CMAJ Podcasts
CMAJ Podcasts
How short-term opioid prescriptions affect long-term outcomes
A recent article in CMAJ entitled Effect of emergency department opioid prescribing on health outcomes examines a key concern facing many clinicians: can a single opioid prescription for acute pain lead to long-term harm? This study aimed to clarify the risks and inform safer prescribing practices.
Dr. Grant Innes, the study’s senior author, analyzed more than a decade of data from Alberta emergency departments to compare outcomes between patients who did and did not receive an opioid prescription. The study found no significant difference in rates of overdose, opioid use disorder, or death—challenging widely held fears about short-term opioid use. Innes notes that older and opioid-naive patients may be more vulnerable to adverse outcomes and encourages a balanced approach to pain management.
Dr. Hance Clarke, director of pain services at Toronto General Hospital, emphasizes the importance of structured follow-up and monitoring, especially for patients at higher risk of persistent use. He outlines practical strategies for safe prescribing and highlights underused and emerging alternatives, including ketamine, IV lidocaine, nerve blocks, and sodium channel blockers now in development. Clarke warns against “opioid phobia” and calls for individualized care supported by systems that can detect early warning signs.
The guests encourage physicians to not avoid prescribing opioids when clinically indicated, particularly in cases of severe acute pain. With thoughtful screening and mechanisms for follow-up, opioids can be relatively safe and effective. The goal is not zero prescribing, but safer, smarter prescribing.
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Dr. Blair Bigham
I'm Blair Bigham.
Dr. Mojola Omole
I'm Mojola Omole. This is the CMAJ Podcast. So today, Blair, this is a really fascinating topic.
And I know you're very excited because this is one of your, how do we say, emerg icons.
Dr. Blair Bigham:
Well, yes, but not only does this apply to emergency medicine, it applies to my practice in the ICU. It applies to your practice as a surgeon. I think it applies to almost every physician. Everyone is going to come to a doctor and say, I have pain. Maybe it's acute. Maybe it's chronic.
Maybe they've already tried a bunch of stuff. Maybe they just broke their ankle and their tibia is hanging out of their skin, and they've come to you.
Either way, we're all going to encounter and do encounter people with pain.
And there's a couple of things that come to mind at first. First of all, as someone who embarrassingly has called 911 for themselves when he was having a kidney stone at the age of 26.
Dr. Mojola Omole
Oh, poor baby, poor baby, poor Blair.
Dr. Blair Bigham:
It was so painful. And I remember getting a dose of fentanyl and being like, “Oh.” So pain management is amazing.
It helps people, but at the same time, as a physician, I'm pretty scared of contributing to the opioid epidemic, contributing to somebody's long-term misery if they have a dependency on opioids or if they develop a dependency on the opioids I prescribe them. I remember as a resident, this really weird moment where I was on ortho and I was working a clinic day and someone showed up for follow-up for a broken wrist and I was going through their pills and on the prescription bottle for morphine was my name. Because I was on emerg the month prior and I fixed their wrist and sent them home on morphine.
And I was like, oh my God, my name is on the bottle. I am responsible for this person taking morphine. I remember being so like, it was so weird to see my name as a prescriber. It was a little bit scary.
Dr. Mojola Omole
That's 100% scary.
Dr. Blair Bigham:
Jola, do you ever get nervous sending people home on pain medication?
Dr. Mojola Omole
I don't actually, because I do a very, like, I do a very regimented, you know, very limited dose. And I do really encourage patients to take Tylenol, you know, around the clock, Advil around the clock, and then use the Dilaudid to supplement. And I do a lot, I spend a lot of time talking to patients about how pain works and how, you know, some of these, like this might not take away everything. And how to do other aspects of it.
Dr. Blair Bigham
I don't have time to do that in the ER. But fortunately, some of my emergency medicine colleagues have dug into this. And so we're going to be looking at a paper today, published in CMAJ, entitled, “Effective emergency department opioid prescribing on health outcomes.”
Dr. Mojola Omole
And then we will speak with Dr. Hance Clark, the Director of Pain Services and the Medical Director of a Pain Research Unit at the Toronto General Hospital.
Dr. Blair Bigham
He's going to talk to us about his best practice tips when it comes to opioid prescribing, as well as alternatives to opioids, like ketamine, lidocaine, and some novel drugs that have hit the newspapers recently.
Dr. Mojola Omole
But first, let's speak to Dr. Grant Innes,
Dr. Blair Bigham
One of my heroes in emergency medicine. Dr. Grant Innes is an emergency physician and senior author of the research article in CMAJ entitled Effective emergency department opioid prescribing on health outcomes. He's also an adjunct professor in the Department of Emergency Medicine at the University of Calgary, and a clinical professor of emergency medicine at the University of British Columbia. Grant, thank you so much for joining us today.
Dr. Grant Innes
Well, thank you for letting me come and chat with you guys about this topic.
Dr. Blair Bigham
Oh, it is our pleasure. So we should flag that your study was looking at opioid prescriptions in acute pain and not chronic pain, not palliative pain, things like that.
Dr. Grant Innes
Exactly. Somebody has an acute event or an injury, they come in, they get a prescription for an opioid. So that's probably going to be a brief prescription.
That's going to be short term, might be days or a week. So it's not going to be a repeating prescription. Yeah.
Dr. Blair Bigham
Now, we're both emergency doctors. We probably have a similar view on this, but maybe not. But tell me, what patterns or concerns were you seeing at work that made you want to study the impact of opioid prescriptions in the ER?
Dr. Grant Innes
Well, we obviously were in the middle of this increasing epidemic of opioid related deaths. And opioid prescriptions have been identified by lots of people as a possible causal factor. And I think the hypothesis is that some physician provides an opioid prescription.
This leads the patient into prescription misuse, maybe addiction, maybe party drugs. And ultimately accessing opioids on an illegal market. And then they ultimately overdose and death.
So about five years ago, there was a lot of media focus on emergency department opioid prescribing. I listened to many sad stories on the news or on podcasts about people who had an acute injury of some sort, maybe broke their arm. They got an opioid prescription.
They developed an opioid use disorder. And ultimately they overdosed and died. And so I talked to some of my public health colleagues and tried to look into what's the evidence in terms of this connection between an acute prescription and subsequent harm.
And there's actually little or no research looking at what happens to somebody after they get an opioid prescription for an acute event. So that was what led me to wanna do this study. Yeah, and of course, as these things go, it ended up taking several years.
Dr. Blair Bigham
That's so interesting because the rumor is strong, right? There is a very, I don't know what, I guess we're about to find out, but a very strong belief that I should really try my very best not to prescribe oral morphine, hydromorphone, oxycodone to people who have an acute injury for this fear that I'm somehow going to ruin their life later on down the road. So what did your study find?
Dr. Grant Innes
Well, what we found was that, you know, we looked at every patient that was treated in an Alberta emergency department over a 10-year period. And we compared the patients who got an opioid prescription to a really well-matched population who didn't. And looked at what happened to those people over a year.
We looked at several outcomes. Most important, I guess, in the context of the opioid epidemic is risk of death, which was no different for treated and untreated patients.
Dr. Blair Bigham
No different.
Dr. Grant Innes
We tried to look at what we called opioid-specific events. So these are opioid-related emergency department visits, overdoses, no difference in those events. And we tried to identify patients who developed patterns of new opioid use disorder.
So people who were treated with opioid agonist drugs, methadone, buprenorphine, and so on. And there was no difference in those outcomes either.
Dr. Blair Bigham
Wow.
Dr. Grant Innes
There was a couple of differences.
Dr. Blair Bigham
Yeah. So, I mean, your top-level results are making me think the rumour's not true. Who is at risk? What concerning findings did you have?
Dr. Grant Innes
Well, we thought that probably opioids may have some effect on people. And there was two outcomes that we found that were a little bit different. One is that the patients who got an opioid prescription in the emergency department did have more prescription opioid use over the subsequent year.
So in the treated group, 4.5% of opioid-treated patients ended up with at least 120 days of an opioid prescription during the following year versus 3.5% in the untreated group. So not a big difference, but a difference. And that's compatible with previous studies, I guess.
And the question is, was it possible that there was something about the index event that led to more opioid prescriptions down the road?
Dr. Blair Bigham
Like a worse fracture or something that would just be more painful?
Dr. Mojola Omole
Or you have to have an operation, right? To me, as the surgeon, that's the first thing that comes to my mind that, well, like if you came in for a reason, let's say you came in for gallbladder and then they sent you home with some opioids, the next day you're going to come back for your ultrasound and you have surgery, then you're going to have more pain.
Dr. Grant Innes
Yeah, so it might've had something to do with the underlying condition or it might've had something to do with the fact that they got an opioid. And the other thing that we noticed was a higher rate of all-cause hospitalization over the following year. So about 16% versus 15%, again, not a big difference, but we think it's real just based on the huge sample size and we had very good matching.
And so we think, and we thought this before the study, we had this idea that maybe opioids cause some adverse effects, but they may not always be identified by the physicians as opioid-related effects. So if you're an older person, maybe you fall and break your hip and that was actually an opioid side effect, or maybe you used some opioids, get some mood changes, you get depressed, you end up in a hospital. Maybe you get nausea, vomiting, GI upset from your opioid and end up in a hospital.
So we think that there are some effects of these opioids that are real, that are causing some adverse health effects. But interestingly, none of the opioid-specific outcomes seem to be different when you received an opioid.
Dr. Blair Bigham
So given that strong rumour sense that emergency doctors, and I don't know, Jola, does this apply to surgeons too? Are you guys sort of reluctant or trying to find non-opioid solutions to pain?
Dr. Mojola Omole
So I think in general, I think each surgeon is different. When I trained, North York General here in Toronto had just come out with the guidelines via anesthesia in terms of how to prescribe pain medications post-operatively. And it was pretty much just Tylenol, Advil, around the clock.
Advil, if you can tolerate it. And then just 20 doses of an opioid, and they recommended Dilaudid.
Dr. Blair Bigham
Interesting, okay.
Dr. Mojola Omole
And so that's literally what I give for every patient. And then we'll reassess the patient if there's, obviously, if you have complications and you need more pain medication, that we'll discuss it. But that was their prescription for patients who are going home post-surgical.
Dr. Blair Bigham
So Grant, given the limited research before your study and what you actually found, what do you think ER docs and surgeons and family docs should make of this? Should we loosen up a little bit to better control pain? Or should we still be hesitant of opioids?
Dr. Grant Innes
Well, I think it's reasonable to be cautious about opioids. Clearly, they are drugs of concern and they do have potential for harm. I think the bottom line is maybe don't throw out the baby with the bathwater.
I think it's interesting. I've been doing this for quite a while, and about 20 years ago, we were all learning from very credible pain experts that we were not treating pain adequately and that because we were not treating pain, people were suffering and then developing chronic pain. And there was a big push to prescribe more opioids.
Some of that may have been driven by industry, and I think some of it was driven by evidence. But opioid prescribing increased and then we started to see rising opioid misuse and opioid-related overdose deaths, and I think kind of got onto a bandwagon. And well, we initially got onto a bandwagon prescribing opioids, and now it seems like there's a bandwagon going the other direction.
And many doctors now seem to believe no matter what people have, broken ribs or kidney stone or fractured arms or spines, that you should never prescribe an opioid.
And so I think what our data would show is that single opioid prescriptions for acute pain, I mean, they're not risk-free, but the likelihood of harm is quite low and not likely to outweigh the benefit of treating somebody with severe pain. I think, and we came up with this number needed to harm of about 55 prescriptions to cause one of those, either you end up using more prescriptions down the road or you end up in a hospital within the next year, but no change in death or apparent opioid use disorders, overdoses.
I think that we also noticed that there's patient differences. And so some patients are probably at a little bit more risk than others.
Dr. Blair Bigham
Let's get granular on that. Are there specific groups where you would say, oh, extra caution is advisable?
Dr. Grant Innes
Yeah, we looked at sort of two main outcomes. One was how likely is one of these adverse outcomes after a prescription is handed out. And in that group, not surprisingly, the groups that had the greatest trouble were people with other substance use disorders or mental health problems.
And I think physicians intuitively understand that these people get into trouble. And so when somebody with another substance use disorder or a mental health problem comes into an emergency department, I think physicians are very reticent to treat them. The other outcome we looked at is not just how likely is an adverse outcome, but what's the increase in the risk of an adverse outcome associated with the prescription.
And interestingly, so that high risk group of substance use disorders, mental health problems, they had very little incremental risk. So if you gave them a prescription, they were at significant risk of an outcome. But if you didn't give them a prescription, they were almost at equal risk of having an adverse outcome.
So interestingly, the iatrogenic potential was very low in that group.
Dr. Blair Bigham
Interesting.
Dr. Grant Innes
And the iatrogenic potential actually seemed highest in opioid naive patients and older patients.
Dr. Blair Bigham
Tell me a little bit more about that. How does that information affect your practice?
Dr. Grant Innes
Well, I think you're always a little bit cautious prescribing opioids and you always ask the questions and tell the patient you're thinking about prescribing an opioid. And do they have any concerns about alcohol use or addiction problems in the past?
Dr. Blair Bigham
So you screen people with those questions before you prescribe?
Dr. Grant Innes
Yes. And I just explain, this is an opioid. Sometimes they can be addictive and have you had problems with addiction or alcohol use and do you have any concerns about getting an opioid?
And so pretty, it's a low bar because people just get to say, yes, I'm fine with that or no. And I'm more cautious in older people for the reasons that we talked about and now I'm a little bit more cautious in opioid naive people. And so just to clarify a bit, in our study, we had three types of patients based on their previous opioid use.
We had people with opioid use disorder or who were already on opioids. We excluded those people. So we didn't study those.
Then we had people who were opioid naive. They had not had an opioid prescription within a year of the study. And we had opioid exposed patients who had an opioid prescription but didn't fit any sort of opioid misuse criteria or chronic use criteria.
And the risk was higher in the opioid naive patients. And the only way that I can, I don't know, see that is that maybe there's a certain risk of opioids for everyone. And if you take patients who have had previous exposures to opioids and do not meet any criteria for opioid related problems, maybe they've defined themselves already as people who are okay or manage these drugs without problems.
The interesting thing is I'm maybe a little more liberal about giving people who have substance use or mental health problems an opioid prescription if they have severe pain. Part of that comes from this study and part of it comes from previous work I did when I worked in downtown Vancouver at St. Paul's Hospital, which I feel like is the Mecca for opioid use in Canada. And so saw many substance use disorders and often coming in with severe pain.
And I would always ask residents when they had a patient like this, how are we gonna treat this pain? And most of the residents would say, well, we can't give them opioids. And in fact, I thought the correct answer at the time was, no, no, they need analgesics just like anyone else.
They're unresponsive to many analgesics and less responsive to opioids. And probably we have to actually give these people more opioids if they have a legitimate painful condition that needs to be treated.
Dr. Blair Bigham
Grant, if you had maybe two messages that you thought, not only emergency doctors, but anybody who might prescribe opioids to a naive patient, an opioid naive patient, not that the patients are naive. What would those top lines be?
Dr. Grant Innes
I would say, don't throw the baby out with the bathwater if you've got patients with severe pain and who need to be treated, that the likelihood of harm is quite low with a single opioid prescription for acute pain. I'd say that we found that the risk of adverse outcomes was fairly similar in treated and untreated patients. And I guess I would say, think about the patient characteristics and how those modify the fairly low risk that's associated with the prescription.
Dr. Blair Bigham
Awesome. Well, thank you so much for joining us today, Grant.
Dr. Grant Innes
Oh, it was great.
Dr. Blair Bigham
Dr. Grant Innes is an emergency physician legend and co-author of the article in CMAJ.
Dr. Mojola Omole
He's a legend.
Dr. Blair Bigham
He is a legend. Absolutely.
Dr. Grant Innes
Yeah, a legend in my own mind.
Dr. Blair Bigham
He joins us from the Okanagan Valley in British Columbia.
Dr. Mojola Omole
Now let's explore how physicians can safely prescribe opioids when they are needed and what alternatives could possibly exist. Dr. Hance Clarke is a staff anesthesiologist and the director of the pain services at the Toronto General Hospital. He's an associate professor in the Department of Anesthesia and Pain Medicine at the University of Toronto. And he's also the president of the Canadian Pain Society. Thank you so much for joining us today.
Dr. Hance Clarke
Thanks for the invitation, Jola.
Dr. Mojola Omole
So some physicians now believe opioids should never be prescribed, even for like severe acute pain, like broken ribs or someone having kidney stones. What do you think of this reluctance to prescribe opioids?
Dr. Hance Clarke
I think we're in the space of opioid phobia. We've been here for quite some time. And so when you look at the number of patients that are prescribed opioids in the acute pain setting in particular, the number is pretty small.
It's still significant when you talk about the hundreds of millions of people that get prescribed opioids in that setting. The key here is to ensure you have a system in place to track those folks that might be getting into trouble. And so if I were to break my femur or have some major trauma, you better believe I'd be expecting to get an opioid when I get to an emergency department.
Not hearing that I shouldn't receive this for this small percentage of developing something like an opioid use disorder in the future.
Dr. Blair Bigham
So I think I'm guilty of opioid phobia. I'm an emergency doctor. I'm cautious.
I wouldn't say I never prescribe opioids, but it makes me nervous to send somebody home on an opioid. How can ER docs prescribe opioids safely, given this deeply rooted fear of overprescribing?
Dr. Hance Clarke
And Blair, those differences or that issue was created, and you clearly have been reading all media and the data associated with the potential to develop an opioid use disorder. And it's clear that in the chronic, non-cancer pain setting, that was a terrible place to be prescribing opioids. And so as an emergency physician, I think the messages that Grant gave are excellent.
You need to also know your high-risk patients. And in any setting, you're going to have those. And so an opioid naive and young males in particular, those are high-risk individuals you're prescribing to.
As he said, the elderly for risk of falls, things of that nature, and the condition you're prescribing for. So, you know, if you have a low back pain condition, really and truly, that would be a rare scenario that you'd be hopefully handing out an opioid for a patient that's totally naive when there are so many other alternatives, right?
Dr. Mojola Omole
So are there cases where opioids are never the right choice in the ER?
Dr. Hance Clarke
There's never an answer that's never and never an answer that's always Jola. So it's always case dependent, I would say. There are very rare instances where you might want to give an opioid.
And I think that low back pain, acute injury is certainly one of them as your initial go-to medication. But let's say someone's tried a few things and they're really struggling. Again, there's no harm in that acute scenario of giving them something that can get them back to work the next day or keep them functioning.
Again, the ultimate scenario is who's following that patient and are they filling another script? Do they now need another third and fourth script? Now you're running into issues where you're moving outside of that acute pain scenario.
Dr. Mojola Omole
So can long-term opioid prescription be managed safely?
Dr. Hance Clarke
There are lots of patients out there living on their opioids and what we call them are grandfathered patients, which are on doses that are quite significant. And if you ask me, the truest Canadian at risk right now for an overdose in our current healthcare system, where it's hard to find a family doc, is somebody on those high-dose opioids that has their family physician retire. Where do they go?
They can't get into a pain clinic for months. And you know, that true IV drug user that Grant talked about in St. Paul's in Vancouver, they have a RAAM clinic. They have all types of drop-in centers that they can be prescribed their safe supply and various other medications.
But that individual who's had this physician retire can't find someone to prescribe that opioid and they're the ones who really run into trouble and end up sometimes in that illicit world. And you see it happening quite a bit in the U.S. I was just on a meeting last night with the National Pain Advisory Council in, out of Washington and they were talking about this significant issue and building on their telemedicine pathways to prescribe opioids to help some of these folks. And in Canada, we're lucky that continued well past COVID so we can still do a lot of telemedicine here and prescribe opioids, etc.
Dr. Mojola Omole
Is that part of like your transitional pain program? Can you just describe that a little bit to us?
Dr. Hance Clarke
Yeah, so it was kind of based out of the similar data that Grant was talking about. So we had one group in the city say that if you had any operation, any minor operation, I gave you an opioid or I gave you an NSAID for that matter, you had a 10% risk of being on a persistent opioid a year after surgery. And to us, that sounded not quite right.
So we said, let's look at the same Ontario database and let's look at all major surgical interventions because if you have a major surgical intervention, we're giving you an IVPCA. That means you're exposed to an opioid and based on this data, it should be a massive number of people still persisting on their opioids a year later. And of course, the data showed that at six months, it was 3.1% and at a year, it was about 1.8%. And so when you look at that, then people say, well, so you're making, Global News, I remember, picked up the phone and said, Dr. Clark, you're making 3.1% of all people opioid addicts at six months. I said, well, hold on a second. There's a thing called pain and there are people who have neuropathic. Why do people believe, I know you're a surgeon, Jola, but why do people believe that you can cut them open, close them back up and they will never have a disability as a consequence of that intervention?
Dr. Mojola Omole
Well, my patients don't bleed, but that's a point.
Dr. Hance Clarke
And so the fact is, for 85% of people, that may well be the case. But if you're that unlucky 15%, you could end up in that scenario and there were no services. We knew all about these risk factors.
So some of the risk factors that Grant talked about, that, you know, if you're a young woman, if you have mental health issues, if you have, if you're actually, if it's a young woman with cancer in particular, or if you're a young man, if you have a significant trauma in your past, any type of physical violence, sexual violence, all of these things lead you at high, to become higher risk for developing a persistent opioid problem. And so we built the services around understanding these risk factors and figuring out how, one, we can help these people have less pain long term, reduce their opioids, but overall have a better trajectory and less disability as a consequence of their pain long term.
Dr. Mojola Omole
So, for example, let's say you have that typical patient that you just described, but they come in through the emerg and they broke their femur, they broke something, and you need to give them an opioid. Is there a way to build that kind of transition? Like if you recognize that this is a high risk patient, but they still need pain management, is there a way to build that into the emergency system, emergency medicine?
Dr. Hance Clarke
Jola, I could have set that question up myself, but I can tell you that absolutely. And there are some of the new, young emerg residents coming out of our pain program here in Toronto that are looking to do these types of things and get some traction. Because if you think about, you are the initial prescriber of an opioid naive person, and you build that into your emerg where, you know, just someone just flags, do they fill a second script or a third script?
You've identified right away that this is a person that might be heading down that pathway. And we know it's not a big number. And so it should be easy to build in some of these types of services to identify the folks that are high risk.
And you'll already know having a priori type of understanding of who might be these folks and track them a little closer.
Dr. Blair Bigham
If we loop back to acute pain just for a second, what does the future look like for acute pain, either post-operatively, in the emergency room, in a family clinic? You know, there's a lot of talk about ketamine. There's talk about some of these novel analgesics that are non-opioid.
A lot of people talk about using nerve blocks for migraine or back pain. What do you think is sort of underutilized right now or up and coming?
Dr. Hance Clarke
Okay, so we'll start with the underutilized. There's no doubt that in the emerg physician domain, you could certainly employ for a true acute pain scenario shoulder et cetera, maybe nerve block or something with some corticosteroid if people aren't brittle diabetics, et cetera, I think that would be pretty cool.
Ketamine's the drug du jour. So ketamine, we use it quite a lot, to be honest with you, as an adjunct post-operatively now in our institution. And so we'll run our patients on lotuses of ketamine.
Dr. Blair Bigham
Just to dwell on ketamine for one second. It's hard to operationalize a pain dose of ketamine in an institution that's using it usually for sedations. For example, like in the ER, people say, oh, you have to move them to recess.
You have to put them on a monitored setting. You have to bring RT down. And I'm like, I'm not sedating them.
I just want to give them like 0.15 per kilo over half an hour or something. And that is almost impossible to do in a clinic setting side of the emergency department in a lot of places. It drives people crazy.
They say, no, no, no, we can't possibly do this. What do you guys do at Toronto General in a clinic? Do they have to be in a monitored setting?
Dr. Hance Clarke
Yeah, I mean, really, it comes down to institutional hurdles, right? And so there are hospitals all across the country that run a lot of ketamine and the hurdles aren't as big. When we first brought this to Toronto General, we had similar type issues.
And just to give everybody a kind of scope in terms of what a pain dose of ketamine is, it's probably around 30 milligrams. Whether you give that as a one-shot dose, or as you say, you run it as a 0.05 mics per kilo over an extended period of time, that's going to get you your kind of pain sparing effects. So it's not a big dose.
If you're talking about sedation doses, you're talking about 100 plus milligrams, et cetera, that lands you in those places. And so we have great now infusion protocols, et cetera, that we can run in the PACU, in, on the wards, et cetera, that doses that are much lower than any type of sedation doses or anesthetic doses for that matter. You jumped on to, you know, what's next?
And I can tell you what's next. You know, this is the first time in two and a half decades that pain drugs are coming back to the market. And so, and why is that?
Oxycodone and Oxycontin were king. And as soon as Purdue came out with that molecule, the pain pipeline shut down completely. And we know why and we know how.
And we know now that we're bouncing back from that. And so I think you guys might've been watching the news in January with that new Vertex drug. So one of the sodium, the NAV1.8 channelopathy kind of medications, Journavx, or I think it's suzetrigine or something like that. And this is a molecule that has huge promise. There are other molecules now in the pipeline.
I think it's Merck potentially who has a NAV1.7 that's even more selective in the periphery versus the central effects. And now you've got a huge amount of interest now in non-opioid-based pharmacology and non-opioid-based medications.
Dr. Blair Bigham
Give us a quick one-minute primer on these new meds, because they've been all over the media and they're quite fresh. What are they?
Dr. Hance Clarke
Yeah, so I have gotten an email about the new Virtex drug at least daily since January 30th when it was announced, as to where can I get it, when it's coming to Canada, etc. So let's be clear, they haven't even brought it to Health Canada as of yet. And I think they will.
And the issue is it's about $15 US a pill at the moment. So think about that landing here. There you go.
And then you have to negotiate with every province. So Canada's never the first place anybody wants to bring a drug because of how hard it is to get to formulary. Now, about the drug itself, so I've sat on a couple of advisory councils for these drugs, and they look really good.
When the NAV1.8 drugs came out 20 years ago, they were terrible. Because what is it doing? It's shutting down all your sodium channels.
They were having cardiac effects. They were having all kinds of effects that were undesired. They've now tweaked the molecule, and some of these new NAV1.7 drugs are specifically said to target, and the early clinical trial data looks pretty promising, the peripheral nerve signal without any central effect. And so if that's truly the case, you have the next blockbuster neuropathic pain med. Think about your diabetic neuropathy patients. Think about all of these post-surgical neuropathies that people have sometimes.
These would be the classic drugs that could take care of some of these things. Sciatic pain, right? You slip your disc, and people are running for their laminectomies, et cetera.
Theoretically, some of these drugs should be quite helpful.
Dr. Blair Bigham
While we're talking about sodium channel blockers, IV lidocaine, similar to IV ketamine, sort of en vogue in the emergency department right now. Do you use a lot of IV lidocaine? And if so, when do you turn for it?
Dr. Hance Clarke
Yeah, we certainly do. And any adjunct in those kind of persistent opioid patients, chronic pain patients, people coming in with significant neuropathic pain, lidocaine, again, what is lidocaine? It's a sodium channel blocker, right?
So it's going to blunt your nervous system. And I don't know if you've seen many of these lidocaine infusions that sometimes we wake up after surgery, and they'll be lying there, and they'll be very kind of comatose-y, just sitting there, and you'll go up to them and say, how much pain do you have? Oh, it's 10 out of 10, or it's 9 out of 10.
But they're so globally slowed that you're not getting much from them because you've dampened down the entire nervous system. So I think it has a role. It certainly can keep your patients calmer, and it has shown to have some good pain-sparing effects.
Just keep an eye on the kind of central slowing that you're doing of the nervous system.
Dr. Mojola Omole
So what are your key takeaways for physicians who do prescribe opioids?
Dr. Hance Clarke
Yeah, and what's becoming a real problem, clearly, is the lack of willingness of primary care to enter into the pain discussion and prescribe opioids and prescribe pain meds, even in that acute setting. And you would think that the family physician in particular would be well-primed because they would give the initial script and see if it becomes an issue and have those discussions. I always say, you know, if you're a pilot, if you know you have the discussion about taking off the plane, you better know how to land it.
And so those discussions need to happen at that first prescription. And Grant said, you know, I'll ask my patients sometimes, have you had a substance use issue in the past? Do you have any, you know, anxiety, depression, traumas, things like that?
These are important questions. And so ensure you ask some of those leading questions, talk about what the limits are in terms of, this is a script, this is a trial, we're going to see how this goes, don't expect that this will continue. And in any part of medicine, setting the expectation is going to be key with your patients.
But when you hand somebody a prescription without having those discussions, you're going to run into trouble sometimes.
Dr. Mojola Omole
For sure. Thank you so much for joining us. This has been really great.
This was super helpful. Yeah. Thank you.
Dr. Hance Clarke
It's been a pleasure, guys. Anytime.
Dr. Mojola Omole
Dr. Hance Clarke is a staff anesthesiologist and director of pain services at the University of Toronto's Department of Anesthesia and Pain Management. He is also the president of the Canadian Pain Society.
Dr. Blair Bigham
Well, Jola, that was a lesson in pain management.
Dr. Mojola Omole
It was really great. I mean, I, for me personally, like, I don't think I'm nervous about prescribing opioids for my patients because they've had, most of them have had an acute injury caused by me, by removing an organ. My scalpel.
And so, but I think it's really important because of just even recognizing even in that spectrum of patients who could maybe one day develop a dependency and knowing how to risk stratify patients when you meet them, I do think is really an important skill that we all need to possess.
Dr. Blair Bigham
And I think Grant's data is so necessary to help break some of these myths, right? This, like, opioid phobia, as Hance called it. That data really does tell us you don't need to be terrified of prescribing an opioid.
Be smart about it, obviously. There are patients who probably shouldn't have one most of the time. But this whole idea of abandoning opioids maybe is overkill.
Dr. Mojola Omole
I mean, it's very reactionary, which is understandable when we have an opioid crisis. However, a lot of people are going to end up suffering from chronic pain and then becoming disabled because their acute pain was not treated.
Dr. Blair Bigham
I think it's also such a fascinating case study in how oxycodone not only changed the world in terms of how physicians manage pain or over-manage pain and how people can become addicted to certain drugs or dependent on certain drugs. But also, I found it so interesting when Hance said, well, there was no research for 20 years because oxycodone was the answer. No one was going to try to beat oxycodone in the marketplace.
Dr. Mojola Omole
Well, because they told us, I remembered the lectures. They were like, it's non-addictive. You can't get addicted.
Everyone take it.
Dr. Blair Bigham
But let's wrap it up and do a quick summary. We've got all of our non-analgesics, Tylenol, NSAIDs, etc. We've also got good old movement, physiotherapy, temperature therapy.
We've got a good old psychological outlook. And then, of course, there is a role for opioids as well. And novel medications, be them ketamine or lidocaine or some sort of an infusion or maybe these new oral sodium channel blockers.
Very exciting time to be a pain medicine doctor.
Dr. Mojola Omole
For sure. And I would hope, though, that with the new sodium channel blockers, there's also maybe not the zest that we had for opioids of like, just take them. You'll be fine.
And that there's a balanced perspective in terms of the complexity that pain management is.
Dr. Blair Bigham
That's it for this week on the CMAJ Podcast. The CMAJ Podcast is produced by PodCraft Productions. I'm Blair Bigham.
Dr. Mojola Omole
And I'm Mojola Omole. Until next time, be well.