Some MDs are invoking the College in order to justify cutting patients off or rapidly tapering their doses. The College is against such action. So why do you think this is happening? The College Boogey Man, just like a child’s Boogey Man arises out of fear of the unknown. For the physi- cian, it is based on a mistaken belief that the College is monitoring their activity and if they do not get their patient’s dose of opioid below at least the recom- mended 90 mg they will be in violation of a rule. It takes a lot of blood, sweat and tears to get a licence and no physician will give it up easily. If a physician believes that they will lose their licence unless they lower the dose of opioids they have been prescribing, they will do that. The primary error in the thinking of the primary care physician is that their belief is a distortion of the truth and rather than check out their concerns with the College or a body like the DeGroote Centre for Pain Management, they make a unilateral, mistaken decision. This is happening so often because there are a lot of patients in this situation. Some patients may achieve a benefit at doses higher than 50 mg or even 90 mg. What do you tell doctors who may have several such patients 34 DIALOGUE ISSUE 1, 2018 Most of the recent opioid investigations resulted in an outcome that will keep the physician in practice. Will that surprise doctors? I am not surprised at all. Simply because a physician is prescribing ‘too much’ opioid does not mean they are a poor physician. Nor does it mean that they do not have their patient’s best interest at heart. Typically it means that the physician is poorly informed about how to handle these medications and they believe they are doing the right thing. Additional education is the right maneuver in most of these cases. It is not surpris- ing that many physicians have a poor understanding of managing opioids. When I was in medical school it was never discussed. In fact, pain was never discussed. Things might have improved since then, but clearly not enough. MD Dr. Jeff Ennis and are worried they may face College sanction? The answer is simple and it is the answer I give my colleagues when I am doing an assessment for the College. Document, document, document. Simply write down exactly what you do and why. Show that you are applying clinical judgment to the situation. That is all there is to it. Talk to your patient about the issue and make them aware of the changes in the guidelines. Tell them that these changes arose because there is evidence of an increased risk of death on doses of opioid above 90 mg and there is less evidence that higher doses lead to improvement in function. Give the patient an opportunity to decide with you whether or not they are prepared to lower their dose. If they are not, record that. You can always revisit the issue with the patient later. If they are prepared to reduce the dose, ‘go low and go slow’. Monitor function. If a patient says they have had enough tapering, then stop. Even if they lower their dose by the equivalent of 10 mg of morphine that is quite an accomplishment.