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The importance of providing non-judgmental care to chronic pain patients

August Messenger 2019, Medical Matters, Prescribing | Posted August 8, 2019
This past month has been very productive when it comes to understanding the complexities of opioid prescribing and looking after chronic pain patients. The op-ed piece printed on July 12 and my July Medical Matters generated a great deal of valuable discussion. We saw a very wide range of opinions on this subject: some people told us I was delusional in my thinking, while others said our message hit the mark. That likely means that we fell somewhere in the middle.

I want to emphasize that the vast majority of physicians are working very hard and providing excellent health care to Albertans. However, the discussion that has taken place over the past few weeks has highlighted that a small number of physicians in Alberta need to recognize the importance of providing non-judgmental care to chronic pain patients, just like any Albertan suffering with a chronic condition.

CPSA’s intent is not to discipline Alberta physicians who prescribe opioids or prescribe them over the recommended guideline’s maximum dosages, as long as this is done in the most appropriate way as outlined in our standard of practice on Prescribing: Drugs Associated with Substance Use Disorder or Substance-Related Harm. There are many Alberta physicians who already prescribe what would be considered high doses (more than 200 OME per day), and their patients are doing very well because they are receiving comprehensive care and the risks have been assessed.

We also have a small number of patients who are currently on extremely high doses, 5,000-10,000 OME per day and, in some cases, these very high doses are combined with benzodiazepines. These extreme cases are reason for us to be concerned, but many of those patients are doing well, and they understand the risks involved. Someday, one of you may need to take over the care of one of these patients, and it’s important to recognize that tapering quickly or cutting these patients off is very dangerous. If you need support with such a case, we’re here to help you.

In this edition of The Messenger, you will see an interview with Dr. Allan McDonald about caring for chronic pain patients and prescribing opioids. He is one of thousands of Alberta doctors who are willing to look after chronic pain patients and, when required, safely prescribe opioids. I would like to personally commend Dr. McDonald for not only being courageous enough to share his thoughts with the medical profession, but more importantly, for looking after pain patients.

Fortuitously, Health Canada’s Canadian Pain Task Force just released a report titled Chronic Pain in Canada: Laying a Foundation for Action. I encourage everyone to read this. There are two paragraphs from the report I would like to highlight for you:

Anxiety and fear around opioids have also led to unmanaged pain. Some Canadians have been unable to access opioid medications when needed for pain and function. Others have faced undue barriers to obtaining or filling their opioid prescriptions, and some have had their opioid dose abruptly lowered or discontinued. This has resulted in unnecessary pain and suffering, and has led some Canadians to obtain illegal drugs to treat their pain. We must do more to strike the right balance – to promote opioid prescribing practices that balance the benefits and risks of these medications based on the individual needs of each patient. (Message from the authors)

Recent dramatic increases in opioid-related overdose deaths in North America have heightened awareness around the risks associated with both short- and long-term opioid use. A toxic illegal supply of opioids is currently the main factor driving drug overdose deaths. However, increased availability of prescription opioids has also contributed to opioid-related hospitalizations and deaths since the early 2000s. Opioid medications have been diverted to the illegal market providing a supply for non-medical use. In addition, a proportion of individuals prescribed opioids for both acute and chronic pain have experienced significant harms including the development of opioid use disorder, overdose, and death. While the relationship between pain, opioids, and opioid-related harms in Canada requires further clarification, available evidence warranted action. (Section 2.3)

I like these two paragraphs because they nicely capture the complexity of this issue. Opioid prescribing certainly has its risks, especially when not prescribed appropriately, but it may also be advantageous in the right circumstances. Refusing to prescribe opioids, refusing to look after chronic pain patients or rapidly reducing opioids are situations that pain patients should not experience. They cause harm to patients, just as over prescribing does. CPSA understands that it’s incredibly hard to stay current on all aspects of medicine, especially when practicing family medicine; therefore, if you don’t feel up-to-date in how best to prescribe opioids or look after complex chronic pain patients, I encourage you to reach out to the Alberta College of Family Physicians (ACFP)’s Collaborative Mentorship Network for Chronic Pain and Addiction.

All patients-no matter their health concern, economic status, sexual orientation, religious affiliation, beliefs about dying or ethnic background-deserve access to non-judgemental care in a safe environment. They deserve to have a medical system and professionals working within that system who accept them, understand their situation and provide them with the safest, highest-quality care possible. No one should ever feel taken advantage of or rejected because of their health needs. I know the vast majority of physicians already meet this expectation, but for the few who don’t, I am asking each of you to do your part in taking on complex patients and working with them to manage their chronic pain.

Your comments are appreciated,

Scott

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