In British Columbia, opioid prescribing practices have come under scrutiny following the implementation of new regulations aimed at reducing opioid-related overdoses. In June 2016, the College of Physicians and Surgeons of B.C. responded by enacting a new practice standard. This standard prohibits clinicians from prescribing, at any given time, more than 90 morphine milligram equivalents per day worth of opioids. These regulations are an attempt to address the growing opioid epidemic. Since 2016, this crisis has senselessly claimed more than 16,000 lives across the province.
The 2016 practice standard sounded an alarming alarm on co-prescribing of opioids and benzodiazepines. It elevated the urgent danger of drug poisoning with the presence of this combination. Dimitra Panagiotoglou’s research discovered a substantial reduction in opioid doses from 2016 to 2018. The study noted a slight decrease in the average days’ supply prescribed in the same time span. The College re-evaluated its standard in 2018 after a misinterpretation had been flagged to them as a concern.
The updated standard addresses several misconceptions that led to unnecessarily aggressive and fearful prescribing. The unintended consequences of this issue affected all patients, both with chronic non-cancer pain and those who needed palliative or cancer care. Those original guidelines, no doubt backed by the best evidence at the time, have undergone dramatic revisions since.
“Individuals decided to pull back on their prescribing, but there was this larger population-level effect in doing so,” stated Panagiotoglou. Just as extended prescribing patterns created adverse effects on patient groups that are vulnerable, it had immediate devastating effects on patients fighting cancer. Within two years after the 2016 rules went into effect, opioid dispensations for cancer patients dropped by 41%. They decreased by 15 percent per person from what was initially projected.
The decline among palliative care patients was even steeper. Their per-capita dosages decreased by 6.1 percent, equating to an average of 1.8 days’ supply less. Patients in receipt of chronic non-cancer pain experienced an 8.2 percent decrease in dispensations. This amounts to about 4.5 fewer days’ supply over a month’s time.
The College of Physicians and Surgeons of B.C. came to realize the value of aggressive pharmacotherapy. This is particularly important for patients living with cancer and those receiving hospice care. “In the 2016 practice standard, (the college) was explicit in acknowledging and endorsing the use of aggressive pharmacotherapy in the context of active cancer, palliative, and end-of-life care,” said a representative from the College.
Despite this endorsement, the emerging narrative of opioids as dangerous and addictive took hold and influenced physician prescribing behavior. This shift in messaging resulted in most physicians becoming more cautious against prescribing opioids, even when it would be appropriate. Panagiotoglou noted that “the ongoing messages that physicians were getting at the time — opioids being bad — influenced their decisions.”
The unintended consequences of these regulatory changes highlight the difficulties of responsibly managing opioid prescriptions in the time of a public health crisis. Many healthcare professionals express concern that efforts to curb opioid misuse must be balanced against the needs of patients who rely on these medications for pain management.
