Fentanyl and other opioids for chronic pain put patients on a dangerous slope

Prince's death from an overdose of fentanyl is a high-profile example of what happens thousands of times every year among people with chronic pain.

The single-page medical examiner's report lists fentanyl overdose as the cause of death. The report includes notes about scars on his left hip and right lower leg, which could be from past surgeries for joint pain.

"There's a good example of a patient who by all accounts was a clean-living guy who eschewed alcohol and didn't exactly abuse drugs per se, but did have chronic pain and was under the care of a physician for chronic pain," said Dr. David Juurlink, head of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre in Toronto.

• Prince autopsy leaves questions about contributing causes of death

"He died either from his therapy or the fact that his therapy led to an opioid use disorder."

Since fentanyl is 50 to 100 times more potent than heroin or morphine, a tiny amount can push people past a tolerant dose into an overdose situation, said Dr. Perry Kendall, British Columbia's provincial health officer in Victoria.

In Canada, Kendall and Juurlink point to a combination of factors that have contributed to a fentanyl overdose crisis:

• After Oxycontin was pulled from the market in 2012 and replaced with tamper-resistant OxyNeo, many provinces said they wouldn't pay for either. Use shifted to fentanyl as well as other more potent opioids.
• Fentanyl patches for cancer pain have been diverted for illicit use, although Kendall said this isn't occurring as much in Canada as in the U.S.
• The illicit market quickly filled with smaller doses of higher potency bootleg fentanyl from China that could be smuggled more easily than large quantities of heroin.  

​Fentanyl-related deaths have surged in Canada. In B.C. alone, deaths involving fentanyl increased from 13 in 2012 to 480 in 2015. In Alberta, fentanyl-detected deaths increased from 29 in 2012 to 274 last year. 

B.C. hadn't seen a toll like that since the mid-1990s, Kendall said. The alarming increase was why he declared an emergency last month, with the goal of getting more resources, attention and timely and detailed data, such as from emergency rooms.

Chronic pain mismanaged

Education is needed for "street entrenched" users, those who turn to the black market when a physician will no longer prescribe an opioid, and recreational users, Kendall said.

For instance, someone who can be convinced not to use opioids while alone and is aware of the signs of overdose, a rapid naloxone injection could be a lifesaver.

There are so many people around the country on high-dose opioids, it's very difficult to craft a cogent argument they're being helped by these drugs.- Dr. David Juurlink

This week in British Columbia  and Nova Scotia, the colleges of physicians of surgeons adopted new guidelines on prescribing opioids, based on those from the U.S. Centers for Disease Control and Prevention.  

Juurlink welcomes the CDC's recommendations, because they discourage using opioids liberally and give suggestions on limiting doses. He remains reluctant to prescribe fentanyl to his non-terminal patients.

"The goal is not to put a patient on a drug that is self-perpetuating and difficult to stop," Juurlink said. "I think until doctors and patients start to appreciate that phenomenon and confront it, we are going to continue to mismanage patients with chronic pain by putting them on opioids for years at a time at high doses in the absence of medical evidence that that's a good thing to do."

There are specific situations where it might be appropriate to prescribe for chronic pain, he said. For example, if someone has debilitating osteoarthritis and other drugs are inadvisable because of kidney or stomach problems, Juurlink said he will occasionally turn to low-dose opioid prescriptions. When he does, he ensures the patient understands the risks and plans an exit strategy.

"It's a very difficult conversation that doctors face every day with these chronic pain patients."

Numerous risks

When putting a new patient on an opioid, it's impossible to know who will benefit, suffer side-effects or spiral into addiction.  

Stopping the drugs is also fraught. Many patients are convinced they need the drugs because of the physical dependency and sickness that occurs when trying to cut back.

"There are so many people around the country on high-dose opioids, it's very difficult to craft a cogent argument they're being helped by these drugs," Juurlink said. "Many of them I think would be much better off, from a depression perspective and a pain perspective, if we could gradually work them down to more sensible doses."

To prevent post-surgical pain for instance, doctors and nurses with Toronto General Hospital's transitional pain program are turning to exercise, psychological techniques, acupuncture and non-opioid medications to address the surgical pain before it turns chronic.