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VIBERT: Has the pendulum swung too far?

If you’re looking for easy answers, stay away from tough questions.
That would mean staying away from medicine, where all the questions seem hard because the easy ones were answered long ago. (Had a good bleeding, lately?)
The word “opioids” strikes fear into the hearts of parents across Canada, and the potential loss of the medication does the same to thousands of Nova Scotians and millions of people nationally who suffer from chronic pain (three or more months of persistent, serious pain).
No one who is informed on the issue disputes that opioids were, and in some cases still are, overprescribed.
It wasn’t that long ago that every junkie in Halifax knew which doctors’ office to visit to “get well” hassle-free. The police will tell you, quietly, that they knew too, but there was little they could do about it when the medical establishment didn’t step up.
Today – late in the game from some perspectives, and with too heavy a hand from others – the medical establishment is very much involved in opioid prescription practices. (Regulating bodies have monitored opioid prescribing for years, but old guidelines were deemed inadequate.)
The new national guidelines on opioid prescription, from a layperson’s reading, seem eminently reasonable yet they are the genesis of the problem.
Fearful of running afoul of the licensing and regulating authorities, some doctors are cutting back on opioid prescriptions or are refusing to accept patients with chronic pain.
Guidelines, by definition, leave the discretion with the practitioner. But either the interpretation or implementation of the guidelines is causing difficulty.
For example, maximum dosage levels recommended in the new guidelines are less than half the previous common dosage for chronic pain, and that seems to be the root of the most prevalent problem faced by people with long histories of opioid pain treatment – insufficient medication.
Yet, the guidelines say, that in these cases doses should be tapered back where possible and no patient should be destabilized by insufficient medication.
Gus Grant, the CEO of the College of Physicians and Surgeons of Nova Scotia (CPSNS), chairs Nova Scotia’s drug monitoring board and helped write the guidelines.
He knows that understanding any problem requires context, including historical context. People, he said, need to remember how we got here – to a national opioid abuse, addiction, and even overdose crisis.
The executive suites of big pharmaceutical companies were the white-collar equivalent of the Medellin cartel, pushing opioid pain killers to doctors who passed them to patients until the carnage grew unavoidable. People were, and are, dying including young people, which heightens the tragedy.
Grant said the pendulum had swung too far. Too many high-dose opioid prescriptions were being written.
The pendulum metaphor suggests it must swing back, generally too far in the opposite direction, before eventually settling at the right balance.
And that is precisely what chronic pain advocates argue. That the pendulum has now swung too far toward restrictions on prescriptions, and people with chronic pain are suffering.
Dalhousie medical school professor, and chronic pain specialist Mary Lynch said there is an environment of fear around opioid prescription.
There are even duelling data sets to support each side of the debate.
Grant says there “can be no doubt that the guidelines are the best synthesis of available science.”  Recent history indicates that as opioid prescriptions increased, so did addictions and related health problems. The obverse is that just 0.3 per cent of chronic pain sufferers treated with opioids develop addiction issues.
There are no easy answers. But the guidelines need to be as advertised – guidelines - and doctors need to know those guidelines are “not meant to replace clinical judgement” as per the explanatory notes.
Finally, as with most everything else in the health sector, there needs to be better – unambiguous and consistent – communications.
The guidelines document, like a conventional communications plan, identifies “primary” and “secondary” audiences.
Family doctors are a primary audience, but many got the message they’d be in big trouble if they prescribed beyond the guidelines’ recommendations. That suggests at least ambiguity in communications between the doctors and the authorities that provide oversight to the profession – the drug monitoring board, the college of physicians, and/or the government.
Chronic pain patients, relegated to secondary audience status, found out they had a problem when they had a problem, I.e. not enough, or no pain medication.
It turns out there are easy answers left in medicine. For example, to the question, Have the new national guidelines been well and properly communicated?
“No,” is both easy and correct answer.


Jim Vibert, a journalist and writer for longer than he cares to admit, consulted or worked for five Nova Scotia governments. He now keeps a close and critical eye on provincial and regional powers.

 

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