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.”