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