For the past 15 years, John has relied on a doctor-prescribed dose of opioids to numb his chronic pain and help him function in day-to-day life.
But after new guidelines were released amid a nation-wide spate of opioid-linked deaths, Johnâs doctor single-handedly decided it was time for him to cut back.
John has lived with severe pain due to a car accident and several workplace injuries. The sudden move triggered immediate signs of withdrawal, including sweating and diarrhea.
âI knew I couldnât function on that, with what it took me to get through the day,â John, who has asked not to be identified, told ŰÎŰ´ŤĂ˝. âI have been on it for 15 years, you canât just take that from me.â
Johnâs case reflects a problem some medical experts have described as Canadaâs second opioid crisis. As doctors take steps to prevent patients from getting hooked on potentially deadly medications, some have withheld the drugs or drastically lowered doses from those who need them most.
More than 4,000 people in Canada died from opioid related overdoses in 2017, and Canadians are the second-highest consumers of opioids in the world, second only to the United States.
The swell in fatal overdoses prompted , published in the Canadian Medical Association Journal and backed by more than 20 medical professionals.
Among the numerous recommendations, the guidelines suggested that doctors encourage patients receiving high-dose opioid therapy -- 90 milligrams or more of morphine equivalents daily (MED) -- to âembark on a gradual dose taperâ and potentially discontinue the drug.
The guidelines warned that even a small dose reduction could lead some patients to experience âsignificant increase in pain or decrease in function.â In some cases, the guidelines said, tapering should be paused or abandoned altogether.
But some doctors are applying those rules overzealously and with no patient input, leaving chronic pain patients without the ability to function, says Dr. Jeffrey Ennis, a veteran pain specialist based in Hamilton, Ont.
âThis is the other opioid crisis,â Dr. Ennis said. âPeople arenât appreciating that there are a whole pile of repercussions that are going on for people whose only crime is they that may have gotten sick or had trauma and now they have chronic pain.â
âThis is a big dealâ
Week after week, Dr. Ennis said heâs seeing patients enter his clinic struggling with drastic changes in their pain management.
âTheir function drops, they canât do what they want to do. They feel betrayed, they feel scared,â he said.
Itâs a problem Dr. Ennis understands first-hand. He has long suffered from chronic pain due to back surgeries, and he is now dealing with prostate cancer. To cope, he relies
âI am uncomfortable from the moment I wake up to the moment I go to sleep. It never stops, and that is the nature of this beast,â he said.
Dr. Ennis said the problem is rooted in a misinterpretation of the new guidelines. He says some doctors read the suggestions as gospel and fear that, if they donât get their patients below the recommended 90 milligrams, their medical licenses could be taken away.
Those misplaced fears are putting some patientsâ health in jeopardy, Dr. Ennis said. And the problem, he believes, isnât limited to Canada.
âI think that it happening more than nationally. I think it is happening internationally,â he said.
The problem can be solved with better doctor-patient communication, Dr. Ennis said.
âThe guidelines are very clear as well: if someone is on more than 90 milligrams, have a discussion with them. Ask them if they are open to the idea of reducing the dose, because being on a high dose there is a risk attached.â
If the patient isnât interested in changing the dose, Dr. Ennis says, âyou have now met the guideline requirement. Thatâs it.â
The final step, he says, is to continue monitoring the patientâs function on an ongoing basis.
âIf it isnât broke, donât fix itâ
For Emma, who also asked not to be identified, cutting back on her painkillers had serious repercussions. A woman in her early 60s with arthritis and bone fractures, Emma says her doctor ordered a significant cut in her OxyContin prescription.
The lowered dose âmade things worse,â Emma said.
âI did that, and now Iâm in the position Iâm in, with a lot of pain â and pain that I canât get control over again,â she said.
After noticing the immediate change, Emma got permission to increase her dose back up. But, since returning to her previous dosage level, the pain hasnât subsided.
âThere is an old saying â if it isnât broke, donât fix it. So had he not touched it I mightâve be fine,â she said.
Health officials agree that tampering with a patientâs prescription should not be done suddenly, and that rapid adjustments could send patients onto the streets looking for drugs.
Instead, changes should be made gradually, said Dr. Irfan Dhalla, vice-president of Evidence Development and Standards for Health Quality Ontario.
âPhysicians should not suddenly discontinue opioids in people who have been receiving them,â Dr. Dhalla said.
âI felt like a junkieâ
Despite some doctors misinterpreting the new guidelines, the recommendations are an important step toward addressing the opioid crisis, Dr. Ennis said.
However, he said the guidelines should be applied carefully on a patient-by-patient basis and not be treated as âcommands.â
âMy job is to identify that group of people who, if I give this (drug) to you it actually gives you a life. And when you see that happen medically, it is a great day,â he said.
Thatâs precisely what happened with John, who reached out to Dr. Ennis about his predicament. His pain is now under control thanks to a proper dose of opioids.
But having a doctor threaten to lower his medication was scary, John said, because it revealed just how much he relies on the prescription.
âFor the first time I felt like a junkie, because I felt dependent on the painkillers,â he said.
After the back-and-forth over his prescription, John said he doesnât expect there will ever come a time when he can live without help from the powerful drug.
âI have other tools, exercise, goal setting and pacing. The medication is part of my life. Not the only part of my life. But part of it.â
With a report from CTVâs medical affairs specialist Avis Favaro and producer Elizabeth St. Philip