By Dr. Wendy Levinson
University of Toronto
and Dr. Laurent Marcoux
As clinicians, we’re bound by professionalism and our ethical responsibilities to do no harm, and to do what we can to address the pain and suffering of our patients. When powerful pain-relieving opioid medications were introduced a few decades ago, they seemed to be a way to do both.
We now know that the marketing of these powerful medications for chronic pain was not based on sound scientific evidence. We also know that the potential for developing physical dependence, addiction and misuse is significant, and considerably higher than once appreciated. We’re now in the midst of a public health crisis, where an increasing number of Canadians are experiencing overdoses or dying from opioids each year.
One report estimates that, in Ontario alone, people filled more than nine million prescriptions for opioids in 2015-16. That’s an increase of half a million prescriptions from three years earlier.
As a profession, we hold a responsibility to be part of the solution and start to turn the tide. This is a complex issue and there are no simple solutions.
A good place to start is in the exam room or at the bedside. Through our conversations with patients, we can discuss options for managing pain, including non-opioid and non-drug alternatives, before considering an opioid prescription. And we should talk about the risks and benefits among the options.
As part of the Choosing Wisely Canada’s Opioid Wisely campaign, professional bodies representing doctors, pharmacists and dentists, among others, are identifying clinical scenarios where scientific evidence shows that an opioid prescription is not warranted and may do more harm than good.
For example, the College of Family Physicians of Canada says that patients should not continue opioids beyond the immediate period after surgery. This is typically three days or less, and rarely more than seven days.
Another example is dentistry. We know that over a third of new opioid prescriptions are written by dentists. The Canadian Association of Hospital Dentists says that opioids (like codeine) should only be prescribed after dental surgery if the pain can’t be managed by safer medications like ibuprofen (Advil) or acetaminophen (Tylenol).
Thinking twice about when patients need an opioid prescription and when they don’t is one important step we can take to deal with the opioid crisis. But in so doing, we must not forget our professional duty to address the pain and suffering of our patients. Recent estimates suggest that 15 to 20 per cent of Canadian adults suffer from chronic pain.
Facing some unpleasant truths about opioids by Dr. Davic Juurlink
Importantly, patients who are already on high doses of opioids must be carefully assessed and managed. And tapering off of opioids should be carried out over a long time, with caution and supports in place. Taking patients off opioids abruptly can do more harm than good.
We must spend the time with patients to discuss the options for addressing their pain and not jump to the prescription pad for a quick fix. We have decades of evidence showing that the quick fix has led to dire long-term consequences for patients and society.
There’s also an urgent need for greater access to evidence-based, publicly-funded options for pain management, including multi-professional teams that are better equipped to address complex situations.
Dr. Wendy Levinson is the chair of Choosing Wisely Canada and a professor of Medicine at the University of Toronto. A graduate of family medicine from the Université Laval, Dr. Laurent Marcoux has devoted his career to clinical and administrative medicine. He served as president of the Canadian Medical Association for 2017-2018.