Opioids -damage control in a nation of victims.

   "Something," think the social warriors, "must be responsible for the lethal epidemic of opioid addiction (and almost every other form of addiction).  God knows, those suffering from every physical and mental pain that the human flesh is subject to, could not be to blame.  In fact, when it comes down to it, they must be the victims.  It must be the fault of those bloody rich, privileged physicians, brainwashed and bribed by the drug companies, that put patients on whatever medication will get them out of the office as quickly as possible."
   You may think I  am being flippant, but that's exactly what many folks think and are encouraged to think, by our elected leaders and their bureaucrats, in order to divert blame from  themselves.   It does not occur to them, or bother them that patients who are awaiting surgery for an excruciatingly painful hip or back,or whatever, are suffering during a deliberate two year waiting list and need serious relief from  their pain.   That the mild to moderate analgesics that their physicians start them on become less effective after a while and physicians are forced to titrate their patients pain with the most effective medications that are available to relieve it.   It does not occur to patients that the very lengthy waiting lists is a deliberate policy by their elected representatives to cut the health care budget under the pretense that it is due to a shortage of physicians and nurse.  It is not, it  is due to misallocation of funds that results in surgeons unable to get operating room time, despite empty operating rooms and nurses being unemployed.   They certainly don't consider Canadians first in allocating tax dollars, so we see the ridiculous payouts to terrorists and others to whom they dispense huge sums that would be available to treat our failing health care system.   They continue to  generate layer after layer of  administridiots,  who convince themselves that they are the health care providers and that doctors and nurses are simply their serf technicians.  That is why we, in Canada, are at the bottom of  the list in quality of health care, in almost every category, compared to other developed nations.  When physicians and nurses ran the health care services we were near the top.  
   When  patients are in  pain, physicians and nurses will do almost anything in their power to relieve pain  and  suffering.   So, a patient who is on a two year waiting  list and visiting their physician regularly, complaining quite justifiably of constant disabling pain, expects to have their pain relieved.  The administridiot, who never comes face to face with the patient, and is oblivious to the patient's suffering suggests that physician's cavalierly dispense narcotics to get the patient out of  his office or for financial gain.   No, the physician sitting across from the patient is trying to help the patient, to relieve his pain.  He/she tries to do this without addicting the patient to pain relieving drugs and sometimes this is interpreted as callousness, or indifference to patient suffering.  The College interpreted such complaints, whether justified or not as an 'under-prescription crisis' and instead of meticulously investigating and researching the situation began to 'educate' physicians to prescribe narcotics much more liberally, often assuming that addiction was rare in people who were prescribed narcotics liberally for the relief of pain.  Meanwhile opioid poisoning lands sixteen patients in hospital each day in Canada and there has been a 15% jump in the past ten years.  The administridiots continue to place the blame for this on physician prescribing habits and sometimes this is true and partly as a result of a concerted effort of educational organizations a few years ago that were encouraging physicians to prescribe narcotics very liberally to relieve non-cancer pain.  The results were disastrous, ranking Canada second only to the United States in opioid abuse.  In an attempt to correct the damage the Royal College of Physicians and Surgeons of Canada published the " 2017 Canadian Opioid Prescribing Guideline", a document so prosaic that a final year medical student could have written it.
   Meanwhile, what is the government of Canada doing?  Well, the Minister of  Health is planning to hold meetings on allowing different drugs such as heroin to be administered outside of  hospital settings: she plans to allow drug checking services at all authorized supervised consumption sites: she want the provinces to establish temporary overdose prevention sites. None of which is  likely to have much effect.
   In fact, there are some who recommend the decriminalization of all illicit narcotic use.
   Unfortunately, we are unlikely to make much progress in this area while the administridiots are making medical decisions that they are unfit to make.  The obvious first step is to rely on experienced health care professionals to develop whatever solutions may be available.
   Making marijuana and other drugs available for recreational purposes is going to compound the problem, not alleviate it.

Comment if you have any views on  this.
    

Opioid Constipation and other problems.

   More than fifty thousand Americans died from drug overdose last year.   Death from synthetic opioids including Fentanyl rose to 9,580.  Deaths from prescription drugs like oxycontin are on the increase and are easily available both legally and illicitly.  CDC figures indicate that American life expectancy has decreased for the first time in many years, in no small part due to drug overdose.  Contemporary statistics for  Canada do not seem to be available but published estimates for 2007 indicated 47,000 addiction related deaths.  Despite the removal of oxycontin from the Ontario drug plan because of the ease of abuse and its decrease as one of the drugs of addiction, closely related drugs are available the overall rate of opioid fatality has increased by 24%.

   Testimony to the widespread  extent of the problem is the fact that opioid constipation is a favorite topic of big pharmacy advertisements these days.  In my many years of medical practice opioid constipation was rather uncommon outside hospital where patients who required narcotics were usually successfully treated prophetically with stool softeners and laxatives as necessary and sent home on them.  Opioids were prescribed for severe pain that was was not relieved adequately by the many other types of analgesics /anti inflammatory drugs that are less addictive and debilitating.  Narcotics were prescribed a great deal more judiciously in those days despite the fact that we were just as concerned with pain relief as contemporary physicians.  Physicians who did prescribe excessively were likely to get a visit from the RCMP.  Narcotic prescribing was sometimes suspended and on occasion licenses were revoked.  We were very aware of and concerned with the consequences of narcotic prescription for more than short time periods and the objective was  always to control pain with less noxious and toxic treatments.  Often, we were successful.
   Now opioids are prescribed so frequently that Opioid Constipation is a common disorder in working, walking and driving patients.  Turn on your TV to watch the news during dinner, and you may well be greeted with Big Pharma's cavalier witty ad for their bold new treatment for Opioid Constipation.  The healthy looking patient jokes with his doctor on receiving his prescription, "I guess I've been holding it in too long, doc!!"  Very funny!  Movantik, (Naloxegol) is believed to reduce the constipation effects of the opioids without reversing the pain relieving or analgesic effects of the  opioid, when given in  the prescribed dosage.  It too has its side effects.
   
    The recently published guidelines regarding prescription  of opioids for non cancer pain may help, but guidelines are only guidelines, not rules and it may be difficult to explain them to the addicted patient on the other side  of your desk.  Physicians will have a very difficult time in getting the genii back in the bottle, particularly when the permissive society is busy uncorking other bottles. 

Here is a letter I copied from an addiction site to emphasize my  point:

"We lost our son in July 2014 at age 22 from Heroin overdose after a long eight year spiral into drug use which started with abusing marijuana. During these years he easily bought illegal drugs as well as prescription drugs from his friends parents medicine cabinets… He also purchased synthetic packaged drugs from “Smoke Shops” also called “Head Shops” which sale their harmful addictive products in decorated packages, call them different names and can legally sale them. Our son was sold “bath salts” from a Smoke shop which he crushed and snorted. The product ate holes in his brain and was causing liver damage and his body to shut down within one week of daily use. He was delusional and put into ICU for two days. He survived it but damage done… Society has a whole has to make changes. People have to be educated on the disease of addiction, doctors have to be more restricted on writing prescriptions, much tighter border control, Smoke shops regulated, kids taught about the dangers of drugs use and what they are saying no to. “Just Say No” is not working anymore and Red Ribbon Week has become more about door decorating and dress up than the seriousness of drug use in most schools. A change of mind set and the ability to deal with stress and pain has to start at a young age so as people get older they will not rely so much on pain killers and drugs which alter the brain. Xanax was very easy for H  to get and so addictive. He later took up Heroin and this became his drug of choice. Families should not have to live the way we did with our son during his battle. Society has much work to do to combat this problem."
   
   Universities across the land are finally attempting to  take some measures to address the growing problem and some are using Narcan kits, an emergency opiate antagonist that reverses the effects of an overdose, in the hope of saving lives.

   Sometimes, it  looks as though the permissive society is going to self-destruct.

Medicine in the Headlines - again.

         Now that I am retired, I have time to peruse what is really happening in Medicine and it isn't a pretty picture.  Over a leisurely breakfast I have time to page through the national paper that I prefer and hardly a day goes by  without some sort of medical  headline.  Often it is trivia, sometimes not.  So  let me tell you about the last two days 'Medlines'.
          August 25th. -  
         "Weak MDs blamed for opioid epidemic", sub heading - 'We kill  more people now than cars do'. 
        At a CMA Meeting in Halifax the CEO of the College of Physicians and Surgeons of Halifax opined that physicians don't understand narcotics and that he frequently sees undisciplined, unstructured and arbitrary use of these medications, by weak-willed, uninformed physicians!   Hello Dr.  Grant, what's your job?   Isn't a main function of the College to protect the public from just such issues as you are criticizing?  What are you getting paid for, because if what you say is true and you haven't addressed it, you are not doing your job.   Grant went on to say "The number of lives ruined by drugs is a problem of enormous magnitude that is killing people".  Well, Dr Grant, if you were not as weak and ineffective as the physicians you are thus labeling, you would have taken this matter in hand, long ago.  You don't know how?  Well let me tell you, but you do have to  be prepared to take responsibility for what you have to do..   When I was a young physician, long long ago and in a place far away, when physicians prescribed inappropriately, they got a warning from the College.  If they did it again, their license to prescribe narcotics was taken away.  If they offended again, their license to practice medicine was taken  away.  Simple.  Effective.  But you have to have guts to implement such a policy.   It is always easy to criticize (particularly one's colleagues), there is a solution, but it takes conviction and effort to remedy the situation. 
         I'll save the next Medline for the next blog. 
 Your comments are welcome.