Dialogue Volume 15, Issue 2 2019 | Page 11

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 11