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The fentanyl ‘crisis’ isn’t what it’s chalked up to be

Ottawa Citizen by Dawn Rae Downton 22 June 2017

The Society of Obstetricians and Gynecologists of Canada, meeting this week in Ottawa, is luring clinicians, exhibitors and media with “hot topics” such as this one: “Opioids are used to manage pain during pregnancy and childbirth, but the risk of addiction is real. What are the alternatives, and what are the risks?”

It was bound to happen: The “fentanyl crisis” has become a marketing meme.  Tell Canadians — even physicians — often enough that we have an “opioid epidemic,” and we’ll believe it. Tell us every day, as the media have over the last year, that chronic pain patients and their doctors have fuelled that “epidemic,” and you get a “hot topic” such as the SOGC’s.

Not only are doctors poisoning their chronic pain patients with opioids, the thinking goes, they’re poisoning those patients’ newborns. The new and confused physicians’ Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, out last month, is meant to stop all that.

But it won’t.

I’m a longtime chronic pain patient who’s used fentanyl under expert supervision for 12 years, and I’ve never been poisoned, or addicted. Certainly I depend on fentanyl. I’d get sick if I were yanked off it. I’d suffer excruciating pain, then suicide without it. But I don’t drug-seek. Often as not, I forget to change my patch — until my pain reminds me to.

Taking opioids for pain doesn’t make you high; it gives you less pain.

What’s meant by “addiction” confounds people, including doctors and reporters. It’s a complex condition with known precursors — past substance abuse; being male; and having a family history, vulnerable genetics, and a comorbid psychiatric disorder. Pregnancy and childbirth isn’t a precursor, nor is therapeutic narcotic use. As the veteran Halifax pain specialist Mary Lynch puts it, “medical exposure to opioids does not cause addiction.”

Lynch has followed several of her opioid-dependent patients through their pregnancies. She says that the principles for using opioids in pregnancy are the same as with any drug used then: She chooses the safest drug in the lowest dose that controls the problem — whether it’s epilepsy, diabetes, hypertension, asthma, or chronic pain.

For intolerable birthing pain, opioid-naïve patients do best with epidurals  usually a local anaesthetic/opioid mix. For chronic pain patients on opioids, before and at delivery, “we maintain the best balance to maximize the health and safety of the fetus and the mother,” Lynch says. Working with obstetricians, “we monitor closely, and we maximize physio, massage, relaxation.” Opioids are in the mix.

Research from UpToDate, a physicians’ online resource, shows that the risk for birth defects is no higher than expected in women using morphine than in those who aren’t. If mom uses opioids for pain before and at term, then doctors watch and, as necessary, treat newborns for opioid withdrawal.

How often does that happen? In 2010, Canada’s College of Family Physicians knew of only one case where a mother on a moderate dose of fentanyl long-term delivered a newborn in mild withdrawal.

According to the SOGC, that’s changed now (and they would know). But, despite the new, ill-informed guideline that conflates them, the definitions of medical opioid use and addiction have not.

So why would the SOGC claim that women can get “addicted” in nine months of pregnancy, or even in hours and hours of labour? Is it because the SOGC needs marketing moxie?

Armed with my “hot topic,” I thumbed through the conference program, looking for it. There’s a session on addicts and pregnancy, another on narcotics and addiction generally, and another on chronic pelvic pain and physiotherapy. Nothing on chronic pain and opioids. Eventually, an SOGC spokesperson  “agree(d) that the topic description may not accurately reflect what the talk is.”

The SOGC is doing exciting research on other topics. Attend the conference for those — but not for the “hot” ones.

Dawn Rae Downton is a writer living in Halifax.