Physicians need to be reassured that their College is behind
them as they manage challenging patients who are facing
difficult problems that require opioid therapy
Can you describe what you are hearing from
physicians in the community?
The prescribing of opioids is an area of practice that gener-
ates a lot of anxiety among physicians. The College is not
anti-opioid, nor does it want to remove physicians who
prescribe opioids from practice. That is not in anyone’s
interest; physicians lose a valuable tool in treatment and
patients lose access to care.
The profession has set the expectations and offered guid-
ance in this area of practice. And physicians need to be
reassured that their College is behind them as they manage
challenging patients who are facing difficult problems that
require opioid therapy.
How can the College be seen to be more
The CPSO’s new opioid strategy clearly points out
that our focus is supportive and educational. We know
that the vast majority of problematic opioid prescrib-
ing issues identified are more than amenable to some
education. With the plethora of educational resources
available, it is easy for physicians to access the help they
need to develop strong and effective prescribing skills.
Physicians need to be mindful of the information in the
Canadian opioid guidelines, but they should be entirely
confident that they will be supported by the College if they
make, document and justify decisions that are collaborative
and have the patient’s best interests at heart.
What kind of effect has the Canadian opioid
Generally, I think the guidelines have had a positive effect
in that they have generated discussion around therapeu-
tic options for managing chronic pain and have led to a
reduced reliance on high dose opioid therapy.
The main thrust of the opioid guidelines is to make it
clear that opioids should not be the automatic default for
DIALOGUE ISSUE 2, 2019
patients with chronic pain. And if opioids are, in fact, in-
dicated, they should rarely be prescribed in high doses for
new chronic pain presentations. Another important goal is
to avoid prescribing high quantities of opioids for lengthy
periods when managing acute pain problems to avoid
making them chronic.
But what about those patients who have been on
high dose opioids for a long time?
Legacy patients represent a separate issue. They are a
diverse group. Some people have been doing very well
on high doses of opioids for long periods of time and
some people are not doing as well and are actually at
risk of harm. With no single or simple approach to
identifying and managing these two different groups
of legacy patients, there was an assumption that all pa-
tients on high doses of opioids for long periods of times
should be tapered, which was, not surprisingly, a source
of much anxiety to both prescribers and patients. The
College recognizes that there is not a single formula that
works for everybody and has never advocated for having
all patients taken off of chronic opioid therapy. Even the
Canadian opioid guidelines acknowledge that tapering
will not always be possible.
The guidelines are intended to simply inform the
standard of practice, not dictate the standard of practice.
They clearly state that there is a place for opioid treat-
ment of chronic pain. Yes, physicians do need to be fa-
miliar with the guidelines but simply as a tool to support
good decision-making. There will be times where it is
necessary to deviate from them in the best interests of pa-
tient care and clearly documenting your decision-making
in such circumstances is an important part of good care.
In fact, mutual decision-making between prescribers and
their patients and good documentation is key to manag-
ing legacy patients on high dose opioid therapy.