This is an article by Marvin Ross, it is published with the author’s permission. The author and Moving Towards Better have no financial involvement
Marvin Ross, Volunteer, Chronic Pain Association of Canada
Have Canadian doctors lost their moral compass? Sadly, the answer might well be yes when compared to their US counterparts. However, let me explain.
In 2016, the US Centers for Disease Control and Prevention (CDC) published its guideline on the prescribing of opioid pain medication for those with chronic non-cancer pain. The report stated:
“Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”
A large part of the reason for this guideline was that it was erroneously believed that over-prescribing was the cause of the overdose deaths being seen throughout the US. Nor was it correct to suggest that doctors’ prescriptions of opiates for their patients were turning them into addicts. Dr. Sally Satel, an addiction specialist at a Washington methadone clinic, lecturer at the Yale University School of Medicine and resident scholar at the American Enterprise Institute has disproved this claim as have many other experts. Writing in Politico, she pointed out that various large scale studies have only found addiction or misuse resulting from opiate prescriptions ranging from 0.12% to less than 8% of those prescribed.
Because of this CDC guideline, US doctors were compelled to reduce their patient doses of opiate medicine unilaterally in a practice called “forced tapering.” Needless to say, the results were a disaster. Patients, who were on stable and higher doses of opiates (e.g. higher than the guideline) for years with good benefit and no ill effects, experienced a return of severe pain and disability. Reports of suicides among pain patients due to their increased pain were common as Satel pointed out.
Both Dr. Satel and Dr. Stefan Kertesz, an addiction and pain specialist at the University of Alabama, described the mistreatment of legitimate pain patients in an article in Slate Magazine. They wrote that the crackdown on opiates was leaving pain patients in very untenable situations and they provided a number of heart wrenching examples of what was happening to many of them.
Following the US lead, Health Canada released a similar guideline in 2017 which they funded via tax-payers money through McMaster University in Hamilton, Ontario. This guideline also severely limited pain medications for those with chronic pain and Canadian doctors now found themselves under attack by their regulatory colleges. As a result, Canadian doctors also began force tapering their patients with equally disastrous effects — a return of pain for those who had been stable for years, suicides, and desperate pain patients seeking out drug dealers to make up for what their doctors would no longer prescribe.
This tragic consequence has happened all over the country as in this case in Ottawa and this in British Columbia where a 60 year old was forced to seek out illicit drugs due to undertreated pain. Syndicated Canadian talk show host Roy Green has been devoting considerable air time to this problem and had to announce that a pain patient who had been on his show and who was not being adequately medicated, had passed away in excruciating pain.
While the plight of pain patients on both sides of the border has been similar, there is one huge difference. Hundreds of American doctors have been speaking out on behalf of their patients. Last fall, the American Medical Association issued a report demanding that the “inappropriate use” of the CDC guideline must stop. This was followed by a pain management task force that issued a report recommending that pain be treated not as a “one-size-fits-all”, but as the complex disease that it is. Then, in March of this year, 300 American physicians demanded that the CDC re-evaluate its guideline and that it clarifies the rules on tapering.
Likely as a result of these criticisms, the CDC made public a letter written on February 28 stating that its opioid guideline was never intended to limit opioids for patients with chronic pain. Then CDC Director Dr. Robert Redfield stated that his agency “is working diligently to evaluate the impact of the guideline and clarify its recommendations to help reduce unintended harms.” Additionally, the Food and Drug Administration (FDA) issued a warning to doctors about the dangers of forcing patients to taper opiates and of tapering too quickly.
In stark contrast, very little has happened in Canada to help alleviate the plight of chronic pain patients. There has been no petition by doctors on behalf of their patients although a few individual doctors have spoken out. Because of patient outcries in British Columbia, the College of Physicians and Surgeons in that province changed their rules and now forbid doctors from refusing to prescribe opiates or from taking on patients who require them. However, this has not been successful in practice but has shown to be words only.
When it comes to tapering, the new BC guideline states that “the merits of tapering to the lowest effective dose must be emphasized. Such tapers must be slow to minimize patient discomfort. Patients attempting a taper need supportive counselling and frequent follow-up. The College recognizes that these attempts may not always be successful; however, the option must not be abandoned.”
Read into this: no matter how distressful this attempt is for your patients, keep at it.
Patients continue to be tapered even if they have been on higher doses for years – often decades – with no problems. Here are two examples of what doctors are getting away with in Ontario. The first is a 77 year old former member of the Canadian military and a retired police detective who had been on long-term opiate therapy for 20 years but has been forced against his will, his pain level, and quality of life to reduce to less and less medication. He described his plight on the Roy Green show and the failure of the Ontario College of Physicians and Surgeons to offer him any help. This is the interview where he describes his current feelings about his suffering as more frightening than when a homicide suspect held a gun to the back of his head.
The second example is that of a young woman who was born with cancer of the lower spine, endured powerful chemotherapy and radiation as a toddler and had numerous unsuccessful surgeries. She was doing reasonably well and functioning until her doctor (forced by his college) began tapering her pain medications all to a disastrous end. She complained in desperation to a callous College of Physicians and Surgeons of Ontario who did nothing to help or protect her health.
I have spoken to some senior physicians on behalf of various pain patients who either cannot find a doctor because they need opiates or are being severely tapered. These few physicians have tried to help but to no avail. No doctors to date have bothered to deal with this problem systemically as have their US counterparts. The creators of the Canadian guideline did respond to an article I wrote in the Canadian Medical Association Journal criticizing what is happening to pain patients. They replied that they were concerned as well with forced tapering and that they speak out against it when they can.
That sounds like a step in the right direction however they have not issued a formal public statement nor has their institution as the CDC and other US counterparts have done. They remain quiet and consequently the current situation remains unabated. The abuse and unethical treatment of pain patients continues on.
Health Canada, which has the same powers at the US Food and Drug Administration, set up a Chronic Pain Task Force to report on the plight of pain patients but their final report will be three years in the future. They recently issued a preliminary report in which they admit that pain patients are facing serious problems but they categorically refuse to order doctors to cease and desist in their attacks on pain patients. The Chronic Pain Association of Canada (CPAC) was quick to renounce their report.
The co-chair of the Task Force, Maria Hudspith, did talk to Roy Green on air and reiterated the problems faced by pain patients in Canada, yet refused to issue any directives to stop what is happening. You can listen to her interview with commentary by Barry Ulmer, Executive Director of CPAC and myself.
The bureaucrats meet but Canadian pain patients continue to suffer and sometimes die. Where are Canadian doctors in all of this and have they indeed lost their moral compass?