“One Size Fits All” Doesn’t Fit When It Comes to Long-Term Opioid Use for People with Chronic Pain

The use of opioids in chronic non-cancer pain continues to be a flashpoint inmedicine. Themedia and others continue to cite rising deaths due to opioids without clarifying that a large percentage of the current deaths are related to illicit highly potent fentanyl and other synthetic opioids coming across our borders from China. This misunderstanding is leading to an increasingly harsh regulatory climate for physicians andmany physicians are electing to avoid opioid prescribing completely. Further, in this environment of fear, there are many instances of physicians refusing to treat people with chronic pain. This is unethical and unacceptable but one can begin to understand given the inappropriate reactions of regulators across the country. In British Columbia the College of Physicians and Surgeons released professional standards and guidelines in June 2016 dealing with the prescribing of drugs with potential formisuse and diversion. The standard supported the controversial maximum dose guidelines published by the US Center for Disease Control (CDC) by stating that doses greater than 50 morphine milligram equivalents (MME) per day warrant careful reassessment and documentation and that doses greater than 90 MME per day warrant substantive evidence of exceptional need and benefit as well as advising against long term opioids in individuals with certain types of pain including headache, fibromyalgia, and axial lowback pain. The guideline section of this document also recommended against use in people withmental health issues or psychiatric disorder and young people. One must use care in these populations but to recommend against opioids for whole diagnostic categories is not evidence-based and is discriminatory. It is also nonpharmacological to recommend the same dose for all people regardless of body mass or age. Last year several other Canadian provinces also adopted the CDC guidelines rather than wait for the update on the 2010 Canadian National Opioid guidelines scheduled for release early this year. This includes Nova Scotia where there are an increasing number of “Explain” letters and phone calls from our provincial Prescription Monitoring Program going out to physicians requesting explanation/ justification of their use of opioids in patients on doses above the maximum recommended by the CDC. Some of this correspondence has been directed tome (M.L.) regarding my patients. Two examples are women with the most severe rheumatoid arthritis I have seen inmy 25-year career treating patients with chronic pain, both of whom would not have been able to mobilize at all without the assistance of the opioid. In Ontario, the College of Physicians and Surgeons sent out 86 simultaneous “Section 75 investigation”notifications to physicians who have at least 8 patients on a dose above 850 mg oral morphine equivalents of opioid therapy per day. This involves a compulsory 20–25 patient chart review that takes a long time to complete and is laborintensive for busy clinicians. It has been called an “educational” exercise but the physicians find it very intimidating. Add to this the Opioid Summit co-hosted by the Federal Minister of Health, which took place November 18–19, 2016 in Ottawa, Ontario. At this summit there was no one on the agenda to present from the person-with-pain perspective. In addition, there was not one medical professional specialized in the management of pain on the speakers list. Fortunately, there were 2 people with pain in the audience andmembers of the Canadian Pain Society (CPS) managed to get the incoming president of CPS on the invitation list days before the conference. The agenda was focused on opioid-related harms and addiction so the voice of those with pain was at a significant disadvantage. This brings us to themost recent Canadian draft recommendations for the use of opioids in chronic non-cancer pain. Our understanding fromdirect communicationwith the Chair of the committee is that individuals on the committee were excluded from voting on recommendations if they had either a financial or intellectual conflict of interest. Avoidance of a financial conflict of interest is necessary, but it appears that the principle of avoidance of an intellectual