Doctors flagged by the Ontario Ministry of Health and Long-Term Care for potential investigations by a regulatory body were prescribing the equivalent in opioids of "150 Tylenol 3s" per day for some patients, making their practices worthy of extra scrutiny, the province's Health Minister says.
Eric Hoskins said it was "appropriate" for the ministry to pass on the names of physicians identified through a review of the province's narcotics monitoring system to the College of Physicians and Surgeons of Ontario, which confirmed on Thursday it is investigating some doctors related to opioid prescribing.
Dr. Hoskins told reporters that 86 doctors are targets of the probes, which The Globe and Mail reported on Wednesday.
"It is a relatively small number of individuals who've been identified through this screening mechanism," Dr. Hoskins said, adding that it was up to the college to decide what to do with the ministry's information. "So I think it's early to tell, but again, just to reiterate, we're talking about a single patient consuming the equivalent of 150 Tylenol 3s in a single 24-hour period. That's a pretty high level of prescribing."
But at least one prominent pain doctor who is under investigation by the college said sometimes dosages of that magnitude could be right for patients – such as when they have become dependent on painkillers over several years and cannot be easily weaned off.
Norman Buckley, chair of the department of anesthesia at McMaster University in Hamilton, said he now rarely starts new referrals to his pain clinic on opioids because he is aware of the risk for long-term dependence. But he struggles with how to help patients who are already hooked.
"It is our impression that many physicians who have been met with this note from the college are actually leaders in the business of chronic-pain management, certainly in Ontario and in Canada, and who have been working very hard to try to address these issues," he said. "I think this is an unfortunate strategy for the college to have taken because it's going to create a lot of conflict where we would have done better to try to enlist collaboration."
The college said in a statement on Thursday that its goal is to "ensure that physicians have the resources and information they need to safely and appropriately prescribe opioids to their patients," and to address unsafe prescribing effectively.
The college declined to comment on specific investigations, except to say it may take a closer look at doctors who prescribe "extremely high daily doses of opioids to multiple patients over extended periods of time," including those who prescribe the equivalent of 650 milligrams of morphine per day and the equivalent of 20,000 milligrams of morphine for a patient at one time. Opioids are powerful painkillers such as fentanyl, oxycodone and hydromorphone.
Still, the decision to launch registrar's investigations – which include a review of 25 patient charts by an external assessor, interviews and often observation of the targeted doctor – is a stronger response to the role of over-prescribing in Canada's opioid crisis than that of some other provinces.
The College of Physicians and Surgeons of British Columbia said it takes an "educational and remedial" approach to high-dosage prescribers flagged by its monitoring database.
Every six months, Nova Scotia uses its Prescription Monitoring Program to identify the 100 doctors who score highest on an 11-category prescriber risk score and sends a letter drawing their attention to the issue.
Depending on the circumstances, it can forward instances of problematic prescribing to the college for potential disciplinary action.
Alberta also views its role as educational. The college there has imposed practice restrictions on 16 doctors related to prescribing opioids and other drugs. Only one case was the result of a formal disciplinary proceeding.
New Brunswick has not formally disciplined any doctors for over-prescribing opioids, said Ed Schollenberg, the college registrar there.
"We suggest strongly to them that they give up their narcotic privileges, and, in exchange for that, we won't do anything further against them," he said. "They've all agreed to that. Many of them have said it was the best thing they ever did."