Chronic pain vs. addiction: New guidelines fuel debate on opioids
May 23, 2010 - canada.com
For doctors with patients who suffer from chronic pain, the release this month of a new set of comprehensive guidelines on prescribing opioids offers the possibility of a cure, of sorts, for the professional ailment known as "opioid-phobia."
Fuelled in part by concern over misuse and abuse of drugs, the guidelines seek to clarify for wary doctors when and when not to prescribe painkillers, such as codeine, morphine and oxycodone — the drug in OxyContin.
Pain specialists hope these first-in-Canada guidelines will convince general practitioners to prescribe opioids when needed, without fearing they're going to turn every patient into an addict.
Others worry the guidelines will do little, if anything at all, to reduce the abuse of, and black market for, drugs such as OxyContin.
"The whole point of the educational endeavours over the last 20 years is to try and get physicians to prescribe more opioids when they're appropriate," said Dr. Norm Buckley, director of the Michael G. DeGroote National Pain Centre at McMaster University in Hamilton, Ont.
"Chronic pain continues to be inadequately treated, and we know that chronic pain costs us more money in Canada annually — in terms of lost work time, ineffective work time and people simply moving to disability from functioning status — than any other disease category except cardiovascular disease."
The guidelines identify "chronic, non-cancer pain" that could benefit from opioids, including arthritis, low-back pain and neck pain, nerve injuries, diabetes and other, more serious conditions. They also suggest screening procedures to identify at-risk or addicted people, and communication and collaboration among doctors and patients for followup.
But others argue it would be naive to think the rules can provide a panacea for a plethora of ills associated with prescription opioids, of which Canada is third-highest prescriber in the world.
"Guidelines and policy around high-potency opioid treatment for pain are tricky, and a complex challenge at the moment," said Benedikt Fischer, a professor of public health at Simon Fraser University.
"On the one hand, we're trying to provide the most effective and beneficial treatment to people who need it, people with pain. At the same time, we have the misuse and problems and harms from misuse of these drugs," he said, noting some chronic pain can sometimes be helped by improved overall health and therapy.
What needs to be recognized, said Fischer, is that the issue is not cut and dry. Screening patients for addiction, for instance, ignores the nuances of the disease, he said.
"What a lot of these policy approaches and guidelines are currently trying to do, is to try and sort of pretend a little bit that there's good people and there's bad people. There's legitimate patients, and it's all about keeping the bad apples out of the basket . . . and unfortunately that's not what reality looks like," said Fischer.
"As a matter of fact, if they were given to me, or you, for a certain length of time, both you and I would likely get addicted to them."
What complicates the issue further is that many people who are in pain are also addicts.
Lenny Mills was already using several drugs, including speed, ecstasy, cocaine and marijuana, when, at 21, he herniated a disk in his lower back. His doctor prescribed Percocet, which contains five milligrams of oxycodone, the painkiller also in pure form in OxyContin.
Before long, Mills, now 26, was snorting $200 a day worth of OxyContin pills, which contained up to 80 mg of oxycodone.
"I would run out of my prescription before it was time to get more. So I turned to the street. It was a lot easier to find OxyContin than it was to find Percocet," said Mills, who was living in Wasaga Beach, Ont., about 130 kilometres north of Toronto.
Now in recovery at Harvest House, a long-term rehabilitation facility in Ottawa, Mills said that even without the initial Percocet prescription, he would have tried OxyContin eventually — a popular drug among his friends.
Mills said his doctor eventually recognized that he was abusing pain medication, and put him on a "weaning" program that steadily decreases prescription doses.
"However, I'm an addict and I just took that opportunity to abuse them even more," said Mills.
Therein lies the rub for specialists: are the drugs inherently addictive, or is it the addict that makes them so?
For Buckley, who said chronic pain affects as much as 30 per cent of his health network area, medication is the most effective way of helping people, especially when specialists don't have time for longer consultations.
"I think the argument is that the drug itself is not the problem," said Buckley. "If you take someone who is addicted, and you give them an addictive substance, then they will manifest their behaviour. If you take someone who is not addicted, and has no predilection for being addicted, the medication itself is not the thing that makes an addict."
He said the guidelines, written by a national team of physicians, researchers, pharmacists and experts, including those from colleges of physicians and surgeons of Canada, will be updated in the next few years.
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