Addressing the challenges of legacy patients, the effect of the Canadian guidelines and the importance of patient collaboration
If you’ve attended a College presentation on opioids prescribing within the last couple of years, it is likely that you have met Dr. Steven Bodley, past president of the CPSO. With his many years of experience in chronic pain management and his knowledge of College policy, he has been the go-to person to explain the College’s approach on prescribing and answer any and all questions on the subject. Recently, we spoke to the North Bay anesthesiologist about what he is hearing in the field, the effect of the Canadian opioid guidelines, the issues arising from legacy patients and the proposed changes to our Prescribing Drugs policy.
Can you describe what you are hearing from physicians in the community?
The prescribing of opioids is an area of practice that generates 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 guidance 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 prescribing 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 therapeutic 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 patients with chronic pain. And if opioids are, in fact, indicated, 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 patients 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 treatment of chronic pain. Yes, physicians do need to be familiar 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 patient 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 managing legacy patients on high dose opioid therapy.
Can you elaborate on the importance of collaborating 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 treatments 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 present treatment, and forced tapers result in significant reductions in function and a lot of stress and unhappiness.
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 diversion 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 practices 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 physician’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 regarding 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.