Whenever possible, physicians need to make decisions with respect to tapering or discontinuation of opioids in collaboration with the patient, states the College’s updated Prescribing Drugs policy.
The policy, which was just approved by Council, reminds physicians that it is not always possible or appropriate to taper below a specific dose, nor is it usually appropriate to suddenly or rapidly taper prescriptions.
Safely reducing long-term opioid medication, where clinically indicated, requires a thoughtful plan of care between physicians and patients, said Dr. Steven Bodley, a member of the policy working group. “You need to have the conversations around opioid risks and benefits, and review the options available including tapering or switching to opioid replacement treatments. 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,” he said.
References to the dosing numbers put forward in opioid guidelines have been removed from the updated policy. “We wanted to take the focus away from a particular number and make it clear that a physician’s clinical judgment is the final arbiter,” said Dr. Bodley, who is an anesthesiologist with a focus on chronic pain management.
Dr. Bodley said that many patients are receptive to tapering after they are engaged in discussions focusing on the efficacy, side effects and risks of high dose opioid therapy.
There are, however, a group of patients that have done very well on high dose opioids, he said. “They have been on stable doses with improved function and few side effects. They are quite comfortable with their present treatment, and forced tapers could result in significant reductions in function and a lot of stress and unhappiness,” said Dr. Bodley.
Switching to suboxone, an opioid with a much wider safety margin and often fewer side effects is one option that can be explored, said Dr. Bodley. 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.
The policy states that when tapering or discontinuing narcotics and controlled substances, physicians must:
- Proceed with consideration for the safety and well-being of the patient;
- Consider and apply, as appropriate, relevant practice standards, quality standards, and clinical practice guidelines;
- Explain to the patient the rationale for tapering or discontinuation, and provide an opportunity for discussion;
- Discuss a strategy to treat withdrawal symptoms, where applicable;
- Whenever possible, make decisions with respect to tapering or discontinuation in collaboration with the patient; and
- Carefully document decision-making and any discussions with the patient.
5 Important things to know about the Prescribing Drugs policy:
- Sets out expectations for all physicians when prescribing drugs.
- Requires physicians to include their CPSO number on prescriptions.
- Includes specific expectations for prescribing narcotics and controlled substances.
- Emphasizes collaborating with the patient on a treatment plan whenever possible.
- Is accompanied by a companion Advice to the Profession document which clarifies how the policy applies in a number of specific practice areas.