Thanks very much for the opportunity to appear today.
My name is Norm Buckley. I'm a professor and chair of the Department of Anesthesia at the Michael G. DeGroote School of Medicine at McMaster University. I also serve as director of the National Pain Centre at McMaster University, an endowed centre with the mission and vision to support best-practice pain management through the dissemination and creation of guidelines for care.
We currently hold the copyright for, and have agreed to disseminate and update, the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, affectionately called “the Canadian opioid guideline”.
I'm also chair of the Canadian Pain Society's special interest group on education. I co-lead, with Professor David Mock of the University of Toronto's school of dentistry, the Canadian Centre on Substance Abuse implementation group for education as part of the First Do No Harm strategy on the issue of misuse and abuse of prescription medications. During the development of the CCSA strategy, I chaired the expert advisory committee on education.
These affiliations notwithstanding, my appearance here today is not as the representative of any of these organizations. I'm appearing at your request. The leaders of these groups are aware that I will be appearing, but they are not in any way responsible for my opinions or my responses. My dean has some mild anxiety about my appearance here, but he's a very brave individual.
My disclosure statement follows in two parts: fiscal and belief.
From the fiscal standpoint, I'm a physician who derives the largest part of his income from fee-for-service clinical earnings. I receive an administrative stipend as chair of the Department of Anesthesia and earnings for academic activities supported by the Hamilton Academic Health Sciences Organization alternate funding plan. I provide some medical legal opinions and I also engage in consulting through a consulting organization, as well as consulting for two provincial health committees.
I carry out research that is funded by a number of sources, including pharmaceutical companies, although funding from peer review sources, such as the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Ontario, exceeds industry funding substantially. Research funding is on a cost recovery basis, and I do not receive income for carrying out research except through the alternate funding plan. In particular, I do not receive income for research from industry.
I have received speakers' fees from a variety of organizations, including industry, medical, legal, and other professional societies.
Since the problem of finding a solution for prescription drug misuse is complicated by issues to do with belief, clinical perspective, and a variety of other issues, it is probably of greater interest to know my beliefs and my clinical perspective. I come from the position of a clinical practitioner in pain management. My patient population is the patient with acute pain or chronic pain, a problem that continues to be poorly understood and a topic that is very poorly taught and treated in our health care professional training programs. Some of these patients also present with mental health disorders, including mood disorders and addiction.
Given the proportion of Canadian population that suffers now and is likely to suffer in the future with pain, and the impact of that suffering on the health care, social, and economic systems, it is my belief that there must be a dramatic change in the function of the Canadian health care system to provide rapid access to appropriate treatment, including early assessment and treatment, with active intervention and physical rehabilitation and psychological treatment as the situation dictates.
The problem of prescription drug abuse seems to be several different things, perhaps depending upon perspective. Selling of prescription medications or diversion of prescription medications into the recreational or abusive sphere for money strikes me as being theft or fraud, and should be treated as such.
The epidemiology of crime is outside my purview today, so I will not comment upon the magnitude of this element, except to say that law enforcement is the appropriate source of information in this regard. Part of the solution may be found in improving communication between health care providers and law enforcement and improving understanding of each other's goals while recognizing that health care professionals are not the police and law enforcement is not health care. There does need to be collaboration.
Use of prescription medications by the addicted patient to meet the demands of their addiction represents addictive behaviour, which is a medical condition. Again, I'm not an expert in this field, and I will limit my comments on this topic, but medical conditions should be identified as such, and treated appropriately. According to Health Canada, behaviours that represent addiction are present in approximately 10% of the population. Since pain is present in approximately 12% to 20% of the population, depending on the study you look at, one would expect a certain amount of crossover amongst these groups. This creates a complicated clinical situation if an abused medication is otherwise appropriate for a pain condition.
The patient who buys medication on the street or borrows medication from a family member or friend because he or she has an untreated pain problem or an undertreated pain problem seems to represent a failure of appropriate medical care, and it should be treated as such.
Prescribing of medications by physicians is a professional practice issue. When this occurs for inappropriate indications, in inappropriate doses, or in an incautious fashion, which may tacitly permit diversion or abuse, this should be amenable to educational and administrative interventions if the appropriate data-gathering tools are in place and directed interventions are undertaken.
When a physician fails to prescribe when appropriate or fails to offer treatment because he or she does not have the knowledge to treat, this should be addressed by directed educational activity. When patients die because they have combined the prescription medication with other intoxicants, intentionally or by accident, this is a tragedy. When it is the result of inability to gain access to appropriate treatment for mood disorders, addiction, or pain, it is a failure of the health care system, and should be treated as such.
There are several models of successful community interventions to address local cultures of prescription drug abuse and diversion. These have been reported elsewhere, but include Project Lazarus from the United States and a community action in Inverness, Nova Scotia.
Lazarus is a broad-based community intervention, which includes physician practice education, community education about pain and addiction, distribution of narcotic antagonists to make emergency treatment of overdoses in their early state possible, law enforcement involvement to address diversion issues, and availability of pain and addiction treatment programs. This program resulted in a dramatic reduction in unintentional death due to overdose and a reduction in diversion and abuse of prescription medications, while not reducing the prescribing of opioid pain medications for patients requiring these. It is noted in passing that the diversion behaviour seems to have translated itself to neighbouring communities, but this does not in any way negate the demonstration of the effective program.
In Inverness a small medical community undertook to implement a pain-management practice guided by the Canadian opioid guideline and to engage the entire community, including pharmacy, law enforcement, and other health care professionals. The result was a dramatic change in prescribing practice; no loss of capacity to treat patients with pain problems, within the context of the guidelines; and a significant reduction in diversion-related health care interactions and criminal activity.
My own observation, from attending several years of meetings having to do with prescription drug misuse and hearing of interventions that have been undertaken, is that one of the common characteristics of communities facing problems having to do with drug misuse is the disruption of the social fabric of that community, or disruption of the social structures in which the drug-abusing individuals function. Returning communities to a functional state seems to be a necessary element of successfully addressing the problem.
Earlier today I forwarded three editorials by Dr. Mary Lynch, past president of the Canadian Pain Society and co-leader of the Canadian Pain Society's national strategy on pain. My goal is to make the case that improving pain education and establishing an understanding of the appropriate response to patients with pain problems can, to a large extent, address problems of prescription drug misuse by providing care that can limit the inappropriate prescribing of medications that may become diverted and/or abused. If pain is appropriately treated, then the patient who seeks out analgesics because his or her pain is not being treated will no longer need to do so. Addiction is a separate medical problem, which also needs to be addressed through appropriate diagnosis and treatment.
Acute pain typically occurs as a result of the reaction to an injury or a metabolic or inflammatory process. This can occur from a variety of sources, including trauma, surgery, arthritis, metabolic disorders such as diabetes, infections such as shingles, the direct effect of cancer or an effect of surgery, radiotherapy or chemotherapy to treat cancer, peripheral nerve injuries due to trauma, central nervous system injuries due to spinal cord injury or stroke, and a variety of other causes.
A great deal is known about the treatment of acute pain, and effective treatments exist that can significantly reduce pain and support recovery. Some pain resolves spontaneously as the underlying disorder is treated, but some does not. Despite knowledge of the physiology and treatment of pain, it is still the case that within our acute care health systems, patients often experience moderate to severe pain. That is pain that can delay recovery or contribute to additional morbidities such as cardiac events, sleep disturbance, and delayed activation and discharge. This can occur up to 75% of the time following surgery for the first few days. In some patients, up to 30% of them, this can persist for as long as three months or more after surgery.
It is possible to do considerably better than this with appropriate education and implementation of treatment systems. Since poorly treated acute pain is one of the predictors of the development of chronic pain, improved treatment is a necessary goal.
Chronic pain states are in some ways analogous to mental health problems, because they are frequently subjective and not immediately apparent to the external observer. They are even less well understood and treated than acute pain states. Its simplest definition is that it occurs when pain has persisted for more than three months, or after the expected resolution of the triggering injury or illness.
Chronic pain interacts with the underlying psychological makeup of the patient and their social situation, to have a behavioural impact that extends beyond the sphere of physical or biological injury. This relationship is well described by a conceptual model referred to as the biopsychosocial model of pain.