What a chronic pain expert wants you to know about pain and overdoses

How did Canada’s opioid overdose crisis happen and how has it impacted the way prescribers and patients manage pain? These questions and more are the focus of the Michael G. DeGroote National Pain Centre.  

Norman Buckley is a professor emeritus in the Department of Anesthesia at McMaster University and was the director of the National Pain Centre for a decade. Buckley is the current scientific director of the Michael G. DeGroote Institute for Pain Research and Care. As an anesthesiologist and chronic pain specialist, he has provided pain care for over 35 years, and since 2010 has led the team that is responsible for disseminating and updating the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Pain.  

We spoke with Buckley about the history of Canada’s opioid overdose crisis, misconceptions around drug use for pain management, and what he wishes both prescribers and patients knew about overdose.  

National data shows an average of 20 people dying per day from toxic opioids. How did we get here?  

In the mid-2000’s, there were an increasing number of prescriptions written by pain specialists and family physicians for opioids for chronic pain care. This was in part because of the desire to treat chronic pain, which is quite common – about 20 per cent of the population on average have their lives affected by chronic pain – and partly because there are not many effective alternative treatments that are covered by provincial health care plans.  

There was also a marketing element, more prominent in the United States but also spilling over into Canada, that minimized the risks of opioids and emphasized their use as a painkiller. As more prescriptions were written, an increasing amount of the prescribed medications were diverted into the illicit or ‘recreational’ market, and began to replace illicit drugs such as heroin. As a result, more overdoses were occurring from prescribed medication, either prescribed to the individual or diverted and used illicitly.  

As awareness of these deaths grew, so did a popular sense that doctors were driving the overdose crisis. Restrictions on prescribing in Canada began to occur – some driven by regulators, but more driven by popular belief and press statements by influential individuals. Some drugs were redesigned to make them less ‘abusable’, with limited effect. Opioid prescribing went down, but deaths increased, driven as it turned out by very potent illicit drugs now entering the market. These illicit drugs are cheap to produce, extremely potent but also unpredictably potent as the ‘quality control’ of their production in illicit settings is very poor. Now most deaths that occur are from illicit drugs similar to fentanyl  not prescribed opioids.  

Overdose is a broad, complex issue. Other than opioids, what is contributing to overdoses in Canada? 

Overdose is a function of either lack of awareness of the drug potency or loss of control of the potency. Lack of awareness may occur perhaps in a prescription setting where the patient decides if ‘some is good more must be better,’ but is unaware of the risk of adding doses, or mixes one drug with another or with alcohol. Loss of control over the content of the drug being used may occur in the illicit setting with inconsistent mixing of components, or addition of different drugs into a mixture, so that the user may unknowingly take a dose much higher than they can tolerate. ? 

From your perspective, what is the biggest misconception about drug use and overdose as it relates to pain management?  

The biggest misconception in my experience is that all patients receiving opioids for chronic pain are addicted, and that when they come to the emergency department they are seeking more drugs. This is rarely the case, but patients can be treated rudely, mistreated or misdiagnosed when they attend the emergency department because of the focus on their opioid use. This potentially leads healthcare staff to overlook serious underlying or co-existent medical conditions.  

What do you wish prescribers and patients knew about overdose?  

I wish that prescribers understood that overdose is quite a rare complication when it comes to use of opioids as prescribed. They also need to know that regulatory bodies do not pursue physicians who are prescribing opioids in a reasonable manner with good record keeping. Some physicians inappropriately restrict their use of opioids for a variety of reasons, but there are a proportion of patients whose pain is better controlled taking opioids, and these patients continue to function effectively. It is also the case that a proportion of patients who try opioids find they are not effective, and so the patient and physician can easily elect not to continue use of opioids.  

And yes, there are some patients who develop inappropriate dependency upon opioids. These patients may continue use despite poor effect and presence of adverse events, including using the drug for a reason other than pain management.  

I wish that patients knew that opioids can be used safely and effectively for chronic pain but that they may also not be effective, and the only way to know is to have a trial period of use. Also – that stopping use of opioids may require some medical assistance to manage side effects of stopping the drugs.  

We know overdose is preventable, but what more can be done to prevent tragic outcomes?  

Use in a safe setting – one with access to reversal drugs and presence of caregivers – may reduce fatal overdose. Identification and treatment of the clinical problem of drug abuse is much more difficult as there aren’t tests such as those that exist for heart disease or diabetes that will identify those likely to misuse drugs in advance, and treatments are still not routinely effective.  

Having said that, with a combination of a patient’s desire to avoid misuse, support from knowledgeable clinicians, and access to medications that assist in reducing the biological drive to use medications, significant successes have been achieved. Simple restriction of prescribing or other access to opioids does not seem to reliably reduce overdoses as we have seen when death by overdose dramatically increased when prescribing was reduced.