The 2017 McMaster guidelines on opioid prescribing have received a lot of criticism from chronic pain patients and doctors who specialize in pain management.
My latest opinion pieces on this topic (aside from the many blogs that I have done on HuffPost Canada) appeared in the Hamilton Spectator and in the Canadian Medical Association Journal. Ottawa pain specialist Dr. Mary Redmond appeared on the Roy Green Show to criticize the guidelines, as did B.C. pain specialist Dr. Owen Williamson. A number of other doctors from across Canada and the U.S. have shared similar opinions. Harvard Medical School's Dr. Peter Grinspoon, writing in the blog Lean Forward, sided with chronic pain patients and commented that "[pain patients] are now being treated as 'addicts' and criminals."
The chair of McMaster's guideline committee, Dr. Jason Busse, disagreed with my comment in the Hamilton Spectator. His letter to the editor, sent in response to my piece, emphasized that opioids are dangerous and that they will lead to addiction. He took issue with my suggestion that fatal overdoses are uncommon, insisting instead that "research published in 2015 found that one of every 550 patients started on chronic opioid therapy for non-cancer pain in Ontario died of opioid-related causes within a median of 2.6 years." He went on: "The proportion was as high as one in 32 (three per cent) among patients receiving 200mg morphine equivalent dose per day or more."
Any death is a tragedy, but we need to put this finding into perspective.
The particular study he referenced was on sex differences in dose escalation of opioids. The researchers culled a database of the disabled and those on social assistance in Ontario, who do not represent a cross-section of society. The 550 in question were only those who were on an abnormally high dose of opioids out of a total number of 32,499 people — 1.7 per cent of all who were evaluated.
One person out of 550 is 0.18 per cent, but one out of 32,499 is mere 0.003 per cent. Moreover, only about 10 per cent of all those prescribed opioids in a 13-year period remained on it for more than three months.
It is only a very small number of patients prescribed opioids, who take very high doses for a long period of time, that run a real risk.
The single fatality that Dr. Busse cited was a very rare case and not typical of the numbers who were on opioids in that 13-year period. The McMaster researchers seem to erroneously attribute a danger to all individuals prescribed with opioids — in fact, it is only a very small number of patients prescribed opioids, who take very high doses for a long period of time, that run a real risk.
Even then, mortality is very low. We could say that of the 550 on very high doses, 549 did well. The Ontario Drug Policy Research Network points out that for 2016, opioid prescriptions are down but overdose deaths are up, so clearly the deaths are mainly among addicts and not those given prescriptions. Health Quality Ontario reported that in 2016, there were 867 opioid-related deaths out of 8,277,790 prescriptions filled. Assuming all the deaths were among those who were legally prescribed — which Health Quality Ontario admits was not the case — that is only 0.01 per cent who died.
For comparison, we need to look at non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, Advil, etc., many of which can be bought over the counter. They have been linked to about 30 per cent of drug-related hospital admissions, and "it's estimated that 12,000 to 16,000 Americans die annually as a result of gastrointestinal bleeding caused by NSAIDs."
As for addiction, the research paper cited to the Spectator by McMaster also dispelled that very myth. Almost 90 per cent of patients in the study took opioids for less than three months, and then stopped. Where was the addiction? Further refutation of that concept can be found in one of my many earlier blog posts.
Patients are petrified and suffering. At the same time, doctors are afraid to prescribe them for their patients, according to this report out of Calgary — a webinar put on by Health Quality Ontario said much the same of doctors in this province, owing to the new prescribing guidelines.
Do we really want our doctors to be in fear when they come to prescribe for us?
This social tinkering in the relationship between patients and doctors will continue to cause people increasing pain and misery if it does not end, just like earlier misguided attempts have done. In 2003-4, there was considerable concern that anti-depressants were causing increased suicide ideation among young people, so regulators issued warning to doctors about possible dangers when giving anti-depressants to their teenaged depressed patients.
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Doctors became fearful and decreased prescriptions by 22 per cent in both the U.S. and the Netherlands, according to one study. The result was a 49 per cent and 14 per cent increase in teen suicides in the Netherlands and U.S., respectively. How many teens lost their lives as a result? How many chronic pain patients will die in misery as a result of curtailing opioid prescriptions?
We really need to rethink what these opioid prescribing guidelines are doing and we need a much broader discussion involving the public.
Correction: An earlier version of this blog attributed the quote "[pain patients] are now being treated as 'addicts' and criminals" to Harvard Medical School. The statement was written by Dr. Peter Grinspoon, a Harvard Medical School teacher.
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