By Dr. David Rouselle

The opioid epidemic has been described as the biggest drug safety crisis of our time.  The College of Physicians and Surgeons of Ontario (CPSO) is concerned about the devastating consequences opioid abuse, misuse and diversion are having on patients, their families, and communities, with an escalating number of overdose poisonings and deaths – this problem touches us all.

Opioid abuse and misuse are highly complex issues involving both illicit and prescription drugs, and there are no quick solutions to this problem.  While prescription opioids are an important and useful therapeutic tool for select patients with certain conditions, prescription opioids carry risks, even when prescribed and used appropriately.

There are many contributing factors to the opioid crisis, however, well-meaning prescribing by physicians has contributed to the problem, and improvements to prescribing practices must be part of the solution.  As the regulatory body for physicians in Ontario, the CPSO is mandated to serve and protect the public.  This includes ensuring that physicians appropriately prescribe opioids.

Our Opioid Strategy comprises a four-pronged approach reflecting our mandate, namely to:  Guide; Assess; Investigate; and Facilitate Education for Ontario’s doctors.  The strategy is contingent on effective communication and collaboration with physicians, the public and health-system partners, and using data and analytics to inform prescribing practices and our regulatory responsibilities.

Patient and public protection are at the forefront of the CPSO’s Opioid Strategy.  Our objectives are to facilitate safe and appropriate opioid prescribing by physicians to patients; protect patient access to care; and reduce risk to both patients and the public.

Key College activities and elements of our Opioid Strategy which promote appropriate opioid prescribing include:

Guidance – Our Prescribing Drugs policy articulates principles of good practice that apply when prescribing any drug and includes specific expectations for appropriate prescribing of narcotics and other controlled substances.  The physician’s role is emphasized in preventing and addressing the risk of abuse, diversion, addiction, and overdose that may arise when opioids are prescribed.

The policy also reflects the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain, and includes updated guidance on alternative treatment options; selecting appropriate doses; monitoring patients for signs of addiction; and tapering.

Assessments – Our assessments of family physicians and other specialty practices have always looked at prescribing practices when applicable, and will include a new emphasis on opioid prescribing.  We are also exploring an alternative approach to responding to potentially moderate-risk prescribing by conducting focused assessments.

Our goal is to support continued prescribing when it is appropriate and informed by both clinical guidelines and CPSO policy.

Investigations – We will continue to work with the Ministry of Health and Long-Term Care to identify levels of opioid prescribing and investigate prescribing practices that may be harmful to patients.  We recently provided an update on the status of investigations that arose from potentially concerning data received from the province’s Narcotics Monitoring System.

While investigations may identify instances of risk of harm to patients when opioid prescribing is continued, there is also a very real risk of harm to patients when opioid prescribing is discontinued.  That’s why we have taken a remedial approach, whenever appropriate, to help physicians practise to current standards.  Our goal is to support education and continued prescribing under supervision, where the physician’s capacity for remediation is apparent.  We are also urging physicians to not suddenly cease prescribing to patients currently on opioid therapy.

Opioid-use disorder and chronic pain are health conditions like any other, and treatments should include all the elements of good practice including treating patients with respect and compassion.  For some, this may include several tactics including a slow taper or opioid replacement therapy/referral to a substitute treatment program for methadone or suboxone.

Facilitating Education – We are collaborating with many partners to ensure that physicians receive the education, training and resources they need to appropriately prescribe opioids.  Our role is to identify and connect physicians with learning needs to educational resources to improve their prescribing practices.

We stress that health system-wide solutions and collaboration amongst government and government agencies, health-care educators, regulators, doctors and other health professionals, and patients are required to address the opioid crisis.  All of the CPSO’s efforts are grounded in a steadfast commitment to improved patient and public safety.

Dr. David Rouselle is President, College of Physicians and Surgeons of Ontario.