05/19/2017 11:57 EDT | Updated 05/19/2017 11:57 EDT

Ontario's War On Pain Patients

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Health Quality Ontario just released a report on opioid use that will do nothing but frighten many doctors into refusing to properly medicate their pain patients. The report, which received extensive media coverage, pointed out that doctors and dentists wrote over 9 million prescriptions in fiscal 2015/16 and that was an increase of about 450,000 prescriptions from 2013/14. This represents 14 per cent of the population so 86 per cent did not get prescribed an opioid. What percentage of the 2013/14 population received prescriptions, they do not say.

My reaction is so what? The so what for them is to show just how dangerous all these prescriptions are and how that may be leading to all the overdose deaths we are reading so much about. That is nonsense, fear mongering, and avoidance of the real problem.

Doctors and dentists prescribe these drugs for post surgical or dental pain; acute pain as the result of a broken bone or other painful trauma; palliative care for terminal cancer; and for chronic pain. Now the report does state that 25 per cent of the prescriptions were for one off reasons like post surgical and broken bones. Only 75 per cent of the prescriptions were for longer periods.

Looking at the age distribution of those who received prescriptions is very telling. Two thirds of those receiving prescriptions are over the age of 45 with the percentage for the over 65 at 27 per cent. Those over 65 are more likely to die and so I can only assume that a chunk of those people are being prescribed for palliative care. The same can be said about those 45 - 64 but for the 45+ patients, they are likely developing chronic illnesses that are progressing and need pain relief.

This becomes even more evident when you look at the age distribution for those getting a one time prescription. Two thirds of that group were under 18.

We are also being bombarded in the media with stories of fentanyl overdoses. Interesting then to see that Health Quality Ontario reports that only one per cent of pain prescriptions is for fentanyl patches and that is down from two per cent.

The assumption in their report is that people are becoming addicted because they were prescribed opioids and possibly some of what doctors prescribe is being diverted to street use. As I pointed out in my blog last August, very little legitimately prescribed pain medication makes it to the street. Most of the street fentanyl comes from illegal labs in China and Mexico and is used to lace pills. In January I wrote about Ontario's two-tier pain med system. The province stopped paying for higher doses of pain meds for the elderly and those on disability. The current report points out that as a result of that policy change of "some opioids being removed from the list of drugs that are covered by public funding, the use of other types of opioids appears to have increased."

The most egregious aspect of this report is the use of anecdotes. Health Quality Ontario cites as an example of the dangers of opioid prescribing the case of one person. It is common knowledge that anecdotes do not make evidence and, as the Logic of Science blog says "Personal anecdotes are often the primary ammunition of those who deny science" and they go on to describe how this approach is common among anti-vaccination types and others.

The question we need to ask is what percentage of people who are prescribed opioids become addicted? This is not addressed by Health Quality Ontario. They just imply that this happens all the time.

It does not!

The Canadian Pain Society is comprised of scientists and health professionals studying pain management and they are affiliated with the International Association for the Study of Pain in Washington DC. Their Pain Working Group, in a 2014 paper, differentiate between abuse (getting high), addiction (continued use despite harm), misuse (other than intended by the prescribing doctor), and dependence (withdrawal symptoms).

The national Canadian Alcohol and Drug Use Monitoring Survey, they report, has found that using opioids without a prescription was at 4.8-5 per cent and use to get high was at 0.3 per cent. When they looked at why that approximately five per cent were using opioids without a prescription, it was found that the vast majority used them so they could treat their own pain. And they were obtaining them because they were having problems getting them from doctors who felt uncomfortable prescribing. Even more doctors will feel uncomfortable given the type of paper produced by Health Quality Ontario.

Other studies the Pain Society cites demonstrate that only 3.27 per cent of people with chronic pain develop abuse or addiction. Among those chronic pain patients with no history of abuse or addiction, only 0.19 per cent develop abuse or addiction. The problems we are seeing are not caused by legitimate prescriptions for legitimate reasons. It is the illegal drugs manufactured in clandestine labs or smuggled in from Mexico and/or China that are the problem. Attacking pain medications and those who prescribe them and use them will not solve that problem. Part of the problem was also generated by stupid government policies.

The Pain Working Group points to the attempt by governments to reduce oxycodone use by making the pills tamper resistant. The result was a decrease in oxycodone use but an increase in heroin use which addicts switched to.

In my January blog, I quoted Dan Malleck, an associate professor in health sciences at Brock University, who wrote an excellent op-ed in the Globe and Mail. He pointed out that all the talk is about painkillers rather than pain itself. Most people take pain medications because they have pain. What is wrong with that?" I agree and so does the Canadian Pain Society. They say that they "support the treatment of pain as a basic human right."

The health Quality Ontario paper does nothing but make that more difficult for people to achieve.

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