'The other opioid crisis': Doctors weaning patients off much-needed painkillers
For the past 15 years, John has relied on a doctor-prescribed dose of opioids to numb his chronic pain and help him function in day-to-day life.
But after new guidelines were released amid a nation-wide spate of opioid-linked deaths, John’s doctor single-handedly decided it was time for him to cut back.
John has lived with severe pain due to a car accident and several workplace injuries. The sudden move triggered immediate signs of withdrawal, including sweating and diarrhea.
“I knew I couldn’t function on that, with what it took me to get through the day,” John, who has asked not to be identified, told CTV News. “I have been on it for 15 years, you can’t just take that from me.”
John’s case reflects a problem some medical experts have described as Canada’s second opioid crisis. As doctors take steps to prevent patients from getting hooked on potentially deadly medications, some have withheld the drugs or drastically lowered doses from those who need them most.
More than 4,000 people in Canada died from opioid related overdoses in 2017, and Canadians are the second-highest consumers of opioids in the world, second only to the United States.
The swell in fatal overdoses prompted new guidelines last May, published in the Canadian Medical Association Journal and backed by more than 20 medical professionals.
Among the numerous recommendations, the guidelines suggested that doctors encourage patients receiving high-dose opioid therapy -- 90 milligrams or more of morphine equivalents daily (MED) -- to “embark on a gradual dose taper” and potentially discontinue the drug.
The guidelines warned that even a small dose reduction could lead some patients to experience “significant increase in pain or decrease in function.” In some cases, the guidelines said, tapering should be paused or abandoned altogether.
But some doctors are applying those rules overzealously and with no patient input, leaving chronic pain patients without the ability to function, says Dr. Jeffrey Ennis, a veteran pain specialist based in Hamilton, Ont.
“This is the other opioid crisis,” Dr. Ennis said. “People aren’t appreciating that there are a whole pile of repercussions that are going on for people whose only crime is they that may have gotten sick or had trauma and now they have chronic pain.”
‘This is a big deal’
Week after week, Dr. Ennis said he’s seeing patients enter his clinic struggling with drastic changes in their pain management.
“Their function drops, they can’t do what they want to do. They feel betrayed, they feel scared,” he said.
It’s a problem Dr. Ennis understands first-hand. He has long suffered from chronic pain due to back surgeries, and he is now dealing with prostate cancer. To cope, he relies a combination of medications and hypnotherapy.
“I am uncomfortable from the moment I wake up to the moment I go to sleep. It never stops, and that is the nature of this beast,” he said.
Dr. Ennis said the problem is rooted in a misinterpretation of the new guidelines. He says some doctors read the suggestions as gospel and fear that, if they don’t get their patients below the recommended 90 milligrams, their medical licenses could be taken away.
Those misplaced fears are putting some patients’ health in jeopardy, Dr. Ennis said. And the problem, he believes, isn’t limited to Canada.
“I think that it happening more than nationally. I think it is happening internationally,” he said.
The problem can be solved with better doctor-patient communication, Dr. Ennis said.
“The guidelines are very clear as well: if someone is on more than 90 milligrams, have a discussion with them. Ask them if they are open to the idea of reducing the dose, because being on a high dose there is a risk attached.”
If the patient isn’t interested in changing the dose, Dr. Ennis says, “you have now met the guideline requirement. That’s it.”
The final step, he says, is to continue monitoring the patient’s function on an ongoing basis.
‘If it isn’t broke, don’t fix it’
For Emma, who also asked not to be identified, cutting back on her painkillers had serious repercussions. A woman in her early 60s with arthritis and bone fractures, Emma says her doctor ordered a significant cut in her OxyContin prescription.
The lowered dose “made things worse,” Emma said.
“I did that, and now I’m in the position I’m in, with a lot of pain – and pain that I can’t get control over again,” she said.
After noticing the immediate change, Emma got permission to increase her dose back up. But, since returning to her previous dosage level, the pain hasn’t subsided.
“There is an old saying – if it isn’t broke, don’t fix it. So had he not touched it I might’ve be fine,” she said.
Health officials agree that tampering with a patient’s prescription should not be done suddenly, and that rapid adjustments could send patients onto the streets looking for drugs.
Instead, changes should be made gradually, said Dr. Irfan Dhalla, vice-president of Evidence Development and Standards for Health Quality Ontario.
“Physicians should not suddenly discontinue opioids in people who have been receiving them,” Dr. Dhalla said.
‘I felt like a junkie’
Despite some doctors misinterpreting the new guidelines, the recommendations are an important step toward addressing the opioid crisis, Dr. Ennis said.
However, he said the guidelines should be applied carefully on a patient-by-patient basis and not be treated as “commands.”
“My job is to identify that group of people who, if I give this (drug) to you it actually gives you a life. And when you see that happen medically, it is a great day,” he said.
That’s precisely what happened with John, who reached out to Dr. Ennis about his predicament. His pain is now under control thanks to a proper dose of opioids.
But having a doctor threaten to lower his medication was scary, John said, because it revealed just how much he relies on the prescription.
“For the first time I felt like a junkie, because I felt dependent on the painkillers,” he said.
After the back-and-forth over his prescription, John said he doesn’t expect there will ever come a time when he can live without help from the powerful drug.
“I have other tools, exercise, goal setting and pacing. The medication is part of my life. Not the only part of my life. But part of it.”
With a report from CTV’s medical affairs specialist Avis Favaro and producer Elizabeth St. Philip