Some MDs are invoking the College in order to
justify cutting patients off or rapidly tapering
their doses. The College is against such action.
So why do you think this is happening?
The College Boogey Man, just like a child’s Boogey
Man arises out of fear of the unknown. For the physi-
cian, it is based on a mistaken belief that the College
is monitoring their activity and if they do not get
their patient’s dose of opioid below at least the recom-
mended 90 mg they will be in violation of a rule. It
takes a lot of blood, sweat and tears to get a licence
and no physician will give it up easily. If a physician
believes that they will lose their licence unless they
lower the dose of opioids they have been prescribing,
they will do that. The primary error in the thinking
of the primary care physician is that their belief is a
distortion of the truth and rather than check out their
concerns with the College or a body like the DeGroote
Centre for Pain Management, they make a unilateral,
mistaken decision. This is happening so often because
there are a lot of patients in this situation.
Some patients may achieve a benefit at doses
higher than 50 mg or even 90 mg. What do you
tell doctors who may have several such patients
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DIALOGUE ISSUE 1, 2018
Most of the recent opioid investigations resulted
in an outcome that will keep the physician in
practice. Will that surprise doctors?
I am not surprised at all. Simply because a physician
is prescribing ‘too much’ opioid does not mean they
are a poor physician. Nor does it mean that they do
not have their patient’s best interest at heart. Typically
it means that the physician is poorly informed about
how to handle these medications and they believe they
are doing the right thing. Additional education is the
right maneuver in most of these cases. It is not surpris-
ing that many physicians have a poor understanding
of managing opioids. When I was in medical school it
was never discussed. In fact, pain was never discussed.
Things might have improved since then, but clearly
not enough.
MD
Dr. Jeff Ennis
and are worried they may face College sanction?
The answer is simple and it is the answer I give my
colleagues when I am doing an assessment for the
College. Document, document, document. Simply
write down exactly what you do and why. Show that
you are applying clinical judgment to the situation.
That is all there is to it. Talk to your patient about
the issue and make them aware of the changes in the
guidelines. Tell them that these changes arose because
there is evidence of an increased risk of death on doses
of opioid above 90 mg and there is less evidence that
higher doses lead to improvement in function. Give
the patient an opportunity to decide with you whether
or not they are prepared to lower their dose. If they
are not, record that. You can always revisit the issue
with the patient later. If they are prepared to reduce
the dose, ‘go low and go slow’. Monitor function. If a
patient says they have had enough tapering, then stop.
Even if they lower their dose by the equivalent of 10
mg of morphine that is quite an accomplishment.