In what many consider to be a very progressive move, Health Canada is reported to be near launching a nation-wide trial where drug users get prescribed heroin. Chris Mackie, the medical officer of health in London, ON, just met with Canada's health minister, Dr Jane Philpott, last week. He is quoted by CBC News that:
"There is evidence that injectable heroin works, and that it works better than other opioid maintenance therapy, and it should be more widely prescribed than it is now."
Dr Philpott had said earlier that pharmaceutical heroin is a life saver. Similar trials in both Vancouver and Montreal found that prescribing heroin to addicts results in a decreased use of street drugs, less crime to pay for the illegal drugs and a reduction in HIV and hepatitis from addicts using dirty needles.
In one of my earlier HuffPost Canada blogs, I talked about the experiences of Portugal which was the first country to decriminalize drug use and they now have the lowest overdose deaths in all of Europe.
Sadly, the progressive nature of this move is offset by the very regressive government policy on legitimate opioid use by patients in pain who are prescribed it by their doctors. The McMaster University Guidelines on the use of opioids for non-cancer pain was funded by both the Canadian Institute of Health Research and Health Canada who will also fund the heroin trials.
I've written a number of blogs here on the stupidity of these guidelines as have others like Roy Green on his syndicated talk show. A number of pain specialists have spoken out against these guidelines on his show and been quoted by me. The criticisms deal with the fact that patients who have been prescribed high doses of opioids for years and are doing well, are suddenly finding themselves being cut off by their doctors or their doses severely restricted. Some are now going to street dealers and others are planning suicide if they cannot get the relief they have had for years.
In what looks like an attempt at damage control, McMaster just did a lengthy webinar trying to explain themselves. The editor of the Guidelines is Dr Jason Busse who is described on the guidelines as an associate professor in the Department of Anesthesia. He is not, however, a medical doctor but a chiropractor which is how he is described in the webinar.
Chiropractors cannot prescribe any medication and, frankly, I would have been far more comfortable if an actual MD who treats chronic pain patients chaired the group and it was composed mostly of those experts. This was a bit like having a naturopath chair a guideline committee for best practices in cancer care.
He does admit in the webinar that they are now starting to hear anecdotal stories that aggressive reductions are being forced on patients by their over zealous doctors and there is the potential to cause more harm as a result. He ended his talk by saying that there is a real danger of reducing opioids for those who are getting relief and that they do not want to put patients in a worse position when the drugs they take are giving them important relief.
But what did he or the others expect when they put out these guidelines?
The guidelines have taken the figure of 90 mg of morphine equivalent (MME) as a standard that should not be exceeded without good reason but he admits that 40 per cent of those who are getting opioids are at doses over 200 MME and that the median dose (50 per cent above and below) is 180. And he then states that reducing these high numbers will result in increased pain, reduced functioning and a mistrust by the patient in the doctor/patient relationship.
Recommendation 9 in the guide suggests that for those patients on more than 90MME, the doctor start to lower the dose but then admits that "Some patients are likely to experience significant increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused and potentially abandoned in such patients." So, if the patient is doing well on whatever dose they are on, why mess with it?
Then we have recommendation 10 that suggests that for those on the higher doses who do experience difficulty when their dose is reduced, doctors divert them from their prescriptions to multi-disciplinary programs like physiotherapy, occupational therapy, a chiropractor, a psychiatrist, etc. Note that as a chiropractor he suggests they can be helpful.
This is a strong recommendation meaning that there is a lot of evidence that it will be successful but he admits that in most areas, these programs are not even available, have long wait lists and can be expensive because they are not covered.
Again, why mess with something that isn't broken?
He does say that the intent of developing guidelines is to reduce the risk to people from an excessive use of opioids but this has to be done without increasing the problems for those who are on high doses. And that is exactly what they have done. Busse even says that the medical evidence is not enough to make these decisions. They also put a high value on patient values and preferences. Patients, he said, value pain reduction much more highly than they do potential side effects.
The argument by some that opioid prescriptions is leading to more drugs on the street he dispelled by saying that only about five per cent of legitimate prescriptions gets diverted. And, as for the long term negative effects of being on opioids, he admits that they do not have valid studies (randomized control trials) that go longer than a year.
But, the unintended consequences of this guideline production is to make many people who were doing well on high doses of opioids for years, fear what their doctors may do and are doing. So, if we can give heroin to illegal drug users to help them, why can we not give opioids to those who need them and get them from their doctors?
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