Dialogue Volume 12 Issue 3 2016 | Page 10

Dr. Paul Dungey • Screen for current and past alcohol, drugs (prescription and non-prescription) and illicit drug use. Consider using screening tools from The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. • Obtain informed consent for prescriptions from patients by complying with the consent requirements including explaining potential benefits, adverse effects, complications and risks. • Consider the evidence related to the effectiveness for the particular diagnosis. For example, opioids are usually not indicated for migraine or tension headaches, or for patients with functional gastro-intestinal problems such as irritable bowel syndrome. • Have a treatment agreement in place before prescribing an opioid. This ensures patients know what is expected of them when they receive a prescription and the circumstances in which prescribing will stop. Don’t just focus on pain scores One root of the problem? Doctors got lulled into thinking they are undertreating chronic pain, says Dr. Greg Murphy, Medical Director, Kingston Orthopedic and Pain Institute. “But there’s no other medication that we’d use as a sole agent for a sole condition, and never measure outcomes. That doesn’t exist. We lost sight of that. In being caught up in trying to help, we were handed a solution that didn’t quite fit,” says Dr. Murphy. Recently, he and Dr. Dungey gave presentations at the College on opioid prescribing and treating chronic non-cancer pain. How can Ontario doctors respond appropriately? Start with following guidelines and by adhering to the College’s Prescribing Drugs policy. For example: 1 10 • Start low and go slow. “Don’t use a cannon when you can use a BB gun,” says Dr. Murphy. “I wouldn’t start someone on a fentanyl patch when I can try them out on Tylenol.” All steps are critical, but Dr. Murphy says the paradigm shift is measuring function. “I’m a pain doctor, and the reality is that I don’t care about pain scores. It doesn’t capture what we’re trying to achieve. Function is king. Function is more important than pain,” he said. 1 The kick, he said, is that opioids work on the endorphin axis “and patients feel better because the endorphin makes them feel better,” he said. He suggests that doctors think about the monitoring they apply to other medications they prescribe. “What if a new blood pressure pill came out and I doubled and doubled and doubled it? … And what if I never measured your blood pressure? That’s a recipe for disaster,” he said. He uses a scale to look not at pain itself but at the impact of pain. Patients answer a series of questions to rank how pain interferes with their mood, activi- Pain scores may have may greater value in settings where function is not otherwise easily assessable e.g. LTC settings.” Dialogue Issue 3, 2016 photoS: JONATHAN SUGARMAN Dungey, an emergency physician by training. “We have to change our practices through guidelines and monitoring.”