NEW GUIDELINES FUEL DEBATE ON PAIN DRUGS

Many Doctors Don't Prescribe Opioids for Fear of Creating
Addicts

For doctors with patients who suffer from chronic pain, the release
this month of a new set of comprehensive guidelines on prescribing
opioids offers the possibility of a cure, of sorts, for the
professional ailment known as "opioid-phobia."

Fuelled in part by concern over misuse and abuse of drugs, the
guidelines seek to clarify for wary doctors when and when not to
prescribe painkillers, such as codeine, morphine and oxycodone -- the
drug in OxyContin.

Pain specialists hope these first-in-Canada guidelines will convince
general practitioners to prescribe opioids when needed, without
fearing they're going to turn every patient into an addict.

Others worry the guidelines will do little, if anything at all, to
reduce the abuse of, and black market for, drugs such as OxyContin.

"The whole point of the educational endeavours over the last 20 years
is to try and get physicians to prescribe more opioids when they're
appropriate," said Dr. Norm Buckley, director of the Michael G.
DeGroote National Pain Centre at McMaster University in Hamilton, Ont.

The guidelines identify "chronic, non-cancer pain" that could benefit
from opioids, including arthritis, low-back pain and neck pain, nerve
injuries, diabetes and other, more serious conditions. They also
suggest screening procedures to identify at-risk or addicted people,
and communication and collaboration among doctors and patients for
followup.

But others argue it would be naive to think the rules can provide a
panacea for a plethora of ills associated with prescription opioids,
of which Canada is third-highest prescriber in the world.

"Guidelines and policy around high-potency opioid treatment for pain
are tricky, and a complex challenge at the moment," said Benedikt
Fischer, a professor of public health at Simon Fraser University.

"On the one hand, we're trying to provide the most effective and
beneficial treatment to people who need it, people with pain. At the
same time, we have the misuse and problems and harms from misuse of
these drugs," he said, noting some chronic pain can sometimes be
helped by improved overall health and therapy.

What needs to be recognized, said Fischer, is that the issue is not
cut and dry. Screening patients for addiction, for instance, ignores
the nuances of the disease, he said.

"What a lot of these policy approaches and guidelines are currently
trying to do, is to try and sort of pretend a little bit that there's
good people and there's bad people. There's legitimate patients, and
it's all about keeping the bad apples out of the basket .. and
unfortunately that's not what reality looks like," said Fischer.

"As a matter of fact, if they were given to me, or you, for a certain
length of time, both you and I would likely get addicted to them."

What complicates the issue further is that many people who are in pain
are also addicts.

Lenny Mills was already using several drugs, including speed, ecstasy,
cocaine and marijuana, when, at 21, he herniated a disk in his lower
back. His doctor prescribed Percocet, which contains five milligrams
of oxycodone, the painkiller also in pure form in OxyContin.

Before long, Mills, now 26, was snorting $200 a day worth of OxyContin
pills, which contained up to 80 mg of oxycodone.

"I would run out of my prescription before it was time to get more. So
I turned to the street. It was a lot easier to find OxyContin than it
was to find Percocet," said Mills, who was living in Wasaga Beach,
Ont., about 130 kilometres north of Toronto.

Now in recovery at Harvest House, a long-term rehabilitation facility
in Ottawa, Mills said that even without the initial Percocet
prescription, he would have tried OxyContin eventually.

Mills said his doctor eventually recognized that he was abusing pain
drugs, and put him on a "weaning" program.

"However, I'm an addict and I just took that opportunity to abuse them
even more," said Mills.

Therein lies the rub for specialists: are the drugs inherently
addictive, or is it the addict that makes them so?

For Buckley, who said chronic pain affects as much as 30 per cent of
his health network area, medication is the most effective way of
helping people, especially when specialists don't have time for longer
consultations.

"I think the argument is that the drug itself is not the problem,"
said Buckley. "If you take someone who is addicted, and you give them
an addictive substance, then they will manifest their behaviour. If
you take someone who is not addicted, and has no predilection for
being addicted, the medication itself is not the thing that makes an
addict."