'All they have to manage pain is their prescription pad': Doctors on front line of opioid crisis

When Brian Paolino was 17, he had no idea taking a few codeine pills from his parents' medicine cabinet would lead to a life-threatening narcotic addiction.

He first used the pills to self-medicate depression and anxiety, gradually moving up to stronger drugs with higher doses. Now 35 and clean for the past four years, the articulate native of Toronto says emergency departments served as his "dealer" for more than 14 years.

"I never bought a single opioid on the street. Ever," says Paolino, who pretended he had temporomandibular joint (TMJ) disorder — an affliction of the jaw — to get pain medication. 

Paolino had a knack for profiling doctors. He systematically mapped out emergency departments from Toronto and the surrounding area, making note of doctors to get prescription painkillers from.

"There were times I'd be praying, 'Dear God, please let the doctor say no.' But they never would. I hated myself because I was such a liar," he says. "I believed my own story. I would get TMJ pain before the refill day."

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Paolino filled his prescriptions at different pharmacies, so his misuse went undiscovered by pharmacists. He thought he might get caught when Ontario implemented a narcotic monitoring system in 2012 to flag problematic use patterns for pharmacists. However, he eventually realized that front-line ER doctors had no access to the system so he avoided being caught.

Canada's opioid crisis 

Prescriptions for opioids have increased sharply in the last decade, making Canada the second highest per-capita user of opioids in the world. Vancouver is on track to double its number of opioid-related deaths this year. And Ontario has seen a four-fold increase in overdose deaths over the last 25 years, according to the Ontario Institute for Clinical Evaluative Sciences.

Canada is in the midst of a full-blown opioid crisis, so curbing prescriptions has become a national priority.

Physicians can end up being the bad guys, whether they choose to prescribe or cutback.- Dr. Suneel Upadhye 

The Canadian Medical Association Journal released new national guidelines for prescribing narcotics on Monday, their first update since 2010.

The list of 10 recommendations instructs Canadian doctors to restrict prescribing opioids to specific situations — like catastrophic injury or chronic pain not responsive to other therapies. Most significantly, it suggests capping doses at the equivalent of 90 milligrams of morphine per day (the 2010 guide was the equivalent of 200 milligrams) and tapering patients down to the lowest effective dose.

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According to Dr. Suneel Upadhye, a Hamilton emergency room physician and chronic pain specialist, these guidelines are helpful but can put doctors in a tough position since many patients can sometimes take two or three times these amounts. 

"Physicians are often caught in the middle. They have patients demanding pain medication on one end and these new guidelines suggesting to do something else," says Upadhye.

Some regulatory bodies have tried to provide some guidance for doctors when it comes to determining dosage. The College of Physicians and Surgeons of B.C., for example, recommends that prescriptions for more than 50 morphine milligram equivalents (MME) per day be carefully reassessed and documented and those for more than 90 MME per day be supported by "substantive evidence of exceptional need and benefit."

But the final decision on how much to prescribe still rests with the individual physician.  

"Physicians can end up being the bad guys, whether they choose to prescribe or cut back," Upadhye said.

The guidelines are also difficult to follow in fast-paced, crowded hospital emergency rooms — Paolino's go-to setting to get a prescription.

"It takes 30 seconds to say yes and 30 minutes to say no. Right?" says Upadhye of dealing with patients seeking pain scripts. "Busy ER physicians just need to get to the next patient who's probably sicker."

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To facilitate his ruse, Paolino convinced a pain specialist that he had debilitating jaw pain. He also chose a subjective ailment. According to Upadhye there's no test — particularly in an ER setting — to determine conclusively whether a patient has TMJ dysfunction. 

"[The specialist] gave me a nice letter saying 'Brian is from a nice family, he doesn't look like he's prone to abuse,'" Paolino says. "But I then used that letter to go to every ER in the world and get more drugs."

While Paolino fabricated his physical pain diagnosis, his underlying chronic condition was psychological.

Managing chronic pain

Andrea Furlan, physician and researcher at Toronto's University Health Network, says one in five Canadians suffer from chronic pain — caused by anything from workplace injury to arthritis.

"Because chronic pain is so common, family physicians and nurse practitioners [everywhere] have patients with chronic pain," says Furlan. "If they don't know how to manage it properly, they will prescribe opioids."

Barry Ulmer, executive director of the Chronic Pain Association of Canada, says the health care system is failing patients for lack of clarity on what the problem is: chronic pain versus addiction. "People don't normally go out seeking opioids for the treatment of their chronic pain condition," says Ulmer. The gap, he says, is that doctors and other medical professionals are not taught how to treat pain properly.  

Dr. Raja Rampersaud, a spine surgeon with the University Health Network, is working on it. He is leading the Inter-Professional Spine Assessment and Education Clinics (ISAEC) in Toronto, Hamilton and Thunder Bay.

"ISAEC was started [in 2012] to focus on back pain, not necessarily on opioids," he explains.  

Now the program is considered a key component of Ontario's opioid addiction strategy. The program has trained 540 family doctors, nurses, and other health-care providers (including physiotherapists and chiropractors) to collaboratively manage complex chronic pain patients, using opioids only when necessary.

ISAEC has already helped over 6,600 patients with their back pain. In April, Ontario announced increased funding for a clinic in Ottawa with plans to expand provincially within two years.  The clinics will also start assessing other types of chronic pain, including hips and knees.

Saskatchewan is the only other province offering similar medical training and streamlined assessments for patients, with clinics located in Saskatoon and Regina.

According to Furlan, a comprehensive national pain strategy is needed to complement the newly released prescribing guidelines to ensure chronic pain sufferers have access to alternative pain treatments.

'Your name is on that oath, not mine'

The opioid crisis in Canada is a reflection of the options available to treat chronic pain, she says. When treating a chronic pain patient, the doctor knows an opioid prescription is likely covered by the patient's drug plan. But non-pharmaceutical  treatments — like physiotherapy, massage and stress reduction, exercise, psychological counselling — take more time to put in place and are often not covered by insurance.

"Because a lot of these options are not available to physicians in their toolkit, all they have to manage pain is their prescription pad," says Furlan. 

Opioid addiction and chronic pain are related, but not the same, says Upadhye. But both patient populations are equally harmed by unchecked narcotic prescribing. Stories like Paolino's, he adds, puts a spotlight on the large gaps in the current system that prescribing guidelines are unlikely to fix.

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Paolino remains unsympathetic towards the doctors he manipulated.

"On one hand you want me to respect you because you have all this training, and on the other hand, this junkie kid easily pulled the wool over your eyes. … At the end of the day, your name is on that oath, not mine."