New prescribing rules confuse BC patients and doctors

July 22, 2016

Many doctors and patients are concerned and confused after strict new prescribing standards were issued by the College of Physician and Surgeons of B.C. for narcotics and other addictive, potentially deadly drugs like sleeping pills.

Last month, B.C.’s 12,000 doctors became the first in Canada to be legally bound by the mandatory prescribing standards meant to reduce addictions to opiates, stimulants and sedatives as well as the potential for diversions when such drugs are sold on the street. Those who don’t follow the safe prescribing rules could face disciplinary action by the college.

College official Dr. Ailve McNestry acknowledged in an interview that she’s received calls, emails and letters from many doctors and patients in the past month, some who mistakenly think such drugs are being banned and that patients must abruptly stop using them.

“We aren’t saying that. In some cases, it may be appropriate for doctors to take patients off these drugs. But nowhere in our document do we say doctors shouldn’t be prescribing such drugs.”

Powerful painkillers like oxycodone, fentanyl or percocet are often required for patients with acute pain, terminal illnesses and cancer-related pain. Other patient categories give the college greater concern, such as when doctors prescribe powerful drugs on a long-term basis for chronic pain conditions like arthritis.

“These guidelines don’t apply to palliative or end of life care, when we are very keen to make sure that patients are treated with utmost empathy, consideration and relief from symptoms,” said McNestry, deputy registrar of the college. “But the college is likely going to be critical if doctors are treating other types of individuals with high doses of narcotics for conditions that don’t merit that dosage or narcotics at all. It’s those cases we want them to be more thoughtful about.”

The new rules dictate that doctors must take careful patient histories, refrain from doling out large quantities and avoid automatic prescription renewals. “We think handing out 250 pills is as much as a patient should get at one time,” she said, noting that would equate, for example, to eight Tylenol 3’s (acetaminophen with codeine) per day.

McNestry said it’s possible doctors need more pharmaceutical prescribing training, especially for conditions that put patients in chronic pain. “There are no easy answers to chronic pain, it’s a subject being looked into so much, and there are serious discussions now about non-prescription treatments for chronic pain since opiates are largely ineffective.”

B.C. Health Minister Terry Lake said one in five residents lives with chronic pain and earlier this week, the government gave Pain B.C. a $50,000 grant to help support the organization’s next pain summit and to develop a pain management/opioid harm reduction strategy. WorkSafe BC recently announced it will hire a consultant to do medical outreach education, to combat the opioid crisis.
British Columbia Health Minister Terry Lake

British Columbia Health Minister Terry Lake DARRYL DYCK / THE CANADIAN PRESS

McNestry said patients with chronic pain should be exploring alternatives to such potent narcotics, including meditation, mindfulness, yoga and other forms of exercise like walking and swimming. A recent meta analysis in JAMA Internal Medicine of 20 studies on narcotics for low back pain showed such drugs relieved low back pain only slightly while carrying many adverse effects. The lead author echoed McNestry’s opinion that being active is often the best remedy.

McNestry said she thinks doctors write prescriptions out of habit or because patients pressure them: “I think some doctors don’t know what else to do if they don’t prescribe because we’ve gotten so used to writing prescriptions.”

Colin Genders, an elderly Lower Mainland resident, is concerned about the new prescribing rules and wonders if patients with a legitimate need for such drugs are being negatively affected by rules meant to reduce drugs ending up on the black market.

“The rules completely ignore a great number of individuals who take these drugs sensibly, in full accordance with doctors’ instructions, people who will be deprived of drugs that alleviate their pain. They will suffer because a significant number of idiots are dying due to abuse of such drugs,” he said.

Genders wrote to the college about the new rules. Joy Bhimiji, manager of drug programs at the college, pointed out that annual deaths from illicit drug overdoses (nearly 400 in the first half of 2016) are now greater than victims killed in motor vehicle accidents (291 in 2014) in B.C.

The Safe Prescribing of Drugs with Potential for Misuse/Diversion standards and guidelines document is meant to protect patients. Doctors are being advised that:

• Long-term opiates are not indicated for medical conditions like headaches, fibromyalgia and low back pain.

• Risks of such drugs are greater in elderly patients because they often have concurrent medical conditions such as cognitive impairment, congestive heart failure, sleep apnea, lung or kidney disease.

• The college isn’t interfering with doctors’ treatment of specific patients, but wants to make sure they know that if they “choose to practice outside of the guidelines, careful documentation of the rationale should be included in the patient record.”

McNestry said the college will decide in September whether refinements to the standards are necessary.

In the meantime, the dangers and over-prescribing of opiates are so topical that on a daily basis, authorities are making pivotal announcements and publications are posting valuable insights. Here are some:

MedPageToday’s Prescribing Opioids is a Dilemma for Every Doctor What Science Says to Do If Your Loved one Has an Opioid Addiction

Journal of the American Medical Association: BC Guidelines on Opioid Disorders Gets Recognition

Sun/Province Health Issues Reporter

Oxycontin Prescription Bottle

Vancouver Sun

Pamela Fayerman