FEATURE
Dr. Steven Bodley
Can you elaborate on the importance of collabo-
rating with patients on treatment decisions?
Safely reducing long-term opioid medication, where
clinically indicated, requires a thoughtful plan of
care between both physicians and patients. You need
to have the conversations around opioid risks and
benefits, and review the options available including
tapering or switching to opioid replacement treat-
ments like suboxone. At the same time, it is important
to be vigilant for signs of aberrant or high risk use,
which means having a different conversation with your
patient.
What if a patient is resistant to conversations
about tapering?
First of all, I would say that the majority of these
patients are not resistant to tapering. In fact, we
heard very early on from primary care physicians just
how receptive to tapering many of their patients were
after discussions focusing on the efficacy, side effects
and risks of high dose opioid therapy. Many patients
tapered fairly easily.
There are, however, a group of patients that have
done very well on high dose opioids. They have been
on stable doses with improved function and few side
effects. They are quite comfortable with their pres-
ent treatment, and forced tapers result in significant
reductions in function and a lot of stress and unhap-
piness.
Switching to suboxone, an opioid with a much
wider safety margin and often fewer side effects, is
one option that can be explored. But as with tapers,
it is critical to have the patient’s support and trust
before moving forward, unless of course there are
complicating factors such as clear evidence of diver-
sion or misuse.
Can you discuss some of the proposed changes
in the College’s draft Prescribing Drugs policy?
The draft policy, which is now out for consultation, reflects
a number of concerns we have heard from patients who feel
they have been arbitrarily tapered or discharged from prac-
tices because of their use of opioids. The draft policy makes
very clear that it is never acceptable for physicians to taper
patients inappropriately or arbitrarily.
And while the policy will clearly leave the prescribing
decisions in the hands of the physicians, it emphasizes
the need for discussion, and collaboration with patients
whenever possible.
We have also removed references to the dosing numbers
put forward in the guidelines as they represent suggestions
and not specific targets. We want to take the focus away
from a particular number and make it clear that a physi-
cian’s clinical judgment is the final arbiter.
In your years as a pain physician, what kind of
realizations have you gleaned about the nature
of chronic pain?
Managing patients suffering from chronic pain is among
the most challenging problems we face. They almost
always bring significant comorbidities that need to be
addressed. The focus must be on alleviating the suffering
that accompanies the pain as by definition there is no
‘cure’ for the pain. Helping patients accept and in a sense
take ownership of their own problem is a huge challenge,
especially given the lack of supportive resources available.
On a more optimistic note, the federal government
recently established the Canadian Pain Task Force
which will provide advice to Health Canada regard-
ing evidence and best practices for the prevention and
management of chronic pain and I am very pleased to
report that the College has been very involved with
this process.
MD
ISSUE 2, 2019 DIALOGUE
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