, the young woman who developed a debilitating condition after an injury to her foot (called Complex Regional Pain Syndrome), who has maintained minimal doses of opioids and has returned to work in a modified position. Nearly 20-30% of the patients in my practice need these drugs. Of course, this is not necessarily a standard percentage of need for a family physician, as they see far fewer patients with serious chronic pain.

The tragedy here is that many physicians refuse to prescribe these medications to worthy patients expecting that the “pain clinic will take over” – something that becomes impossible as we have no manpower and time to become primary opioid prescribers for so many sufferers.

There is immense need for coordinated “patient centered” comprehensive pain management in this and other provinces. Opioids are NOT a panacea and in many cases, must be combined with other pharmacological and non-pharmacological approaches to combat pain effectively.

Hopefully, the concerted and multifaceted efforts of ACTION Ontario, other formal bodies such as the Canadian Pain Society, individual societies in different provinces, together with health providers and patients, can convince the provincial governments and the federal government that to address chronic pain, we need comprehensive, all-inclusive, publically funded pain management that provides treatment options, along with controls and measures to ensure that the taxpayers’ money is used properly.

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)

Director, Comprehensive Pain Program,

Senior Investigator, Krembil Neuroscience Centre

Toronto Western Hospital,

Chair ACTION Ontario