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Are some patients’ opioids being cut back too much, too fast?

Opioid pills
Written by Paul Taylor

Question: I suffer from a rare and very painful genetic disorder. For a decade, my family physician has prescribed opioid drugs to me to ease the pain.  But he recently retired and I had to find another doctor. Now my new doctor refuses to prescribe me the same dose of opioids to keep my pain in check. He says if I’m not satisfied with the care he’s providing, I should find another doctor. I live in a rural Ontario community and that’s not easy. My pain is intolerable. What am I supposed to do?

Answer: You appear to be among the growing number of patients who’ve had their prescriptions inappropriately cut back in what some experts are calling an overreaction to the opioid epidemic.

Simply put, all the public attention on the misuse of opioids has made many family doctors reluctant to prescribe them even when they might benefit patients.

Opioids — including morphine, hydrocodone, oxycodone and fentanyl — are extremely effective for treating acute pain following surgery or a serious injury.

However, it’s also true that they can be problematic when taken for prolonged periods because many patients develop tolerance to opioids.

That means they need higher and higher doses to get pain relief.  The higher doses, in turn, increase the risk of side effects and harm.

To make matters worse, it’s very common for patients to become physically dependent on opioids. If the drug is stopped abruptly, or the dose is reduced by even a little bit, patients can suffer extremely unpleasant withdrawal symptoms — including increased pain.

Yet for many years, doctors liberally prescribed opioids, partly because they believed the unsubstantiated marketing hype of drug companies that claimed opioids are a safe and effective therapy for chronic pain.

The rising Canadian death toll from overdoses — which hit an estimated 4,000 in 2017, from both prescribed and illicitly manufactured drugs — has shown that opioids pose far more risks than once thought.

Efforts are now underway to curb the use of these medications.  Last year, a team of clinicians, researchers, and patients produced new prescribing guidelines for Canadian doctors.

“Opioids should not be considered a first-line therapy for chronic non-cancer pain,” says Jason Busse, the lead author of the guidelines and an associate professor in the Department of Anesthesia at McMaster University in Hamilton.

Instead, he says, physicians should initially try non-opioid medications and other treatments such as cognitive behavioral therapy and mindfulness training.

If the pain is still a problem, then selected patients may consider a trial of opioids with the dose not usually exceeding the equivalent of 90 milligrams of morphine a day, and preferably kept below 50 mg. Previous guidelines, published in 2010, put the cap at 200 mg per day.

This approach should help minimize potential problems for those with newly diagnosed chronic-pain conditions, says Prof. Busse.

But what should be done with the patients who are already taking these drugs? “We now have somewhere between half a million and a million Canadians on long-term opioid therapy for chronic non-cancer pain – many of them at quite high doses,” he says.

According to the new guidelines, doctors should ask opioid users to consider incrementally tapering the amount they are taking to the lowest effective dose and possibly even discontinue the medication.

Prof. Busse stresses that weaning patients from opioids is challenging.

“Some will experience persistent pain or important functional reductions for longer than a month after a small reduction in their dose,” he explains. “For such patients, it is quite reasonable that tapering be paused or abandoned.”

He warns that opioid tapering should be a voluntary process and that forcing patients to reduce their dose “may cause more problems than we are trying to solve.”

And, in fact, that appears to be happening to certain patients, according to pain specialists who have recently seen a surge in referrals from doctors uneasy with prescribing opioids.

“People have been coming into my office in tears after their dose was cut back,” says Dr. Hance Clarke, director of the pain research unit at Toronto General Hospital.  “This is a common story.”

He says patients “who have been stably functioning individuals on prescription opioids for many years” are suddenly being “destabilized.”

To cope with withdrawal symptoms, some are turning to the underground narcotics market – which puts them at risk of consuming potentially deadly counterfeit medications or other highly-addictive drugs, says Dr. Clarke.

He says it is important to differentiate between people who are misusing opioids because they have a disorder such as addiction and patients who take the drugs to control pain so they can function day-to-day.

Some doctors are acting out of fear that they could face disciplinary action from medical authorities if they are deemed to be prescribing opioids at excessive levels, says Dr. Gil Faclier, a pain specialist at Women’s College Hospital and the Toronto Academic Pain Management Institute.

But Dr. Steven Bodley, president of the College of Physicians and Surgeons of Ontario (CPSO), which regulates doctors in the province, insists that such fears are unwarranted – provided doctors are acting in the best interest of their patients.

“Physicians have to use the guidelines to inform their treatment, but they don’t have to necessarily be slavishly attached to them,” says Dr. Bodley, who specializes in chronic-pain management at his North Bay medical practice.

He adds that doctors should use their own clinical judgment to determine the best approach and patients need to be consulted about their care.

“If patients are getting weaned aggressively, inappropriately … they can contact the college,” he advises. Once a patient lodges a complaint, “then we would do an investigation.”

Although this is an option, “some patients may be hesitant to complain and threaten the relationship they have with their doctor,” says Prof. Busse. Patients worry that they may be cut off from their source of medication.

“This is a tremendously polarized issue,” says Prof. Busse. Some doctors are supportive of long-term opioid therapy while others view the treatment with extreme skepticism.

He is concerned that there is so much pressure to diminish the use of opioids “there is a real danger of an over-correction” and that some of the guidelines could be misapplied and misinterpreted.

“In the rush to reduce the harm of high-dose opioid therapy, we have to make sure we don’t paradoxically create an even greater harm by putting patients in a position where they feel compelled to seek out illicit opioids,” he warns.

Even so, all the attention focused on the opioid crisis has led to a positive development – more health-care resources are being made available for the management of chronic pain.

Dr. Bodley points to a mentorship program developed by the Ontario College of Family Physicians. The program puts family doctors in touch with physicians who are experienced in dealing with addiction and chronic-pain patients.

“This is a really helpful resource,” says Dr. Bodley. “Doctors shouldn’t feel that they are hung out there on their own.”

About the author

Paul Taylor

Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. Email your questions to AskPaul@sunnybrook.ca
and follow me on Twitter @epaultaylor