Pubdate: Mon, 26 Sep 2016
Source: Toronto Star (CN ON)
Copyright: 2016 The Toronto Star
Contact:  http://www.thestar.com/
Details: http://www.mapinc.org/media/456
Authors: Hance Clarke and Joel Katz
Page: A13

THERE IS NO SIMPLE OR QUICK FIX TO OUR SOCIETY'S OPIOID CRISIS

Early one morning, while leaving my downtown Toronto home, I heard the
quiet crying of a young woman lying in the alleyway. I saw a
tourniquet and needle on the ground, her valuables scattered in
disarray. I stopped and offered to take her to a centre where she
could get help.

Tragically, this is an all-too-common occurrence across the country.
Scenarios like this will only increase if we restrict opioid
prescribing for chronic pain. We have an opioid abuse problem in
Canada, but we must be careful about how we address it.

Politicians are under significant pressure to make quick decisions
about this issue and see the solution in restricting prescription
opioids. Changing healthcare policy based on the false premise that a
restriction of opioid prescribing will immediately benefit our
society, save lives, and solve the "opioid crisis" is misguided.

A blurring of two issues has occurred. The death rate associated with
illegal drug use is not related to the risk of overdose among chronic
pain patients who are using an opioid long-term under the care of a
qualified pain physician. Publications on the increase in
opioid-related deaths in Ontario lack data on other substances
ingested (e.g., alcohol and benzodiazepines) and whether or not the
person had a history of mental health problems.

Prior to prescribing an opioid, every physician should inquire about a
patient's history of mental health problems, abuse, addiction and
their living situation. The relevant information may not preclude an
opioid prescription, but, in some cases, would certainly trigger a
modification of prescribing practices and referral for other
nonpharmacological interventions.

Although four-out-of-five heroin users admit their path started with a
"prescription" opioid, this does not mean she or he was prescribed the
opioid. They likely acquired it from an individual to whom it had been
prescribed or they purchased it illegally.

The Toronto General Hospital Transitional Pain Service is at the
forefront of managing pain and coexisting opioid misuse and addiction.
The multidisciplinary program combines the worlds of pain medicine and
addiction to help people with their pain while optimizing opioid use.

We recognize that people with chronic pain not only use prescription
opioids to relieve pain; some also may misuse them to avoid withdrawal
symptoms that develop with long-term use at high doses or to manage
other unpleasant symptoms. However, the public is entitled to know
there are many people who function extremely well on their
opioid-based medications.

Pain specialists provide safe and effective care to thousands of
Canadians with chronic pain who enjoy productive and fulfilling lives
given the pain control they obtain from opioid medication. Earlier
this year, the Centers for Disease Control (CDC) published guidelines
for prescribing opioids for chronic pain, highlighting the importance
of integrating nonopioidbased pain medications with non-pharmacologic
treatments for chronic noncancer pain.

Since 2014, the Transitional Pain Service has provided such a tailored
approach to patients before and after major surgery by combining
psychological interventions, nonopioid medications, acupuncture, and
physical therapy all with an emphasis on weaning off opioids as soon
as possible and within reason. Moving forward, provincial funding
plans for pain programs should be focused on supporting services that
emphasize functional recovery and psychological health as much as
medical well-being.

Restricting medication is not a solution. We need to drive change
locally, provincially and nationally.

"Low-hanging fruit" to target for effective change in the prescriber
world includes:

* Eliminating fentanyl patches for all but cancer and palliative care
patients.

* Creating tamper-resistant solutions.

* Targeting areas of health care where opioids are often mismanaged,
which includes postsurgical pain, inflammatory bowel disease, multiple
arthritic conditions, pediatric/adolescent conditions such as sickle
cell disease, emergency departments, and so on.

* Improving physician education.

* Advocating for more psychological services.

Proposing an overnight change that restricts opioid prescribing
indiscriminately will lead to a worsening of the illicit drug epidemic
in this province. People with chronic pain who presently obtain their
opioids through prescription and have never resorted to illicit use
may be forced into illegal channels if placed into acute withdrawal.

The circumstances of the young woman described above will become
increasingly common in neighbourhoods across our province. There is no
quick fix to our society's opioid crisis; a concerted effort is
required from government, law enforcement, industry, and pain
management and addiction experts who are on the front line.

Dr. Hance Clarke is the director of pain services and medical director 
of the Pain Research Unit at Toronto General Hospital. He is an 
assistant professor at the University of Toronto.Dr. Joel Katz is a 
professor and Canada Research Chair in Health Psychology at York 
University. He is research director of the Pain Research Unit at Toronto 
General Hospital.
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MAP posted-by: Matt