Weaning patients off opioids is creating another crisis
“Alex” came into the ER at 9:45 p.m. He had trouble breathing. His lips were blue. By12:05 a.m. Alex was dead. He died from an opioid overdose. This is one example of the opioid crisis.
In response, the government closely monitors physicians who prescribe opioids and a new set of opioid guidelines have been produced to help physicians prescribe this medication more safely. In the past, the recommended upper limit of prescribed opioid was 200 mg of morphine equivalence for a new patient. Now the recommended limit is 50 mg and under certain circumstances, no more than 90 mg. However, flying under the radar of the big opioid crisis is another opioid crisis.
Every week I see patients in my pain clinic who have been prescribed opioids for many years and their dose is being lowered, whether they like it or not, to the point that they cannot function. Their doctor tells them the College of Physicians requires them to do this or they will lose their license to practice. Some patients have gone from being active to doing almost nothing. Some have even become suicidal.
This is the other opioid crisis. But, is it reasonable and necessary?
Do the Canadian guidelines actually tell physicians to lower their patient’s dose of opioid quickly, without their agreement and regardless of their function in the end? Recommendation nine from the Canadian guideline states: “For patients currently using 90 mg morphine equivalents of opioids per day or more, with persistent problematic pain and/or problematic side-effects we suggest tapering opioids to the lowest possible dose, in- cluding discontinuation, rather than no change in opioid therapy.”
What if a patient tries, but they cannot lower their dose because their function deteriorates? The Canadian guidelines also comment about this. “Some patients are likely to experience significant increase in pain or decrease in function that persist more than one month after a small dose reduction; tapering may be paused and potentially abandoned in such patients.”
So, a patient should not be forced to lower their dose.
The guidelines seem clear. Yet, some doctors still “force” their patients to withdraw.
Many physicians have mistakenly interpreted the new guideline to mean that if they do not bring patient doses down to below 50-90 mg they will get in trouble with the college. The only problem is these doctors are not acting according to the very college guidelines they are concerned about.
The college states that a physician must always act in patients’ best interest. A physician must collaborate and communicate with the patient and their other care providers.
Finally, we physicians must never pursue any form of personal advantage at the expense of a patient. When a physician tells a patient they are going to lower their opioid dose, no matter what, because of fear of the college, they are for- getting about collaborating with the patient and doing nothing that leads to personal advantage. The reduction is being done without the clear consent of the patient and by invoking the College Boogey Man the physician is looking after themselves, not the patient.
As an examiner for the college I can tell you the college won’t take a physician’s license if a patient’s dose of opioid is higher than the recommended amount. As long as it is clearly documented that the doctor spoke with their patient about the issue and collectively they made a decision not to lower the dose or they tried and were unsuccessful, then the doctor is in the clear.
When a physician invokes the College Boogey Man as the rationale for their behaviour, they are no longer thinking about the patient, they are thinking about themselves. The issue is now about personal gain, not patient care.
Now it all makes sense. So, any patient on doses of opioids higher than the currently recommended dose should think about trying to lower their mediation. At high doses there is an increased risk of death.
The patient and physician should talk together and come up with a mutually agreed-upon plan. If a patient lowers their dose by a little bit but does not hit the prescribed mark, that, too, is success.
Everyone is worried about the big opioid crisis. But it has stimulated another crisis and we need to pay attention to that one too.
Any patient on doses of opioids higher than the currently recommended dose should think about trying to lower their mediation
Jeff Ennis is an assistant clinical professor in medicine at McMaster University and medical director of the Ennis Centre for Pain Management.