86 Doctors

This past month, 86 doctors from across Ontario have received the devastating news that their practices are being assessed by the College of Physicians and Surgeons of Ontario because of the extent of their opioid prescribing. No patient complaint was made against them but they are all now in the process of preparing their patient records and their offices for the assessment.

I have had a complaint to the College made against me by a former patient. I recall receiving the letter regarding the complaint and how anxious I was as I read it. No matter how effectively we work, or how thorough we are, we all feel as though complaints to the College threaten our career and our livelihood. The period of investigation is stressful and it is difficult to focus on continuing to do a good job with other patients while an investigation is ongoing. I know enough readers have had a complaint made against them to understand the stress I’m describing.

Who are these 86 doctors? From reading the coverage of this story in various news outlets, one is lead to believe that the prescribers are at fault. The Minister of Health describes that the doses some are prescribing “are equivalent to roughly 150 Tylenol 3’s being consumed in one day”. While this may be the equivalent, I doubt that this is actually the form in which these painkillers are being used.

As a psychiatrist, I absolutely agree that we have a serious problem across Canada because of addiction to opioids. As a psychiatrist who treats adolescents, I know that the access to these drugs is so easy that addiction to them is becoming more and more problematic. At the same time, I am concerned for the physicians who are prescribing painkillers in justifiably high doses to patients whose care depends upon them.

So, again, who are the doctors whose patients legitimately require high doses of opioids? Palliative patients, patients with serious addictions who are being weaned off opioids and chronic pain patients can all reasonably receive high doses of opioid drugs. These are all patients with special needs and there are very few doctors in Ontario with the expertise to look after them. We know there are long waits for palliative care. Many of those being weaned of opioids because of addiction problems are in shelters or prisons. Both shelters and prisons are underserved, with vulnerable populations and it is stressful to work in these environments. Chronic pain conditions are also difficult to manage and many doctors do not want this work.

A complaint was made against me to the College by a parent who was unhappy with a report I wrote for the Family Court that was unfavourable toward them having custody of their children. My response to the complaint was that I stopped doing any work where my opinion might be sought for court purposes. Imagine what it would mean if these 86 doctors stopped the work they are doing. What if they stopped doing palliative care, or work with the homeless or people in prison, or those experiencing chronic pain?

The stress of a College complaint is difficult, just one more thing to cope with in a practice of patients with special needs and in which there are few colleagues. I can understand giving up this work over time to avoid these stressors, as much as I know we desperately need these doctors who do this work.

In this special circumstance, where we do need to understand opioid prescribing and opioid addiction better, might there not have been a better way to find out more about those who prescribe high doses of opioids? To find out more about their patients? I am not saying that the College is insensitive or arbitrary. I do think the College of Physicians and Surgeons of Ontario works very hard to take an educational approach. I am saying, however, that good doctors, who strive to provide the best care to the point of perfectionism, become so anxious when they hear from the college that it affects their sense of wellbeing. A person can only put up with this for so long before they do give up, and it is some of the most vulnerable patients who will be affected.

4 thoughts on “86 Doctors

  1. First time reading your blog, beautifully written.
    I don’t blame doctors who weren’t one of the 86 giving up in response to this; it’s was arbitrary and unfair, to the doctors and their patients..

  2. Dr Beck,

    I could not agree with you more. The public severely underestimates how terrifying the CPSO can act towards its members. Even if a fragment of those doctors stop prescribing, thousands of patients, many of whom were doing nothing wrong with their medication, will be hung out to dry. Of course, the number of skittish doctors will end up much higher than 86, because there are almost certainly hundreds, even several thousands of doctors with no interest in raising the eyebrow of the College over opioids.

    The only thing I would add is that this entire initiative is missing the point. Yes, getting unsafe prescriptions down is a good thing, for patient and public safety alike. But the present wave of overdose deaths is caused by street drugs, not sloppy prescribing. Not only are policymakers being wilfully ignorant of the unintended consequences of siccing the CPSO on prescribers, they’re being wilfully negligent of the real problem.

  3. Dear Dr. Gail Beck

    When I arrived in Canada, 13 years ago, and observed how physicians and dentists (prescribed to my two daughters , after they had wisdom teeth removed) easily prescribe opioids I was quite astonished. I am a physician for 34 years, I worked in 3 different countries. I have never experienced such an easy prescribing of opioids, as here in Canada.

    In Israel they are mainly prescribed for acute pain , mainly after major surgical procedure or after acute injuries, for not more than 1 -2 weeks.

    Chronic pain should never be treated with opioids , unless it is for terminal cancer patients.

    In my opinion the problem of chronic pain in North America is a complex problem, as result of different reasons , which need to be approached in different ways .

    1- If a patient developed tolerance and dependence to prescribed opioids , the treatment to chronic pain (as a symptom of tolerance and withdrawal)is not to prescribe more opioids . The treatment of a mistake should not be another mistake.

    2- If the chronic pain results from fibromyalgia the treatment is not opioids

    3- If the chronic pain is somatization , the treatment is not opioids

    4- If the chronic pain is result of an old injury , there are other ways to treat the pain other than medications.

    I do not think those 86 physicians should be worried about the CPSO punitive measures if they prescribed opioids based in evidence based medicine.

    In case of Chronic pain treatment , we must follow medical guidelines. We , physicians, know , for many years that opioids are very dangerous drugs , because of rapid tolerance and consequent addiction.

    A physician who decides to prescribe opioids needs first to do a full assessment of the origin of the pain, and not merely prescribe opioids!. If GPs do not have time for that , they should send the patients to Pain Clinics.

    I sense you easily identify with another doctor who in your opinion might be at risk of being punished by the regulative institution.

    The opioid problem should have been treated years ago.

    Canada is a great nation, but is a nation which its citizens have a very low threshold for pain , and doctors do not teach them how to manage painful situations.

    Yours Respectfully

    Marcia Shapir

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