“Pain can vary. For a patient with a knee replacement, pain may be slight after surgery but more intense as they start physiotherapy,” says Dr. Bheeshma Ravi, an orthopaedic surgeon at Sunnybrook’s Holland Bone and Joint Program. “We know medications are helpful if [patients] need them, but risky to have in the home if they don’t.” 

To support patients, teams are piloting RECOVERED (Reclaiming ExCess Opioids for VERifiEd Disposal), a program offering a secure way to dispose of medication they don’t need.  

Hip and knee joint replacement patients at the Holland Centre are asked to bring in all medications to their six-week follow-up with their doctors. At this appointment, the doctor reviews pain management and medication needs with the patient. If pain medications are no longer needed, the patient can return the unused portion. Any returned opioids are locked away and removed only by authorized personnel for verified disposal. 

“RECOVERED works in tandem with other pain management supports, including education for patients while in hospital and 24-hour on-call assistance,” says Andrew Kennedy, project co-lead and manager of the Pre-operative Clinic at the Holland Centre. 

While the program is primarily about helping manage post-surgery pain, it offers additional benefits to patients, adds Dr. Ravi, project co-lead. “We hope by participating in RECOVERED, they may [also] feel empowered in helping to reduce harm.” 

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The Answer: Your question demonstrates the pain and suffering that occurs when an individual has a mental health issue not adequately addressed. The moment I read your e-mail, I contacted Sunnybrook’s Psychiatrist-in-Chief, Ari Zaretsky, who specializes in mood disorders and cognitive therapy. He suggests that you return to your family doctor. Explain the symptoms impairing your function have not responded to your psychiatrist’s interventions.

“He needs a fresh look so I would suggest he get an evaluation from another psychiatrist to evaluate his diagnosis and treatment regimen,” Dr. Zaretsky said in an interview. “Even if the diagnosis is, in fact, correct and in keeping with the first psychiatrist’s assessment, most patients need a combination of medication and psychotherapy or psychosocial interventions.”

It’s not uncommon for patients to have more than one diagnosis. You describe yourself as having severe depression and Attention Deficit Hyperactivity Disorder, [ADHD] the latter of which is characterized by inattentiveness, over-activity, impulsivity, or a combination of those three symptoms.

Every adult who has this disorder has had it as a child, though many children may not have been diagnosed. Only about one-third of diagnosed children will grow out of the problem by adulthood, typically after the central nervous system has matured and brain has become fully wired, around age 20, according to Dr. Zaretsky.

That, in part, is why Dr. Zaretsky screens every new patient referred to him for ADHD, which affects five per cent of the population, typically more males than females.

“ADHD is common and often missed. People tend to focus on the mood disorder,” he said. “…You should target the ADHD with psycho-stimulants and cognitive behavior therapy that teaches the patient to become more organized and to be able to manage themselves more effectively.”

Chronic inattention, distractibility, forgetting appointments, severe procrastination and impulsivity are common symptoms of ADHD. In some cases, those with ADHD have difficulty holding down jobs due to their intolerance of boredom the need to do tasks that require attention to detail.

Typically, in cases where patients have the two diagnoses of depression and ADHD, the depression is treated first in order to provide the motivation and energy required to tackle the chronic ADHD problems.

Dr. Zaretsky said a day treatment program would be critically important to your treatment. In such a group, there are structured activities that can help you learn life skills. He also recommends you exercise, if you aren’t already doing that.

“Even though it is very difficult to be motivated to exercise when you are depressed,” says Dr. Zaretsky, “aerobic exercise is very beneficial to the brain and leads to the growth of new neurons.” If you are self-medicating with drugs or alcohol, to soothe your distress, refrain from both, as it will compound your issues in a “very significant way,” he said.

To sum up, please visit your family doctor, request another referral to a psychiatrist for a fresh look at your diagnoses, and request that you be enrolled in a day treatment program in your area. Thank you for your bravery in writing this letter and describing your symptoms so articulately.

The post When a mental health issue requires a second opinion appeared first on Your Health Matters.

The Answer: In this post, patient Emily Nicholas, who is a Patients’ Association of Canada board member, is one of the experts providing advice on how to navigate the health care system for pain management. As a patient, she knows this story because she lived it: she had a hip replacement in July 2010 at age 28 and was prescribed tramadol – similar to a narcotic – by an orthopaedic resident. It didn’t work very well and by hour three, the next pill couldn’t come soon enough. She was also placed on morphine for breakthrough pain, which made her so nauseous, she had to take gravol to help alleviate it. Ms. Nicholas was told to switch to ibuprofen when she felt ready but no one told her what ready felt like, leaving her to figure this out on her own.

“They can only give you a rough estimate of the length of time you will need the medication,” she said in an interview. “The amount of pain and suffering that came after was more intense and persisted for longer than I had expected.”

She points to information sheets from the pharmacy she was provided. For six, typed pages, in words that few would describe as patient friendly, the drug’s uses and precautions were explained.

“The patient often has a lot of insight into their condition, but is kept out of the loop,” said Ms. Nicholas, who has an interest in patient engagement and health policy design. “Just putting information out there, doesn’t mean you are communicating it.”

While the information sheets do note that tramadol can cause withdrawal reactions, especially when used regularly for a long time or in high doses, they suggest patients see a doctor to reduce the dose gradually. Now that Ms. Nicholas was no longer seeing the orthopaedic resident, what doctor was going to help her get off of the medication, a month after taking it?

Ms. Nicholas went cold turkey in late August 2010, dropping the tramadol. Within days, she felt like she had the flu and had this odd sensation of a shock-like pain in the back of her neck. She didn’t make the connection straight away ­ that she might be experiencing withdrawal symptoms.

“I thought I was getting the flu,” said Ms. Nicholas, now 30. “I was anxious and shaky, with the feeling of shocks up my head.”

Realizing she might be experiencing withdrawal, she went back on the pills, reducing their dose, until she was able to get off of them for good.

Ms. Nicholas wishes she had been given a plan for pain relief and weaning from the pain drugs. She also wished she was provided alternatives, including the shot bean bags, body pillows and deep breathing exercises she later discovered on her own.

Anesthesiologist Chris Idestrup, director of the Acute Pain Service at Sunnybrook, said patients are typically provided a bundled approach to pain management in a hospital setting consisting of a combination of acetaminophen, anti-inflammatory medication, plus nerve blocks and possibly opioids. When patients are ready to leave hospital, they typically go to one drug – be it tramadol, another drug that is a combination of oxycodone and acetaminophen or acetaminophen. He described the medication Ms. Nicholas was on as “middle of the road,” in regard to its strength, and one that is prescribed if patients “are not able to tolerate a stronger opioid.”

He indicated that post-surgical patients are typically started on stronger medicine, such as morphine, which would be reduced to a weaker opioid if it were too strong. He recommends patients ask their doctor if there are other medications they can take in addition: by throwing an anti-inflammatory into the mix – another drug that is a mixture of oxycodone and acetaminophen – that would help reduce the need for other pain medication and decrease the side effects of one drug.

“Realistically, after surgery, patients might need to use opioids to control pain for two or three weeks, some require it for longer,” Dr. Idestrup said in an interview.

Oftentimes, he says, patients can wean themselves off the drug by tapering it by about 20 per cent per day. Sometimes it is as simple as dropping one tablet each day so that by day 12, the patient is not taking any medication.

“Instead of taking two in the morning, take one in the morning,” he said. “Drop a pill each day and see how you deal with that.”

He recommends patients see their family physician, a week or two after being home, with their pain medication in hand. If still on the maximum dose, discuss whether they should be set up with a “weaning protocol” to get off of the medication.

“I wish I had known that it was okay to try to get your physician on the phone,” she adds, “And to ask for what you need and tell them what you want.”

The post The Patient as Expert appeared first on Your Health Matters.

It’s getting nasty, folks. In one corner, (big) pharmacy, duking it out with the Ontario government in the other. It’s all over proposed changes to the province’s prescription drug system. But long before this battle got brewing, Sunnybrook Health Sciences Centre was piloting a broader solution. Call it, thinking inside the box.

Imagine a large green bank machine, but instead of money, this one dispenses medications (about 300 of the most commonly prescribed drugs). It’s the latest convenience in a long line of predecessors, including remote controls and cell phones. How did we live without them? Well, we could soon be saying the same thing about PharmaTrust Med Centres.

It’s an idea with long legs. As a parent, I know I’ve been stuck driving around looking for a 24-hour pharmacy on more than one occasion. With the current conflict between pharmacies and government, that could become even more difficult. This so-called “virtual pharmacy” is hoping to fill a void, especially in more remote communities.

How it works is pretty simple. After receiving your prescription from your doctor, you scan it into the machine itself. That information is transmitted to a remote pharmacist who pops up onto a television screen in front of you. You pick up the phone connected to the Med Centre and have a discussion with the pharmacist, just like you would in person, to make sure the medication is safe and appropriate. Once that’s determined, you can pay on site using your debit or credit card. And within a few minutes, the machine dispenses your medication, along with prescribing information.

The first one located in a downtown Toronto hospital is currently at Sunnybrook’s Holland Orthopaedic and Arthritic Centre. It’s also been piloted at Sunnybrook’s Bayview campus, with a thumbs-up response. Informal analysis finds most people would use it again, or recommend it to a friend.

PharmaTrust won’t replace your local or hospital pharmacy, especially for patients who would rather speak with an expert in person, but it is another choice. And it’s an innovative one that may be the future.

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