Utilizing Opioids Safely: Being the Doctor and not the Dealer

1. Utilizing Opioids Safely: Being the Doctor and not the Dealer PSP Pain Management Module Galt Wilson, MD, MSc, FCFP Keith White, MB ChB

3. 20% of Canadians live with Chronic Non-cancer Pain (CNCP) “I would not have survived without opioids” “The pharmaceutical infiltration into pain management narrows a doctor’s understanding of pain and healing.” --Lous Heshusius. Inside Chronic Pain: An intimate and critical account.

6. Reward Pathway

7. Good medicine is good theatre. • Jack encounters 3 doctors. - With thanks to Dr. Steve Barron. • The Easy Mark • The Confrontation • In Control

8. Prescription Review Program (PRP)The College Perspective: Collegial & Educational • Quality Assurance—privileged under the Health Professions Act.

9. 1. Don’t turn patients away. “People with chronic pain need family physicians…”

10. 2. Your prescribing is your responsibility- be clear about that. “Currently, prescribing practices vary widely among family physicians and pain physicians. Therefore physicians must prescribe opioids according to their best judgment, even if this goes against the wishes of patients, the recommendations of consultants, or the practices of patients’ previous physicians.” - Kahan et al.

11. 3. Be clear about what you are treating Always distinguish between: • Acute pain • Pain at the end of life • Chronic non-cancer pain Lancet. June 25, 2011. (357—p 2151)

12. 4. Patient selection is (probably) key • Strong relative contraindications: • Addiction (self or a household member) • Mental illness • Young age • Functional somatic disorders

13. Patient selection JAMA, Published online May 9, 2013

14. You can’t mend a broken heart with a prescription… “The D.S.M. would do well to recognize that a broken heart is not a medical condition, and that medication is ill-suited to repair some tears.”

15. 5. Realistic Expectations • Modest reduction in pain intensity. • Uncertain functional improvement. • Modest dosing: 60-85 morphine equivalents • Addiction never systematically studied

16. 6. Principles of Safe Prescribing • Limit dose. (no empirical basis for titrating up) • Limit dispense size and duration. • Do not combine opioids with benzodiazepines and/or sedative hypnotics. Zero tolerance for alcohol.

17. 7. Make prescribing contingent on specific nondrug (lifestyle) interventions: Moderate exercise. Sleep hygiene. Smoking/alcohol cessation. Healthy eating. BC Self-management Program (http://www.selfmanagementbc.ca/chronicpainprogram)

18. 8. “Universal precautions” for safety • Treatment agreements • Random urine drug screens • Pill counts • Frequent visits Mandatory in ER and Walk-in settings.

19. To learn more about the role of opioids • Canadian Guideline http://nationalpaincentre.mcmaster.ca/opioid/ • Provincial Academic Detailing (PAD) module—coming to your community • College Prescribers’ Course (twice yearly)—College website. Limited enrollment. Standardized patients. Collegial. • Call the College Prescription Review Program

20. Come to our annual CME event March 7-8, 2014. “…attend this course before receiving [your] first Duplicate Prescription Pad” Register via College website— Physicians/Professional Development/Upcoming Chronic Pain and Suffering Symposium

21. We’re on trial—but we can manage this. “These examples convinced me that no amount of education would permit controlled release oxycodone to be prescribed safely by the vast majority of prescribers.” NOT the College experience.

22. Summary: Eight Prescribing Principles for Healers • Don’t turn patients away. • Your prescribing is your responsibility • Be clear about what you are treating • Patient selection is (probably) key • Realistic expectations: modest potential benefit and significant risk. • Modest dose/dispense size; No combinations • Make prescribing contingent on basic lifestyle expectations. • Review PharmaNet every time you Rx.