The continuing increase in the prescribing of opioids in Ontario is a classic example of tragedy of the commons. Like the many years of overprescribing antibiotics that now threaten society’s ability to overcome bacterial infections, the cause of this tragedy rests to a considerable extent with Canada’s physicians and dentists. For twenty years health professionals have been encouraged to treat chronic pain with opioids, being told by drug companies and pain experts that it was heartless to not attempt to alleviate suffering with these medications. Yet now it is apparent that far too many physicians and dentists have failed to associate the connection between their prescribing habits and the widely reported opioid crisis Canada is experiencing and are continuing to make it worse, not better. Where does the buck stop in dealing with this tragedy?
It seems obvious that it should stop with each prescribing health professional and his or her adherence to the high moral and ethical principle to do no harm. Clearly many are doing harm both to the individual patients to whom they are giving unnecessarily powerful, addictive drugs and to society as a whole. Prescribers struggle to reduce opioid prescriptions for chronic pain in the face of limited access to other options for treating chronic pain, and strong resistance from patients who are tolerant or in many cases addicted to opioids. But in the end they have the responsibility and the power to taper and discontinue these powerful medications.
Physicians and dentists come within the ranks of the self-regulated professions throughout Canada’s provinces and territories. The regulatory Colleges should urgently update their guidelines on opioid prescribing practices, monitor the adherence of physicians and dentists to them, and take disciplinary action against those who do not do so. The College of Physicians and Surgeons of British Columbia has taken an important first step by adopting enforceable standards for prescribing.4 The current opioid crisis in Canada is a wake-up call both to individual health professionals and their regulatory Colleges to pay closer attention to well-formulated evidence-based clinical guidelines lest they be, in future, replaced by hard and fast rules permitting no exceptions founded on professional judgement. Such guidelines, of course, must be free of inappropriate influences from pharmaceutical manufacturers.
In addition to prescribers, pharmacists and their regulatory Colleges could play an important role in resolving the opioid crisis, the Colleges through the development of guidelines and protocols and pharmacists through their role as the gatekeepers of prescription drugs. Pharmacists are in a position to identify opioid diversion and misuse. With extension of their authority to reduce the volume of opioid prescriptions as they now can for other drugs they could help to eliminate inappropriate prescribing.
Failing the buck’s stopping with individual physicians and dentists, society will insist that it stop with our provincial and federal governments. A compendium of governmental responses to the opioid crisis was released in 2016. It described many promising actions but, understandably, taking responsibility for monitoring and enforcing adherence to clinical guidelines relating to prescribing opioids was not among them. Nor should it be. Individual physicians and dentists and their regulatory Colleges are primary owners of this major problem in Canada’s public health.
 suggestion by Queen’s MPA student Grace Tahhan
Authored by members of the Queen’s Health Policy Council: