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Whilst disciplining a Dr is great, how about the patients who actually depend upon that Drs prescriptions. Maybe in large urban areas this is not a problem, however in small rural northern areas this does become one. The problem being that there are not that many Drs and those that practice have waiting lists. When you stop a Dr from prescribing narcotics, patients that do NOT abuse them also suffer. In our case, my 85 year old wife, has a need for the narcotic being prescribed as your specialists will not treat her degenerating spinal injury suffered 30 years ago. When you make these desicions to limit Drs prescribing narcotics, you should also send out a list of alternatives for the patients who require these drugs for a quality of life…
I am a Chronic Pain patient and Advocate. I have may patients on my roster. The May 08, 2017 McMaster Guidelines have been the most draconian and egregious set of guidelines to hit both the patient and medical profession. Of the many pain specialists, family doctors and ER doctors, I have been told to my face that “we will not advocate for our patients as far as opioids are concerned. The unintended consequences have been the cause of two patients going to the street for pain relief and died. I have served my country, my province and the citizens of the Durham Region, and now I am 76 YOA and suffer intractable intractable pain, my doctor is worried about his license and a section 75 investigation. Doctors are practicing medicine (pain) by regulation and not their best clinical judgement. The November 2016 meeting in Ottawa was in my opinion, stacked against the use of opioids. Not a balanced debate!
I am fully aware the many if not most family doctors have prescribed opioids to patients that should NOT take opioids. The College let these doctors slide until the crisis manifested its head.
Make the criteria for prescribing opioids as in use at my clinic. Pain scores, urine tests, face to face appointments before opioids are prescribed. Prescribe only enough medication to last 10-14 days. Deal with only one pharmacy and only one doctor. 95% of Senior chronic pain patients DO NOT abuse their medication.
TO THE COLLEGE PRESIDENT; avoid the vested interested groups that have staked their professional reputations on denying pain relief (adequate) to seniors. Enable doctors to use their clinical judgement in the ER and family practice.
I have attributable medical histories from patients that are being harmed. These patients have given me permission to disclose, however I will provide the patients written permission if you really want their input.
Re: Prescribing by Physicians who are receiving money from Pharmaceutical Companies.
The main marketing tool by pharmaceutical companies is paying specialist and family physicians to give post-graduate lectures to other physicians,the present opioid epidemic being the result of pain specialists who were not only promoting these drugs very heavily, but were even attending seminars paid for by the manufacturers to learn how to conduct their lectures to more effectively transmit the message of ‘safe opioids’.
I have worked on publicity and advertising for the Health Education Council of the U.K. doing national health campaigns, and as an employee for a major pharmaceutical company, so I am able to recognize that the majority of lectures I have attended on Diabetes in the last four years are also often following a script, suggesting the lecturer is reproducing an industry designed lecture.
In my practice it is easy to recognize physicians who are receiving money to promote certain drugs as every patient of mine who sees them have had nearly all their medications(ACE inhibitors, ARB’s, Statins) changed to a different non-generic ACE, ARB, or Statin or to a new non-generic combination often quadrupling the cost of their drugs, especially tragic for my patients who are working poor. My colleagues complain of similar problems with certain specialists.
Obviously for litigation reasons physicians are bound as much as possible to follow national guidelines but nearly all published guidelines are written by physicians who are receiving money from the pharmaceutical industry, and their recommendations on lowering blood pressure or lowering the diabetes Hb A1C suggest much lower levels than is indicated by the information from the major medical journals.
Allowing physicians who are receiving medications from pharmaceutical companies from lecturing or otherwise instructing other physicians, puts them in an ethical conflict with their duty both to the art of medicine and to their medical colleagues. It greatly increases the cost of Pharmacare for every Province and leads to overprescribing, and in the case of the opioid epidemic, to the death of thousands of Canadians. The only justification is that it is subsidies the post-graduate learning required of physicians but at the cost of their learning misinformation and over prescribing drugs that are unnecessary for their patient’s health and the financial health of Canadian Medicare.
I suggest that physicians who are receiving money from the pharmaceutical be banned from lecturing or other instruction of other physicians. Certainly if there is ever a National Inquiry into the causes of the opioid epidemic the fact that the medical community has not dealt with this most obvious conflict of interest for physicians will have dire outcomes for the present organization of physician discipline.
Office of the Information and Privacy Commissioner of Ontario
Response in PDF format.
Professional Association of Residents of Ontario
Response in PDF format.
I was prescribed a medication at lowest dose. The decision was to try it and increase dose if required. After a month trial it was evident the medication was only working for 12 hours. I returned to a group clinic and asked to have it twice a day from one a day. This was readily agreed to. I questioned the requirement to officially note this with pharmacy and was provided with a copy of a note indicating increase dosage to two times a day. A month later I returned with note to the pharmacy for a refill given I had only had 10 days left of medication. The medication cannot be abruptly stopped – has to be a wean off otherwise there are serious health side effects. I was told this was not acceptable and I had to have a new prescription. I contacted the clinic and was told I had to return for a second appointment to repeat the appointment and obtain the amended prescription – the Doctor note was not acceptable. They could not do a refill as the medication by dosage original was fine for at least six weeks and my medical plan would not allow any advance refill. I was unable to get an appointment so had to take off work and sit for hours on a walk in basis to REPEAT the same appointment. We have two OHIP billings for a simple increase of dosage as suggested by the originating doctor. The Prescribing drugs was reviewed and whereas it is common sense and protocol to issue a new prescription with the amendment – this was not done by the Doctor. It needs to be clear for our new Doctors and those under supervision that may or may not be closely monitored on what would be a simple process implemented. Note the previous doctor had put the information in my file that was accessible to the other clinic doctors at the same facility.
I understand and laud the college’s action on prescribing drugs to patient. For to long there has been little or no control on this vital function of Ontario/Canadian doctors. Because of the lack of control, patients have been hurt. Doctors that were prescribing opioids have now stopped because of the fear of sanctions of the college. The college is responsible for keeping this fear at a fever pitch and the result is patients are dying. Suicide by using street drugs because their doctor has cut them back of off. Illicit drug use by a few, unjustified prescribing of opioids by a few doctors can be controlled. To control addicts, NOT POSSIBLE. To control the few doctors ABSOLUTELY POSSIBLE.
The college is in place to protect patients and you are failing miserably. Because of the college is allowing, and promoting the practicing of medicine by government guidelines and NOT THE DOCTOR’S CLINICAL JUDGEMENT patients are suffering intractable pain. A 150 years ago patients suffered because we did not have the drugs. We do now. Treat the few addicts, and let our doctors treat millions who suffer. Re educate doctors that need it, sanction the doctors that will not comply with re education.
RESPOND TO QUESTIONS AND POSTS TO THE INDIVIDUAL THAT MADE THE POST, NOT WITH A FORM LETTER THAT CANNOT DEAL WITH INCREDIBLE PAIN AND SUFFERING/
An older version of this policy identified naloxone as a permitted drug for third-party prescribing. This clause was eliminated when naloxone was delisted as a prescription drug (it is now non-prescription). In many communities (and my hospital), this created the perception that third-party distribution of naloxone was no longer permitted, when in fact the regulations were actually making its distribution more open and permissible. This highlighted a serious gap in the policy: physicians often “prescribe” non-prescription drugs. This policy should therefore be written to refer to both prescription drugs (Schedule 1) and non-prescription drugs (Schedule II and III). Therefore, even if a drug is no longer a Schedule 1 drug, the policy should still consider and refer to it because physicians often prescribe these drugs. So the clause on naloxone should be restored.
Most of the strictures on providing samples are appropriate, but a couple are not. I usually use samples to provide medication such as antihypertensive or lipid-lowering drugs to patients who cannot afford them. As a specialist my note to the family physician already says the names and doses of the medications the patient is taking, and the patient has usually been stable on the medication for some time, so the two following strictures are usually unnecessary:
-Document the drug samples given to patients, including the date provided, name of the drug, drug strength, quantity or duration of therapy, instructions for use, and the fact that the drug’s material risks, including material side effects, contraindications or precautions were discussed with the patient;
– Share information about drug samples provided with other health-care providers, as appropriate.
The current policy is vague in its wording around electronic transmission of prescriptions.
While the policy is flattering about EMR and electronic prescribing, the College must be clear about whether it permits or does not permit emailing of prescriptions
In other words is the College part of the solution in getting rid of faxconversion at both ends or part of the ongoing problem.
It is extremely important for the profession to clearly know where this roadblock lies so their attention can be focused on that obstruction
My thoughts on the Prescribing Drugs policy:
1. I did like where the previous policy specifically stated that if a physician is going to prescribe a chronic medication, he or she should also follow-up with that patient to ensure that a) the side effects are manageable and b) the dosage is correct. The current policy simply says follow-up as needed (with whom?). As an emergency physician, part of the reason I don’t typically prescribe chronic medications is because I almost never see a patient again. Having this spelled out in the prior CPSO policy was helpful to aid my non-emergency physician colleagues (e.g. cardiologists, internists, etc) to understand why we as emergency physicians are reluctant to start emergency patients (who are being discharged from the ED) on new chronic medications (eg. antihypertensives, anticoagulants, etc). Of course, this displays a fundamental misunderstanding of the purpose of emergency medicine, which is to stabilize the emergent condition, then to hand the baton of care back to the longitudinal care providers, rather than to try to take on preventative (ongoing) care. But having it explicitly stated in the previous CPSO policy facilitated understanding by other types of physicians, who could finally grasp why emergency physicians don’t usually initiate chronic, preventative medications (but instead refer the patient to their longitudinal care provider to do so).
2. I do not agree with the section, “Some physicians have blanket ‘no refill’ policies, meaning they will not authorize refills for any patient, for any drug, in any circumstance. The College prohibits the use of blanket ‘no refill’ policies because they are not consistent with patient-centered care and have no clinical basis”. While I do not have a ‘blanket’ no refill policy, per se, as an emergency physician I almost never give out refills, nor should I, based on the single exposure I had to the patient sometime in the past. Things may have changed since then, and as I have no ongoing relationship with the patient in order to determine this (i.e. to see the patient again), it is inappropriate for me to refill medications that were appropriate a month ago. Nor can I even tell the patient to come back to the ER to see me (can you imagine the increase in emergency care resource use if all ER physicians did this, in response to this policy?? A sudden increase in ED visits in Ontario would not be beneficial to the health care system), since I don’t work regular hours (e.g. Wednesdays from 9-5). My shifts have no pattern to them, so the patient would have to ‘guess’ when I am working in the ER, in order to see me again.
So I think emergency physicians should have what is almost tantamount to a ‘blanket’ no refill policy, since they almost never see the patient again. Simply stating that this has “no clinical basis” is false. The ‘clinical basis’ is as I have stated above, and is quite “consistent with patient-centred care” (i.e. not hurting the patients), in the context of my practice (emergency medicine).
Otherwise looks good.
Very thorough documentation of prescribing.
I appreciate that in some ways it is general (requirements for confidentiality and maintenance of privacy of information) and also electronic records.
I don’t the policy needs to be replicating policy that exists and is ongoing /developing alongside of developments in IT
I think it is important that the overriding steps and goals are clear. I appreciate the aspects related to assessment prior to prescribing – it delineates the intention and examples of exceptions (STI for partner) etc.
I have the impression that if we all kept this policy in hand, as written, and followed it, many problems would be prevented / averted.
Well for starters instead of having the physicians in Ontario paying the CPSO for its management fee in dealing with the Opioid crisis perhaps it should be spent on lobbying against the government. Not only has the government supported free injection clinics, the free distribution of Narcan, the promotion of legalizing the addicting substance of marijuana (for purely a tax grab) but continues to promote the addictive alcohol distribution in the small grocery stores. This is insulting that the CPSO and government are pushing in different directions and we the financial supporters of the CPSO are being harshly judged continuously for our decision processes. How can a true Canadian not feel embarrassed that the Prime Minister of Canada supports the manufacturing , legalization and distribution of addictive substances. This is NOT SOMETHING I FEEL WE THE PHYSICIANS through the CPSO should be spending any time money or energy on in that we are being undermined by the Government of Canada sticky to deepen their pockets . This is EXTREMELY SAD. A response from a specific person on the CPSO would be appreciated.
One potential problem not discussed in the policy is the compliance with limited use requirements of the Ontario Drug Benefit Plan. For example, the Canadian Cardiovascular Society (CCS) guidelines for stroke prevention in atrial fibrillation recommend direct-acting oral anticoagulants (DOACs) over warfarin. The ODBP requires that warfarin be used unless strict requirements be met before the use of a limited use code. Since the DOACs are much more convenient to use, there is a temptation to use the LU code without complying with the requirements. This is a potentially serious problem, since anticoagulants are the commonest cause of serious adverse drug reactions resulting in emergency room visits in the USA. One DOAC, rivaroxaban, has caused over 3,000 deaths in 2016. What should we do when professional guidelines and government policy are not aligned?
I was severely injured in a work related accident in 2009. Through that injury it was discovered that I had degenerative disc disease which was exasperated due to this injury. From this point on, I have had issues with mobility and my ADL’s. After trying several types of anti inflammatory medications,progressing to different NSAIDS with no relief, I was put on Teva Morphine 15mgs and Statex 5mgs for breakthrough pain. This has worked well for me for the past 6 yrs. There have been many times in the past two years where I have requested an increase but was denied.
In September of 2016, I broke my fibula and tibia bones in my left leg. Spiral fracture in the fibula which was repaired with pins, plates and screws. The base of the tibia where it attaches to the ankle was totally crushed. The ortho surgeon did his best to repair that, again using pins plates and screws. When I was released, the only change in my medication was in the Statex 5mg where an extra dose was added. For six weeks, I was in a “soft cast”. I was not allowed to put any weight on that foot at all. In that period of time, my scheduled 3 mnth appt. with my Dr.came. I called several times to speak with my Dr, never once being allowed to speak to her. The receptionist told me every time, that I could not have my prescriptions renewed without seeing the Dr. I explained that I was not allowed out of bed, I was only asking for enough for the month. Still I was not allowed to speak with my Dr. Now, I was out of my medication. The increase the Ortho Surgeon gave me was for 4 days. Note, I had already been on this medication for 5 yrs. I do not abuse, and have not abused my meds.
While healing from surgery, I also ended up with severe withdrawal. Sweats, chills, vomiting, the whole ordeal. When I was finally able to go for an appointment, I was on crutches now in a solid cast. I was angry, and totally seized up physical. My mental state was depressive and to make it worse, my Dr didn’t even know I had called.
That being said,” I understand policies are in place for a reason. However, there needs to be an understanding that there is going to be special circumstances that arise, like mine, when a Dr. should not be afraid of disciplinary measure”s.
I Sugget consideration that the informd consent component be a paient signed consent document such as for a procedure especially for those drugs that 1) my or may not have a beneficial effect but the number needed to treat (NNT) is so high that individual benefit is likely marginal and 2) will likely be consumed for a very long time. with risk of side effects increasing with time and dose. These chronic prophylactic agents should be recorded as highly recommended or simply suggested. The signed consent would indicate that the patient has had an opportunity to consider his/her acceptance of theses odds and whether they wish to take the medication on that basis.
I am much more concerned about patients taking drugs that they believe they must take and not realize that the drug is optional and may not convey any benefit..
In going through the guidelines on prescribing, it would be good to consider reuse of medication that are not used by a patient considering the huge cost of prescriptions. While I understand the reason behind disposing these medicines, a check and balance approach by pharmacists and the drug companies might help to reuse the medicine safely by a another patient who cannot afford these prescription.
Also, the burden of prescription on a given doctor is extensive and time consuming. Are there more simplified ways for these policies with out compromising safety?
I am a disabled MD and need MM and opioids to control my chronic pain. MM costs 16$/day and is not covered by OMA SUNLIFE program which I feel it a bias against MM eg oil 2ml QID prn pain..Also on oxycodone 20mg tid or 90 MEQ of Morphine/day that costs about $1 buck per day.. the 60 mg of oxycodone provides good relief for 12/hours/day the other 12 hours per day you suffer and this has been going on for over a year..despite my protestations to my FD..I now have a new FD and he is afraid to go over 90mg GUIDELINES…NOTE GUIDELINES DOES NOT EQUAL GOSPEL…The Media, CPSO, CMA, CMA , MOHLTC,CDC,JAMA and AMA have all conspired to force these GUIDELINES ON PHYSICIANS and have taken the PATIENT out of the equation.. eg so what if they are in pain 12 hours per day..There is ZERO diversion risk with ME as I need every mg of those opioids…PLEASE RETURN GUIDELINES BACK TO 200MG PER DAY OR AT LEAST 150MG/DAY AND TAKE INTO ACCOUNT BODY WEIGHT EG 100kg as a starter..SUFFERING IN ONTARIO MD
Response in PDF format.
Thank you for asking me to have my input on opioids use in non cancer patients.
I have 5 patients who receive oxyneo on regular basis.
My general opinion regarding use of OPIOIDS.
1.THEY RELIEVE ARTHRITIC PAIN SUCCESSFULLY
2 LOW RISK FOR SERIOUS SIDE EFFECTS TALKING MAJOR ORGANS LIKE KIDNEYS AND LIVER.
3 RENAL FUNCTION SHOULD BE MONITORED YEARLY.
4 THEY SHOULD NOT BE PRESCRIBED FOR LONG TERM USE IN POPULATION YOUNGER THAN 50 YEARS OF AGE.
5 SHOULD NOT BE PRESCRIBED TO PEOPLE OF RIGHT AGE BUT ALCOHOL ABUSE AND RECREATIONAL DRUG USE.
6 THERE IS HIGH DEGREE OD DEPENDENCY AND CONCOMITANT DRUGS USE LIKE MARIJUANA—IN MY HUMBLE OPINION LEGALIZATION OF MARIJUANA FOR GENERAL AND
MEDICAL USE IS A MISTAKE—BOTH DRUGS MUST NOT BE TAKEN AT THE SAME TIME.
7 LONG ACTING OPIOIDS SHOWED TO BE VERY BENEFICIAL IN RELIEVING OFTEN SEVERE PAIN IN OSTEOARTHRITIS/THUS SHOULD BE ALLOWED TO BE USED IN OLDER
POPULATION.SUPERVISION IS REQUIRED.THEY CARRY PRACTICALLY NO SIDE EFFECTS AS COMPERED TO ANTI-INFLAMMATORY AND TYLENOL WHICH DOES NOT
PROVIDE DESIRED RELIEVE FROM PAIN AND IS VERY DAMAGING TO LIVER.
I trust that my input has been helpful to all concerned.I used only my personal experience with my patients only.
Response in PDF format.
OMA Section on General and Family Practice
Response in PDF format.
CannAmm Occupational Testing Services
Response in PDF format.
Ontario Medical Association
Response in PDF format.