Safe Prescribing of Drugs with Potential for Misuse/Diversion was a reframing of its predecessor―then a professional guidance document called Prescribing Principles, which was developed in 2012 based on the expert advice of members of the Prescription Review Committee. It outlined precautions specifically related to prescribing opiates.
The publication of the revised standard was timely as BC and other jurisdictions in Canada were in the midst of dealing with an escalating public health crisis related to prescription drug misuse, and the criminal importation of illicitly manufactured opioids such as fentanyl and carfentanyl. It was elevated to a standard at that time to emphasize the profession’s collective responsibility to prescribe safely and be aware of abuse risk.
One year later – what has changed?
In response to the crisis of overdose deaths, Canada’s minister of health, the Honourable Jane Philpott, together with the provinces, territories and other partners, initiated the Joint Statement of Action to Address the Opioid Crisis, which outlines specific commitments from 30 partners to act on this crisis, including the College of Physicians and Surgeons of BC and other regulators.
In a letter to the provincial ministers of health, Minister Philpott specifically called on the provincial and territorial medical regulators to consider endorsing the updated 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain and to develop enforceable standards for physicians to support appropriate prescribing. This College was pleased to report that it had already adopted a standards-based approach to safe prescribing.
There has been a lot of broad public commentary about why North Americans, who have the highest standards of living and greatest access to health care in the world, have become the highest consumers of prescription opioids. There has also been discussion about the role of pharmaceutical company marketing in the making of this epidemic, and physicians in Canada and the US are appropriately examining these relationships.
Physicians who are engaged in the College’s Prescription Review Program gain a better understanding of why there is a need to continue to remediate prescribing. Physicians continue to call the College for advice, often realizing that that they need support and guidance. The Prescription Review Program staff and medical consultants hired by the program spend a lot of time speaking to individual physicians about the difficulties of treating legacy patients (those who were started on prescriptions of long-term opioids often at very high doses, and various sedatives many years ago and are reluctant to stop).
The College continues to stress that the practice standard is about safe prescribing. There are and will be patients who benefit from opioid therapy for chronic pain. The abrupt discontinuation of long-term opioids and benzodiazepines is both inappropriate and potentially dangerous. Patients need to know of the potential harms related to prescription opioids, and take-home doses of Naloxone should be considered for patients receiving opioid therapy. Patients who are addicted need to be directed to substitute opioid therapy such as methadone or buprenorphine.
The College is looking forward to meeting and working with the new minister of health and the minister of mental health and addiction to address the current opioid overdose problem, and will be seeking their support to develop and implement a provincial prescription monitoring program to maximize the reporting potential of the existing PharmaNet database, and support regulatory follow-up related to prescribing. Evidence from the United States supports that better regulation of prescribing reduces drug overdose deaths.¹ Future regulatory activities will eventually include the requirement for all physicians in primary care to have PharmaNet access in their medical offices and not just in walk-in clinics and methadone clinics, which is the current requirement. To operationalize this, the College will also encourage improvements to the existing PharmaNet platform to make point-of-care access easier and more functional for busy clinicians.
Heidi M. Oetter, MD
Registrar and CEO