Originally published March 2012 / revised November 2015
Caring effectively for patients who have chronic, non-cancer pain is a complex challenge for Canadian physicians. Management of chronic non-cancer pain can present significant patient safety and medico-legal issues. Prescription opioid use has increased substantially and deaths from overdose of prescription opioids have more than doubled in Canada since the early 1990s.1
When starting a new practice or taking over another physician's practice, physicians can expect to have some patients who request treatment with opioids. The CMPA regularly receives calls from physicians who express discomfort with the challenges envisioned with this group of patients. Generally, medical regulatory authorities (Colleges) in all of the provinces and territories emphasize that "clinical competence and scope of practice must not be used as a means of unfairly refusing patients with complex healthcare needs or patients who are perceived to be otherwise difficult."2
Given the high prevalence of chronic pain, it would be expected that to care for these patients a physician would either have the knowledge, seek out the knowledge, or consult appropriately. Colleges in all provinces and territories are clear that suffering from chronic pain is not a reason to refuse a patient into one's practice. Physicians who are uncomfortable caring for patients with chronic pain should seek out appropriate consultation and continuing professional development opportunities. It would be prudent to be familiar with the resources available on the various College websites to assist in providing care.
However, a physician, initiating a patient-doctor relationship with a patient who is taking opioids for chronic pain, is not obligated to continue the treatment. The physician may choose to suggest a tapering of the opioids, a more appropriate, longer-acting opioid, or the use of alternate pain management.
A 64-year-old male with chronic pain following a motor vehicle accident complained to a College that his physicians did not provide him with prescriptions for a opioid analgesic.
After reviewing the matter, the College wrote that the prescribing physicians are under no obligation to provide medications, treatments, or investigations that they do not feel are appropriate. Further, the College stated that a patient is under no obligation to attend a particular physician and a physician is under no obligation to treat a particular patient, unless it is an emergency.
For patients with chronic pain, it is generally accepted that the treating physician should document previous investigations and interventions, both pharmacologic and non-pharmacologic, which have been used to treat the pain. The physician should make reasonable attempts to ask the patient about the evidence for the effect these treatments have had. Medical records from previous caregivers and prescribers should be obtained. There should be a review of the cause of the pain as well as of other medical conditions that might be aggravating or prolonging the pain, with further testing or consultation, if required. The ultimate decision of whether the medication will be prescribed remains with the physician.
When opioids have been prescribed for chronic pain, failure to closely monitor patient status may result in complaints to Colleges or legal actions.
An adult female with a history of depression and anxiety, chronic pain, and carpal tunnel syndrome complained to a College that her family physician had overprescribed medications leading to addiction and had not recommended tapering or discontinuing her medications despite deterioration in her general health and addiction.
A review of the file revealed overlapping prescriptions for short- and long-acting opioids, as well as other psychiatric medications. The College expert found deficiencies in the documentation of the patient's initial history and physical examination, and severely deficient reassessments. Opioid medications had been escalated with no rationale documented in the medical record. The effect of the medications on the patient's pain was not described. The College instructed the physician to enroll in a record-keeping course and in a opioid prescribing course.
Although opioids have been shown to decrease pain in some types of chronic conditions, their effect on the functional status of patients is not at all clear. There can be significant side effects to the use of opioids. It is, therefore, prudent for physicians who are contemplating the use of opioid medication for a patient to undertake and document a complete informed consent discussion, including the potential risks, benefits, and alternatives. Inquiring into the presence or absence of risk factors for addiction is advisable. Documenting the rationale for the choice of each pharmacologic or non-pharmacologic treatment is also important.
Physicians choosing opioid medications as part of the treatment plan may consult one of the published guidelines on this topic and incorporate into their practice some of the tools for treating these challenging conditions. It is generally recommended that opioids only be prescribed for one patient by one physician. Permission should be requested for access to any pharmacy patient profiles, if available, and random urine drug screens should be considered. Warning signs of abuse such as requests for early renewal and lost prescriptions should be monitored closely and acted upon appropriately.
Many physicians have found opioid treatment contracts that outline the responsibilities of the patient and the physician are useful in managing these patients, especially in regard to escalation of dose and lost prescriptions. The elements of the contract, including the consequences for non-adherence, should be clearly documented.
Patients with chronic pain who are on opioid medications but do not have a primary care physician can be especially challenging. A cautious approach is prudent.
A 43-year-old female with fibromyalgia and no family doctor presented to an emergency department from time to time for treatment.
After seeing her more than once, the emergency physician suggested she seek help for her chronic pain at a methadone clinic. Some time later on a subsequent visit, the doctor told her he would no longer renew her medication in the emergency department because he had learned she was double doctoring and was insisting on lengthy repeats of her medication. The patient complained. The College felt that the doctor's eventual decision to stop providing medication refills and his suggestion the patient find more suitable follow-up care were the correct approaches to take under the circumstances.
Having an overly accommodating approach to patient requests for opioid refills in the emergency department or walk-in clinic can have dire consequences.
A 40-year-old male presented to a walk-in clinic complaining of chronic back pain and requesting a prescription refill for his fentanyl patch.
He said his own doctor was on leave. The doctor who saw him provided a prescription for 10 more patches. A few hours later this man was found dead, having extracted and injected the fentanyl. His wife complained to the College. The College acknowledged that it can be difficult, especially on a weekend or after hours, to reach a family physician to confirm information about a patient. However, the physician would have been alerted to a possible problem if he had consulted the prescription information program available in his province as this patient had actually received a prescription sufficient for 60 days just 3 weeks prior. The College also stated they would expect that patients be advised of the risks of fentanyl patches and of using the patches in any way other than application to the skin.
Members working in walk-in clinics and emergency departments frequently call the Association to ask if they can refuse to provide opioid refills. As noted in case 1, the decision to prescribe is ultimately the physician's. If physicians decide to provide a refill, it may be prudent to only prescribe a small carrying dose sufficient for a holiday period or weekend until patients can contact their usual prescriber. Physicians should be especially skeptical if patients are unable to identify their prescriber. Members have also asked if signs indicating that opioids will not be prescribed can be posted. Medical facilities contemplating such signage should consider the pros and cons of doing so. If such signs were to be posted, these should not prevent physicians from prescribing opioids when the physician determines that opioids are in fact indicated.
Unfortunately, some individuals with opioid addictions may go to great lengths to acquire these drugs. Members may find some useful precautions to avoid prescription opioid misuse within the available Canadian guidelines. Issues of prescription fraud are reviewed in the article, "Suspect unlawful activity with prescriptions or medications? Here’s how to respond". Prescription fraud and aggressive or abusive behaviour are common evidence of loss of trust in the physician-patient relationship. Members facing the difficult task of terminating this relationship are directed to the article, "Ending the doctor-patient relationship," and should also consult the relevant College policy on this topic.
CMPA members with further questions on this challenging topic are encouraged to contact the CMPA for advice.
Resources and references
National Opioid User Guideline Group, National Pain Centre, McMaster University, "Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain," April 30, 2010. Retrieved on December 20, 2011 from http://nationalpaincentre.mcmaster.ca/opioid/
Collège des médecins du Québec, « Douleur chronique et opioides : l'essentiel ». Retrieved on December 20, 2011. http://www.cmq.org/fr/Public/Profil/Commun/AProposOrdre/Publications/
- Dhalla, I.A., Mamdani, M.M., Sivilotti, M.L.A., Kopp, S., Qureshi, O., Juurlink, D.N. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Medical Association Journal (2009) Vol.181, no.12 p.891-6.
- College of Physicians and Surgeons of Ontario, Policy # 1-09, Accepting New Patients, April 2009. Retrieved on February 15, 2012 from http://www.cpso.on.ca/policies/default.aspx?ID=2506