Opioid high-prescribing doctors under CPSO investigation to ensure appropriate and safe use

The College of Physicians and Surgeons of Ontario (CPSO) has launched investigations into 86 doctors who have prescribed very high doses of opioids to their patients, according to a story in the Globe and Mail.According to the story, the Ministry of Health and Long-Term Care gave the names to the college after searching a narcotics monitoring database for two categories of high-dose prescribers.The investigations appear to be another part of the Ontario government’s mission to combat abuse of prescription painkillers, including targeting physicians who prescribe high doses. For example, next year, Ontario will become the first province to stop paying for high-dose opioid medications under its public drug plan.The CPSO confirmed it is investigating some physicians related to opioid prescribing but is unable to provide information about active investigations.CPSO president, Dr. Joel Kirsh said in a statement that when the self-regulatory body receives information from the provincial government’s Narcotics Monitoring System, or another source, that suggests a physician has prescribed extremely high daily doses of opioids to multiple patients over extended periods of time, it will consider the accuracy of the information and the clinical context in which the prescribing occurs. Any investigation will include seeking more information from the prescribing physician and others in order to better evaluate the prescribing.The Globe and Mail reported the ministry used two algorithms to identify doctors. It looked for physicians who had eight patients or more for whom they had prescribed opioids in amounts equivalent to 650 milligrams of morphine a day, or who had prescribed the equivalent of 20,000 milligrams of morphine for a patient at one time, usually as a long-term prescription.The Canadian guidelines for opioid prescribing, which were published in 2010, say that doctors should closely monitor patients who have chronic pain not related to cancer who are on a dose above 200 milligrams of morphine or its equivalent per day.But the investigations have raised fears that the threat of disciplinary action could lead pain doctors to decrease their opioid prescribing or cut people off, leaving patients to deal with withdrawal symptoms or turn to other methods to acquire opioids.“Understanding and questioning prescribing practices is not intended to discourage appropriate opioid prescribing, and we stress that it is our expectation that physicians who are the subject of an investigation will not suddenly cease prescribing to patients currently on opioid therapy as such an act would not be good medical care,” Dr. Kirsh said in his statement, adding that the goal is to ensure physicians have the proper resources to safely prescribe the drugs.Dr. Darren Cargill, section chair for palliative medicine at the Ontario Medical Association, told the Medical Post that from what he observes, the investigations don’t appear to include allegations of wrongdoing.“They may be flagging doctors to see if additional education might be needed, if they are following appropriate guidelines and if help can be given for them to be in line with other prescribers.”Dr. Cargill remembers that when the Narcotics Monitoring System was introduced some physicians responded by cutting their opioid prescribing out of fear of disciplinary action.“The example I use is when you are on the highway and you see an OPP car. Many drivers pump their brakes even if they are not speeding. They are worried because someone is paying attention,” he said. “Most doctors are prescribing properly but some might respond by pumping the brakes. I would never want to see a patient not getting the treatment they need from a knee jerk reaction. But it is a bit of human nature.”To combat this, Dr. Cargill says the assumption should be that there is nothing nefarious occurring and that the college intends to assist physicians rather than punish them.“If we want appropriate prescribing, we need to have that mindset.”

Opioid high-prescribing doctors under CPSO investigation to ensure appropriate and safe use

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