The opioid epidemic is garnering more and more attention these days. Government at all levels has been slow to respond to the crisis, and we still lack a comprehensive top-down plan to deal effectively with it. Doctors are often blamed for perpetuating the problem as the number of opioid prescriptions continues to climb year by year.
Undoubtedlythere are physicians overprescribing these dangerous drugs, and I'm not excusing their actions in any way. Rather I want to highlight the hypocrisy of bemoaning the number of opioid prescriptions while simultaneously implementing policy that encourages exactly that. We undervalue the systemic factors that influence how many patients receive an opioid prescription, and without an appreciation of those factors this crisis cannot be solved.
In the interest of space I'm going to take you through a brief summary of how we got here. For a long time opioids were reserved for acute pain (trauma or surgery) or the severe pain that many cancer patients suffered at the end of their lives. Chronic, non-cancer pain had not been considered very important but about 20 years ago that attitude began to change. Pain became the "fifth vital sign" and health care in general became more attentive to pain and more oriented towards treating it.
Pharmaceutical companies like Purdue developed new long-acting opioid drugs (slow release to allow a constant dose of opioid in the bloodstream), and pushed the idea that long-term use of opioids was beneficial for patients with chronic pain. Ultimately, Purdue lied about the addictive potential of these new drugs, leading to an explosion of opioid dependency and abuse in the intervening years.
We're learning more each day about the risks of long-term use of opioids, which have been implicated in things like major injuries, liver disease, depression and (paradoxically) increased pain. More recently we're seeing a massive flood of cheap, bootleg opioids arriving from overseas that are designed to imitate prescription drugs. Typically they are incredibly potent and likewise incredibly dangerous.
The irony is that the evidence doesn't even support the primacy of opioids in chronic pain treatment. It is vastly overused, even by responsible prescribers. As well, there is reasonable evidence for non-pharmaceutical treatments like physical therapy, acupuncture, mindfulness meditation and cognitive behavioural therapy.
Unfortunately, non-pharmaceutical options tend to be expensive, and the provincial government has only made that worse. Since 2004 Ontario has drastically reduced funding for modalities like chiropracticand physiotherapy, effectively making them inaccessible to a large swath of patients. Likewise, psychotherapy has received very little financial support as a treatment. We know that patients with lower socioeconomic status are more likely to suffer from chronic pain, yet options like physiotherapy and mindfulness meditation are often only available to those who can afford to pay privately or have additional insurance.
By cutting off access to non-pharmaceutical modalities, the government is all but mandating the impossible choice between long-term drug therapy and a life of pain. This puts enormous pressure on physicians to support their patients by prescribing medication, especially when pain is so great it may mean an inability to work and a further decent into poverty.
If the government is serious about reducing the number of opioid prescriptions it needs to take down the barriers to opioid alternatives.
But why opioids specifically rather than other pain medications? The answer to this complex, but I can break it down into two parts. First, during the era that Purdue and other makers of long-acting opioids were heavily marketing these drugs, doctors and medical trainees were on the receiving end of a very aggressive push to shun the old-fashioned reticence towards opioids. The prescribing patterns of an entire generation of physicians were successfully skewed towards opioids.
Second, a good number of non-opioid drug treatments are quite expensive, and even the ones that are cheaper still don't always work well enough to be used in isolation. Commonly, patients end up on a combination of different agents (which can help reduce the amount of opioid medication they are using), but this can be a very costly situation. If a patient can't afford more than one or two medications, they will be hard pressed to drop the one they are already chemically dependent on, even if in the long-term it is the worse choice for them.
If the government is serious about reducing the number of opioid prescriptions it needs to take down the barriers to opioid alternatives. Increase funding for physical and psychological therapies and drug treatment of chronic pain will decrease. Provide low-income patients with subsidies for non-opioid pharmaceuticals and doctors will prescribe them more often. Simply expecting that doctors will stop prescribing opioids without improving access to non-opioid treatment options is short-sighted and, frankly, doomed to fail.
It may seem like I'm just asking for more money to be thrown at the problem. But consider the high cost of this epidemic and then tell me why we should be directing funds towards a pound of cure but not an ounce of prevention.
More recently the province has expanded the privilege of prescribing opioids to nurse practitioners, a contradictory move given the criticism that too many opioid prescriptions are currently being written. Certainly nurse practitioners can be responsible prescribers of these medications, but they are no less influenced by the systemic issues that affect physicians. Yet without meaningfully changing any of those systemic factors, the government has decided that now is the time to increase the number of providers capable of prescribing opioids. So who will shoulder the blame as the inevitable happens and the number of opioid prescriptions is higher next year than it was this year?
Unfortunately, we are still without a comprehensive plan to address these issues. Such a plan would address the multi-factorial reasons that opioids are prescribed and remove the barriers to alternatives. Many have called for a national pain strategy to optimize our treatment of pain. We are lagging behind other countries such as Australia and the U.S. in this regard. The call for a thoughtful, well designed policy around opioids and chronic pain has never been so loud, nor the need so urgent.
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