PRACTICE PARTNER
Opioids can be an effective tool , but discussing them requires context and inquiry .
portant . So is what he calls being tactful but blunt . Tell the patient that your job as a doctor is to help them manage their pain , and also explain how opioids can cause harm and that harm can be a side effect . Or sometimes the harm can masquerade as benefit , i . e ., the perception that the drugs are helping when they ’ re just hampering withdrawal – “ Where the main reason to be on a drug is because you ’ ve been on it ,” Dr . Juurlink says .
Acknowledge the fear of tapering With patients who are already on high-dose opioids ( whether existing patients or those you ’ ve inherited ), the tapering conversation has its own challenges . Patients have understandable fears . The fear of change , fear of withdrawal , fear of pain , or fear that lower doses or non-opioid alternatives won ’ t work . “ There ’ s often a preference to keep things the way they are . Or you hear ‘ I ’ m a legitimate pain patient , not an addict . This allows me to get out of bed in the morning .’ You need to go slowly ,” says Dr . Juurlink . Going slow applies to both the discussion and the strategy . First , take the time : these patients need 45 minutes , not 5 minutes . Doctors should also reassure them that coming off opioids won ’ t happen overnight . Writing a prescription too quickly can be a mistake . So can weaning patients too quickly . The right messages can support success .
Admit that harm might be difficult for both the doctor and the patient to evaluate . Talk about the possible effects related to prolonged and high opioid use . The perception of what ’ s normal – around pain , physical and mental function and other possible impacts – can become skewed over time . Patients may not fully recognize the problems or their sources .
Don ’ t judge the patient with comments about their actions , e . g ., going through pills too quickly . Instead , concentrate on the potential harms .
Clarify the rationale behind recommending a taper , i . e ., the clinical evidence and the changes in clinical thinking .
Acknowledge the patient ’ s fears , but explain how life should improve with the right taper .
Reinforce that the taper will be individualized and gradual , maybe even a year or more , to give the body time to adjust . If needed , the taper can be paused .
Explain that ultimately this is about getting to a place where the risk-reward balance tilts strongly in favour of the benefits .
“ The buy-in is very important ,” Dr . Juurlink says . “ These are people who may not be addicted but whose lives revolve around pain meds . People who taper slowly , especially from high doses , may have challenges initially but do end up feeling better . They will no longer feel that they are imprisoned .” MD
ISSUE 3 , 2017 DIALOGUE 39