PRACTICE PARTNER
Dr. David Juurlink
In looking at any
course of action, doc-
tors routinely put the
potential benefits and
harms on a scale. In the case
of opioids, should the rewards
outweigh the risk any more than
usual? “It’s reasonable to make the assertion
that they should have a higher threshold,”
says Dr. Juurlink.
Why? The potential harms are so much
higher, and the benefits tend to attenuate
over time. That’s a key message to weave into
the conversation, and it’s also a call to probe.
Does the patient have a history of addic-
tion of any type? Are there other risk factors,
like untreated mental illness or childhood
trauma? These are sensitive topics, risks de-
pend on multiple factors, and patients may
not always be truthful. But it’s incumbent to
ask, says Dr. Juurlink, and to think carefully
if an opioid prescription is worth the risk.
If the patient is in serious pain, and if it is
affecting quality of life, and if there are no
red flags, a trial of opioids may well be war-
ranted. The conversation should cover a plan
to keep the dose low and an exit plan, says
Dr. Juurlink. It’s vital to ensure that both the
doctor and patient are on the same page.
Measure of respect
“Doctors have lost a measure of respect for
opioids. In the right patient, it can make a
major improvement. In the wrong patient, it
can ruin their life,” he said.
Dr. Juurlink was a pharmacist by train-
ing before he obtained his medical degree.
In addition to his clinical, teaching, and
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DIALOGUE ISSUE 3, 2017
administrative activities,
Dr. Juurlink maintains
an active research pro-
gram in the field of drug
safety. He says it’s important
for doctors and patients to
always return to the goal of pre-
scribing.
“It isn’t simply pain relief; it’s affording the
patient more benefit than harm,” he says.
“People want to be free of pain, and reliev-
ing suffering is what we do. But we put a lot
more faith in pain medications than they
deserve.”
Today’s opioid crisis doesn’t just revolve
around over-prescribing, dosages, misuse
and abuse. The issue also relates to the na-
ture of conversations with patients, whether
on starting opioids or tapering off.
These conversations can be difficult yet
productive. Start by recognizing that pre-
scribing opioids is a “solemn exercise”, says
Dr. Juurlink.
People can become dependent quickly. He
mentions one individual who experienced
opioid withdrawal after being on Percocet
for just three days. This patient knew the
signs; after all, he himself was a doctor.
Dr. Juurlink isn’t opposed to opioids. They
can be an effective tool, but discussing them
requires context and inquiry.
To begin, the conversation isn’t just about
relief. It’s about improved function and
quality of life. There may be other solutions.
When patients are in pain, however, it might
not be what they want to hear.
Talking about all the non-pharmaceutical
options (physio, massage therapy, etc.) is im-