Dialogue Volume 12 Issue 3 2016 - Page 18

s cheduled rather than PRN dosing. Prescribe small doses to be dispensed frequently (as often as daily). With frequent dispensing, you will not need to renew the script if the patient runs out early. 6 If timely referral to opioid substitution treatment is not available, you may prescribe buprenorphine yourself, following the product monograph and buprenorphine guidelines. It is a very safe medication and patients with an opioid use disorder do much better on buprenorphine than on potent opioids.  7 Contact an experienced methadone prescriber if you are looking after a hospitalized patient on methadone or buprenorphine. Occasionally the dose may need to be tapered (e.g., if the patient has started sedating drugs while in hospital.) If a patient on methadone is going to jail, ensure they can remain on their dose of methadone while in jail. This can be done by arranging to have their last dose before incarceration witnessed, thus meeting the requirements in Corrections Services Canada with respect to dose. Opioid tapering in a patient without an opioid use disorder: Tapering is indicated for “opioid failures” (severe pain-related disability and high pain scores despite a dose of 90-120 mg morphine equivalents per day or more). Tapering often improves mood, pain and function in these patients. Tapering is also indicated for patients who experience dose-related complications such as fatigue, sedation, dysphoria, or 18 Dialogue Issue 3, 2016 sleep apnea. Tapering should be done slowly, over weeks or months. Daily dispensing is usually not necessary, nor is complete cessation of the opioid – patients often feel and function better at a lower dose (closer to 50 mg morphine equivalents per day). Addressing an aggressive patient: The College’s Ending the Physician-Patient Relationship states that it is reasonable to discharge a patient from your practice if they are threatening or abusive towards you or other staff, or if you have proof that they are selling your prescription (e.g., a report from the police). Ensure that you terminate the relationship in accord with the College’s policy. The policy states that physicians have to provide notice, be helpful to the patient in finding another provider and give them a reasonable amount of time to do that, and provide care in the interim, including renewing prescriptions. Becoming familiar with the risks of abrupt cessation of opioids, strategies for overdose prevention, and resources to guide tapering and assessment of opioid use disorder may mitigate risks associated with reducing opioid prescribing. MD Dr. Meldon Kahan is Medical Director, Substance Use Service, Women’s College Hospital Dr. Pamela Leece is a Clinical Associate, Substance Use Service, Women’s College Hospital Dr. Sheryl Spithoff is a Staff Physician, Department of Family and Community Medicine, Women’s College Hospital