Whenever he runs out of his pills, Tony hops in his car or goes for a walk and buys Percocet off the street.
Sometimes it’s once a week, other times it’s every few days.
The Toronto-area resident, whose last name is being withheld to protect his identity, says his doctor refused to fill his Percocet prescription in July after he had been on the pain pills for the past five years.
Tony says his doctor worried he had developed a dependency on the drug after he asked for his prescription to refill every 26 days instead of 28. He now gets Percocet solely from dealers.
A car crash followed by subsequent operations has left Tony in chronic pain, and the 63-year-old says he needs the pills to function. He does not want to be addicted and wants to be tapered off the pills safely — not left out to dry.
Tony feels like the way he was cut off left him with no choice but to buy street drugs. He is worried about withdrawal and has raised his concerns with his doctor.
“ tough enough for a healthy person, but I’ve had four massive heart attacks,” he says. “I’m pretty sure withdrawal could be dangerous for me.”
What are the new opioid-prescribing guidelines?
Tony’s case could be an example of the new opioid guidelines gone wrong.
In 2017, the opioid crisis sparked the introduction of new Canadian opioid-prescribing guidelines, which include information on tapering. In the U.S., new guidelines have also changed prescribing habits, causing health-care providers to stop prescribing the painkillers as liberally as they had in the past or, sometimes, altogether.
The “crackdown” is intended to reduce opioid use as addiction and overdose rates have climbed in recent years.
But these new opioid guidelines are frequently misinterpreted, experts say, resulting in high-dose opioid users being tapered off too quickly. For people who have come to rely on these drugs, a sudden change in dosage not only causes symptoms of withdrawal but can also be dangerous.
“Everybody has jumped on this bandwagon, and they’ve indiscriminately, in many cases, cut people off suddenly without any thought about what the unintended consequences are going to be,” says Dr. Peter Selby, chief of medicine with the psychiatry division at the Centre for Addictions and Mental Health.
For those who have developed a dependency, the risks are even greater.
“You can’t just cut people off because … simply detoxing people off opioids puts them at high risk for overdose deaths and puts them at high risk for relapse,” Selby says.
“We have seen these unintended consequences both south of the border … and occurring here as well.”
Selby says that while there are certain circumstances in which it is ethical for a doctor to refuse to refill opioid prescriptions, a medical assessment must be conducted and the rationale documented.
If a patient meets the criteria for an opioid use disorder, Selby says, the doctor needs to assess the risk of harm and make appropriate arrangements if they have decided to not give the prescription.
For people with an opioid addiction, opioid agonist therapies using methadone or buprenorphine are recommended treatments.
It’s not wise to ever leave a patient without support.
Why are doctors misinterpreting guidelines?
The Canadian chronic non-cancer pain guidelines suggest that for patients beginning opioid therapy, doses should be restricted to under 90 milligrams of morphine or its equivalent daily, with the maximum single dose under 50 milligrams.
Patients who are already on a high dose of opioids, which is considered more than 90 milligrams of morphine per day or its equivalent, “should be encouraged to embark on a gradual dose taper and multidisciplinary support offered where available to those who experience challenges,” the guidelines state.
Dr. David Juurlink, head of the clinical pharmacology and toxicology division at Sunnybrook Health Sciences Centre and a professor at the University of Toronto, says many physicians interpret these guidelines to mean high-dose users need to be cut down to 90 milligrams — and fast.
For long-term users of opioids, their doses have likely been steadily upped for years, and they may be on incredibly high doses, Juurlink says.
“If you’re on 400 milligrams of morphine today, and I, as a physician, misinterpret the guideline to say you should be cut back to 90 milligrams a day and just do that abruptly, you run the risk of getting extremely sick,” Juurlink explains.
The potential harms of tapering are directly related to how quickly the tapering takes place.
“When the dose is tapered too rapidly, we destabilize patients whose bodies have become accustomed to high doses of these drugs,” he says.
This puts patients into opioid withdrawal. Symptoms of withdrawal include nausea, vomiting, drowsiness, confusion, depression, sweating and muscle aches.
“Opioid withdrawal in some people manifests as a flare in pain,” Juurlink says.
“And so people will, quite understandably, interpret that as the loss of the beneficial therapy when, in fact, if it was beneficial, they wouldn’t have escalated to those high doses in the first place.
“What they’re going through is withdrawal.”
According to Lena Salach and Loren Regier, co-directors of academic detailing at the Centre for Effective Practice (CEP), there are challenges physicians face around prescribing opioids. CEP is an independent organization that supports health-care workers and provides guidance on opioid tapering.
Salach and Regier say doctors are more cautious around prescribing opioids and point to a qualitative study on family physicians and their role in managing the opioid crisis.
The research found that doctors “experience a tension adhering to guidelines while attempting to effectively manage patient symptoms, which creates a feeling of being caught in the middle of the opioid crisis.”
“This is why provide family physicians with visits on managing opioid therapy for patients living with chronic non-cancer pain,” say Salach and Regier. “They help family physicians weigh the benefits and risks.”
How should people be tapered off opioids?
Juurlink says opioid tapering should happen at the “patient’s pace.”
“I like to frame it as a marathon rather than a sprint; there’s no urgency to get people on lower doses,” he says.
The Canadian guidelines say a “gradual dose reduction of five to 10 per cent of the morphine equivalent dose every two to four weeks with frequent follow-up is a reasonable rate of opioid tapering.”
“Slower tapers are recommended for patients who are anxious about tapering, may be psychologically dependent on opioids, have co-morbid cardio-respiratory conditions or express a preference for a slow taper,” the guidelines state.
Juurlink says patients on high doses often fear tapering off the powerful pain meds because the process happens too quickly. If a patient has been a long-term user of opioids for many years, their dosage could be very high, meaning coming off the drugs may be harder.
Selby says that if a patient is cut off too quickly and is struggling with pain, they may be inclined to turn to opioids bought off the street.
“This kind of situation can leave people very desperate,” he says.
What about long-term users with chronic pain?
Some long-term users who experience chronic pain say the stigma around opioids has negatively affected their well-being.
HELP_Alberta, an advocacy group for chronic pain sufferers in the province, says patients who use medications to manage day-to-day pain now have issues accessing opioids.
Chronic pain patients who say they do not abuse their opioids and are not addicted feel the barriers to access are unfair.
“As they lose their medication, they lose their life in all kinds of ways,” Penny Kowalchuk, southern Alberta representative for HELP_Alberta, previously told Global News.
“What I’m seeing — it started with my family and now, especially as part of HELP_Alberta in southern Alberta — is a lot of patients that are being de-prescribed from their medications for no reason.”
Other health advocates have also argued opioids are important for people living with chronic pain and that tapering and de-prescribing efforts are hurting such patients.
But Juurlink doesn’t agree that opioids are a necessary part of most people’s pain treatment.
He says there’s very little data to support that opioids are effective at treating long-term pain. What’s more, he argues, the harms of opioids often outweigh possible benefits.
“The pills shouldn’t be abruptly taken away, but there’s still merit in a discussion about gradual, patient-centred tapering to improve all the side effects ,” Juurlink says.
Health-care providers need to put their patients’ well-being first, Selby says, and not taper them off opioids in a way that causes harm. It’s also important that patients have a strong support system and access to resources.
If someone has an underlying pain disorder that isn’t treated properly, he adds, they will seek out whatever medication they need to ease that pain.
“That doesn’t mean that they are addicted or bad people, it just means that the system has failed them,” Selby says.
Whenever Tony buys pills, it’s a gamble: he doesn’t know if they are tainted or laced with another substance, like fentanyl.
Still, street drugs feel like his only choice.
“I don’t know how long I’m going to live for,” he says. “All I want to be able to do is get by, and this helps me function.”
— With files from Danica Ferris
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