time, for the right patient, in
the safest way. “We need to
find the balance,” Dr. Murphy says, “just like any other
medical tool.”
Shifting to evidencebased prescribing
“We need to give
physicians the
education to
manage these
patients properly.”
Complicating matters is the
popularity of the black market for opioids. Dr. Dungey shows a web
page advertising illicit fentanyl, which he
found in just a few clicks.
Websites like these are troubling, but he
rejects the argument that changing prescribing patterns won’t affect illicit drug
traffic. Most people who suffer opioid abuse
have their first exposure from prescribed (or
diverted) products, he says. In other words,
black market websites – as popular as they
may be – are not most people’s introduction to opioids.
When you decide to prescribe opioids to
someone, he says, you need to do so in correct, non-escalating doses, with functional
assessments, and with plans to wean people
down. “It’s not happening often enough,”
Dr. Dungey says. “We need to give physicians the education to manage these
patients properly.”
The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer
Pain (under the stewardship of the Michael
G. DeGroote Institute for Pain Research
and Care) is under revision to ensure it
reflects evolving evidence and today’s environment. The updated guideline should be
released in early 2017. The Canadian guideline and the more conservative guideline
from the U.S. Centers for Disease Control
12
Dialogue Issue 3, 2016
and Prevention are available
at http://www.cpso.on.ca/
CPSO-Members/ContinuingProfessional-Development/
CPD-Practice-ImprovementResources/Medical-ExpertRole-Resources.
But the dosages only tell
part of the story. The dosage
– whatever it is – is not the
take home message, says Dr. Murphy. “We
should be magnifying the functional score.
If you’re using universal precautions and
the guidelines, the watchful dose becomes
irrelevant.”
At his clinic, Dr. Murphy sees bad situations at either end of the spectrum. For
every patient who has a doctor who won’t
prescribe anything for pain, there’s another
patient who is taking 1000 mg of morphine
but who has never had a functional assessment done.
The pendulum should be in the middle,
Dr. Murphy says. Underprescribing can be
just as much of a problem as overprescribing. “Safe prescribing is the answer,” he
says.
In a way, the current conversation about
opioids reminds Dr. Dungey of a previous
prescribing debate.
“When I started practising in 1989,
there was an overprescription of antibiotics for viral illnesses. It has taken us two
decades to change that medical culture,”
says Dr. Dungey. “Now we use best evidence on when to use antibiotics or not,
and which are best. There’s a huge amount
of evidence-based research in that field, and
I kind of feel we’re in the infancy of that
again on this issue.”
MD