The right drug for the right patient

Dear colleagues,

As I reflect on more than 30 years of clinical practice, I find that my most challenging situations involved patients with chronic noncancer pain. Difficulty in getting clarity about the cause of their pain, the presence of comorbidities, complex personal and social situations, and worry about potential misuse or diversion of pharmacologic treatment contributed to my anxiety about acquiescing to requests to increase the dosage of medications with potential for abuse. On a personal level, I have seen relatives with symptoms not always adequately relieved by medication, sometimes because of inadequate amounts or time intervals. I truly hope that we figure this out better, as a profession, if I ever need care of this nature myself; no one is immune to being touched or influenced by this complex situation.

Canada is the second highest per capita consumer of opioids, after the United States.¹ In the past 10 years, our per capita use has doubled; related deaths have also doubled and are now twice that of HIV mortality rates.¹ The number of Canadians seeking treatment has also doubled, challenging our health care system. Use of opioids (14%) is the fourth most popular substance-related behaviour among Ontario students after alcohol comsumption (more than a sip) (55%), cannabis use (22%), and binge drinking (22%).² Overprescribing and nonmedical use of sedatives and stimulants is also of concern, particularly for women and youth.¹

Your College often gets asked to provide representation on working groups that have the potential to influence the care we provide for our patients, as well as to affect public policy. Under the auspices of the Canadian Centre on Substance Abuse, the CFPC joined forces with other provider groups, governments, regulators, industry leaders, First Nations representatives, enforcement officers, researchers, patients, and families to examine and address the growing problem of prescription drug misuse in Canada. First Do No Harm: Responding to Canada’s Prescription Drug Crisis¹ sets the stage for reflecting on our individual and shared responsibility to reduce harm and prevent deaths related to this important issue. The 58 recommendations are grouped around 5 main themes: prevention, education, treatment, monitoring and surveillance, and law enforcement; they will be implemented during the next 10 years. An annual report will be disseminated to monitor progress.

I know that many of you feel the weight of this situation and live every day with the difficulties engendered by it. As a College, we want to assure you of our understanding of the challenges this issue presents. Some glimpses of hope are on the horizon. Under the new Section of Family Physicians with Special Interests or Focused Practices, members of the Addiction Medicine Program Committee and the Chronic Pain Program Committee are exploring ways of better supporting you in these important patient care areas. They are helping to facilitate continuing professional development sessions and networking breakfasts at Family Medicine Forum 2013. They plan to collaborate on improving standards for training family medicine residents. They have highlighted important mentoring programs in which family doctors can be linked, electronically or by telephone, to other clinicians with expertise in these areas. One program was initiated by the Ontario College of Family Physicians; others are in place in the Atlantic provinces and in Quebec. Finally, members of these committees provided important feedback to an earlier draft of the First Do No Harm strategy.¹ I want to thank them for their input on this.

As there is evidence to suggest that many of those who suffered harm (overdose, hospitalization, or death) from prescription drugs had received prescriptions from physicians within a few months preceding the event, we do need to keep current about the safe prescribing of such medication.³ We are often the most important health care link for many patients with chronic pain. Offering support, encouraging active rather than passive coping skills, and using opioids judiciously to improve patient function, after careful screening for substance abuse risk, are important elements of a sound approach. Please visit the Resources sections of the above program committees (www.cfpc.ca/Committees) for additional information and tools (eg, the Opioid Manager, low-risk drinking guidelines, and relevant continuing professional development events).

The CFPC is committed to continuing to collaborate with the Canadian Centre on Substance Abuse and other partners in the implementation and evaluation of the strategy. Collectively, we are working toward a Canada that allows for the benefits while minimizing the harms associated with prescription drugs.

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