Physician regulatory colleges in four provinces, alarmed by Canada's opioid epidemic and frustrated by a lack of federal action, are endorsing new national standards in the United States for prescribing painkillers.
The guidelines, published in March by the Centers for Disease Control and Prevention, urge doctors to try non-drug approaches first to treat chronic pain and to prescribe opioids sparingly by starting patients with low doses and providing only a few days' supply. The guidelines are part of a growing backlash against practices developed two decades ago, when doctors began prescribing opioids to relieve moderate to severe pain as pharmaceutical companies promoted their benefits.
The Canadian guidelines for prescribing opioids, by contrast, have not been revised since 2010, leaving them out of date with current research on the risks associated with taking painkillers. The maximum dose recommended in the Canadian guidelines is 200 morphine milligram equivalents a day – four times the amount highlighted in the CDC document. The CDC guidelines advise doctors to carefully weigh the benefits and risks when increasing a patient's dose to more than 50 morphine milligram equivalents a day and to avoid increasing dosages to more than 90 milligrams.
The Michael G. DeGroote National Pain Centre at McMaster University is overseeing the revision of the Canadian guidelines, which are scheduled for release in January. Meldon Kahan, medical director of the Substance Use Service at Women's College Hospital in Toronto and a member of the advisory panel in 2010, said the guidelines should have been updated much faster.
"Given the nature of the crisis, which is getting worse," he said, "it's kind of unacceptable to me that it has taken so long."
An ongoing Globe and Mail investigation found that neither Ottawa nor the provinces are taking adequate steps to stop doctors from indiscriminately prescribing highly addictive opioids to treat chronic pain. Canada consumes more prescription opioids on a per-capita basis than any other country in the world, says a recent United Nations report. In 2015, doctors wrote 53 opioid prescriptions for every 100 people in Canada, according to figures compiled for The Globe by IMS Brogan, which tracks pharmaceutical sales.
The College of Physicians and Surgeons in British Columbia, Nova Scotia, New Brunswick and Newfoundland and Labrador are going ahead with their own initiatives to rein in opioid prescribing. The moves come against the backdrop of a public-health crisis involving fentanyl-related overdoses.
B.C. and Alberta have been hit the hardest – of the 201 overdose deaths so far this year in B.C., 64 were associated with fentanyl – but the problem is rapidly spreading east.
Illicit fentanyl, largely a product of organized crime, has its roots in Canada's epidemic of prescription painkiller abuse.
On Friday, the Nova Scotia college's professional standards committee endorsed the blueprint set out by the CDC in the U.S. for prescribing opioids.
"I think there will be many voices in the chorus that will lead to change," said Gus Grant, registrar of the College of Physicians and Surgeons of Nova Scotia. "The regulatory colleges will be one of them. It is important for the profession as a whole to take appropriate ownership of our contribution to this crisis."
In New Brunswick, the college is looking at incorporating the CDC guidelines into a prescription monitoring system it plans to unveil next year to help doctors identify patients who seek prescriptions from multiple physicians.
The CDC guidelines recognize one of the "bigger issues," said Ed Schollenberg, registrar of the college in New Brunswick. "It's not the last prescription somebody might have a problem with," he said. "It's what happens early on."
The college in Newfoundland and Labrador is developing a mandatory prescribing program for new doctors – the first in Canada – and plans to incorporate the CDC guidelines into that, a spokesman said. The Nova Scotia college is a partner in this initiative.
In B.C., the college published its own prescribing principles in 2014, noting that "no more than the equivalent of 100 morphine milligram equivalents a day, usually less, is required in most cases." The college's prescription review and methadone panels, which regularly review coroners reports, were troubled by the number of deaths linked to prescription opioids.
The 100-milligram threshold will soon decrease even further. Last month, the B.C. college board endorsed the CDC guidelines and directed the body to review and update its own prescribing principles to reflect them.
Ailve McNestry, deputy registrar at the College of Physicians and Surgeons of B.C., said the board "wanted to show professional leadership" in endorsing the CDC guidelines, particularly in light of Provincial Health Officer Perry Kendall's recent declaration of a public-health emergency amid a surge in overdose deaths.
"The Canadian guidelines of 2010 are now six years old and the ongoing Canadian epidemic of opioid use disorders and opioid overdoses speaks to the need for an updated guideline on this topic," Dr. McNestry said. "The CDC has done this work and provided a timely resource."
Although the CDC guidelines are voluntary, medical experts say that by stressing non-opioid therapies for treating chronic non-cancer pain, they attempt to tackle the underlying causes of the crisis – the over-prescribing of a drug whose risks are substantial and benefits uncertain. Canada's current guidelines, by contrast, endorse the use of opioids, stating that the drug can be an effective treatment – albeit with potential risks – for such pain and should be considered.
The recommendations in the Canadian guidelines do little to address the limitations of the evidence on the effectiveness for treating chronic pain with opioids or the risks associated with the drugs, said Benedikt Fischer, a senior scientist at Toronto's Centre for Addiction and Mental Health. Nor, he said, do they contain much in the way of clear directives on when not to prescribe the drug.
"It's basically a document predominantly in support of prescribing," Dr. Fischer said. "Any qualifying things are mostly soft or ambivalent at best."
Jason Busse, an assistant professor in McMaster University's department of anesthesia and co-lead of the group working on updating the Canadian prescribing guidelines, said he anticipates that the revised version will contain a substantially lower recommended daily dose. The reason the current guideline contains a maximum threshold of 200 milligrams, Dr. Busse said, is because the 49 members on the 2010 panel – many of whom received funding from pharmaceutical companies – had to reach a consensus.
"They had a lot of people arguing for very high doses," he said.
Not everyone consulted for the consensus document agreed with the final product. Dr. McNestry, the B.C. deputy registrar, said there were "a significant number of people" who felt that a "watchful dose" of 200 milligrams was high.
This time around, the McMaster team has gone to great lengths to ensure that none of the 13 panel members who will vote on the revised guidelines has any potential conflicts of interest – including ties to big pharma – that could influence their recommendation, Dr. Busse said.
The McMaster team has also assembled a group of 20 individuals representing patients, two of whom will vote on the revised guidelines.
Ada Guidice-Tompson is one of the 18 non-voting patient representatives. Her son, Michael, died in 2004 of an opioid overdose after he was prescribed the drug to treat pain associated with kidney stones. He was 29.
Ms. Guidice-Tompson said she is frustrated over the delays in revising the Canadian guidelines in the face of "mounting proof" that opioids harm patients more than they help. She is also concerned that the guidelines will continue to be biased in favour of using opioids to treat pain.
"We are not really seeing the true picture of the harm that these drugs can do," she said. "We need to underscore that the harm occurs in a therapeutic setting."