Dialogue Volume 13 Issue 3 2017 - Page 38

PRACTICE PARTNER Dr. David Juurlink In looking at any course of action, doc- tors routinely put the potential benefits and harms on a scale. In the case of opioids, should the rewards outweigh the risk any more than usual? “It’s reasonable to make the assertion that they should have a higher threshold,” says Dr. Juurlink. Why? The potential harms are so much higher, and the benefits tend to attenuate over time. That’s a key message to weave into the conversation, and it’s also a call to probe. Does the patient have a history of addic- tion of any type? Are there other risk factors, like untreated mental illness or childhood trauma? These are sensitive topics, risks de- pend on multiple factors, and patients may not always be truthful. But it’s incumbent to ask, says Dr. Juurlink, and to think carefully if an opioid prescription is worth the risk. If the patient is in serious pain, and if it is affecting quality of life, and if there are no red flags, a trial of opioids may well be war- ranted. The conversation should cover a plan to keep the dose low and an exit plan, says Dr. Juurlink. It’s vital to ensure that both the doctor and patient are on the same page. Measure of respect “Doctors have lost a measure of respect for opioids. In the right patient, it can make a major improvement. In the wrong patient, it can ruin their life,” he said. Dr. Juurlink was a pharmacist by train- ing before he obtained his medical degree. In addition to his clinical, teaching, and 38 DIALOGUE ISSUE 3, 2017 administrative activities, Dr. Juurlink maintains an active research pro- gram in the field of drug safety. He says it’s important for doctors and patients to always return to the goal of pre- scribing. “It isn’t simply pain relief; it’s affording the patient more benefit than harm,” he says. “People want to be free of pain, and reliev- ing suffering is what we do. But we put a lot more faith in pain medications than they deserve.” Today’s opioid crisis doesn’t just revolve around over-prescribing, dosages, misuse and abuse. The issue also relates to the na- ture of conversations with patients, whether on starting opioids or tapering off. These conversations can be difficult yet productive. Start by recognizing that pre- scribing opioids is a “solemn exercise”, says Dr. Juurlink. People can become dependent quickly. He mentions one individual who experienced opioid withdrawal after being on Percocet for just three days. This patient knew the signs; after all, he himself was a doctor. Dr. Juurlink isn’t opposed to opioids. They can be an effective tool, but discussing them requires context and inquiry. To begin, the conversation isn’t just about relief. It’s about improved function and quality of life. There may be other solutions. When patients are in pain, however, it might not be what they want to hear. Talking about all the non-pharmaceutical options (physio, massage therapy, etc.) is im-