Dialogue Volume 15, Issue 2 2019 - Page 10

SECTION TK FEATURE 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 supportive? 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 guidelines had? 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 10 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.