Who’s writing the script?

Are docs to blame for the national opioid abuse problem? Federal Health Minister Leona Aglukkaq certainly lined-up firmly on one side of the fence, telling provincial health ministers in a Nov. 19, 2012 letter that “if the country is ‘flooded’ with prescription drugs, it can only be in part because some medical professionals are making it possible” and the provinces are being lax in cracking down on foot-loose prescribers (www.cmaj.ca/site/earlyreleases/4theRecord.xhtml).

None of the provinces appear to have taken up Aglukkaq’s invitation to start shovelling along information about physicians who are being overly generous in the prescription of opioids, as Health Canada spokesperson Stephane Shank writes in an email that the Controlled Substances and Tobacco Directorate has not received a report to that effect over the course of the past year.

Yet Health Canada remains of the opinion that the physicians are enablers.

“You have to ask yourself: Where does the drug come from that is being abused?” says Dr. Paul Gully, senior medical advisor for the department. “One has to question whether it’s coming as a result of physicians prescribing too much of the drug and increasing dosages over longer periods of time than perhaps an individual patient needs. … Clearly, the physicians have control of it in terms of availability for the most part and therefore it’s logical to look at their part in this.”

Several observers, though, counter that Aglukkaq and Health Canada are viewing the issue through the filter of fallacy.

“I think it’s an overly simplistic approach,” says Dr. Irfan Dhalla, assistant professor of medicine and health policy, management and evaluation at the University of Toronto in Ontario and scientist in the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

“In a sense, she’s correct that it is physicians who write the prescriptions,” Dhalla says. “But that ignores the fact that Health Canada determines what drugs are allowed on the market and what drugs are not allowed on the market and for what indications.”

The federal government says the nation’s opioid abuse problem is a function of over-prescribing by physicians but the provincial governments argue that’s an “overly simplistic” interpretation of the problem.

Image courtesy of © 2013 Thinkstock

Health Canada should be ensuring that the indications on opioids are evidence-based, he says, adding that many physicians feel those are too often expressed much more broadly and ambiguously than they should be. The indications for oxycodone include moderate and severe pain, while there’s no limitation on dosages and the drug’s monograph doesn’t include data about the maximum duration of treatment, he notes.

It can lead to inappropriate prescribing, Dhalla adds. “Because the product monographs are so broad, the pharmaceutical companies have been able to market the drugs very aggressively and leaders within the profession have also persuaded a lot of primary care doctors that very potent opioids are safe and that there is little risk in increasing the dose to levels which would have been viewed not too long ago as unimaginably high.”

“So that’s where I think it’s overly simplistic, to just blame physicians for this. Physicians rely on information that is provided to them by experts and even pharmaceutical companies, and it’s Health Canada’s role to make sure that the information that physicians are receiving is accurate, and I think that they have not done that well enough.”

Others say singling out physicians is simply unjust.

“The medications can come from one of three places. They can come from the physicians writing prescriptions. They can come from diverted means such as being diverted from wholesalers or pharmacies. And the third is over the Internet from outside of the country,” says Doug Spitzig, a pharmacist with the College of Physicians and Surgeons in Saskatchewan and the manager of the province’s Prescription Review Program. “So to say that it’s just the prescribers that are the problem — I think that’s a little broad.”

Over the past six years, Saskatchewan has had only a few cases of physicians prescribing opioids to line their own pockets, Spitzig adds. “We haven’t forwarded any cases to Health Canada. We have better capacity of dealing with the overprescribing than the feds do.”

Most physicians who overprescribe opioids do so because they lack proper education about their use, and are struggling to handle their patients’ ambiguous symptoms, Spitzig says. Physicians “are ill equipped to deal with the chronic pain problem and so what happens is that they end up maybe prescribing inappropriately and there is nobody there to help them with that. … Physicians are used a bit as a scapegoat. I think society as a whole should take the responsibility.”

Ontario Health Minister Deb Matthews, who led the provincial and territorial charge to limit generic oxycodone that eventually prompted Aglukkaq’s outburst, argues that federal efforts to lay the blame on physicians are counterproductive. “I think just to point fingers at doctors and say ‘it’s your fault, you’re prescribing too much’ isn’t that helpful.”

In rejecting the call for a ban on generic oxycodone, Aglukkaq said that if the provinces and territories aren’t up to the task of cracking down on physicians, they should be willing to cede some of their jurisdiction over health and allow the federal government to step in with legislation to constrain the authority of some physicians to prescribe such drugs (www.hc-sc.gc.ca/ahc-asc/media/ftr-ati/_2012/2012_173-eng.php).

Health Canada has since approved applications from six companies to manufacture generic forms of controlled-release oxycodone (http://webprod5.hc-sc.gc.ca/noc-ac/start-debuter.do?lang=eng)