Lisa Bromley : Opioids and Pain Management : Guidelines and Resources

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Lisa Bromley, Family Physician, Sandy Hill Community Health Centre

Opiates and Pain Management

Ontario is facing an opioid crisis that is driven, in part, by prescribing practices. This session will discuss practical ways for clinicians to help patients manage pain. It will include strategies to safely deprescribe and discuss the impact of both medical and recreational cannabis use.

Descriptive Transcript

I work with Len just very briefly. I wrote my first methadone prescription in 2001, and since then I’ve really been sort of in the opioid world. And I’m gonna talk about opioids and pain management, and just quickly give you my impression of the issues and resources, and practical things that can help you. So principles of safe and effective opioid prescribing. We all have inherited opioid patients, and I’d like to make sure that you have tools and have confidence to manage that patient. and tell you about the resources. Disclosures, I do have some industry disclosures with Purdue Pharma and Indivior. In terms of non industry, I am I am a committee member of the College of Physicians and Surgeons of Ontario, an employee of the Ottawa Hospital and I’m a mentor for the Ontario College of Family Physicians collaborative mentoring networks.

Why am I here? Right. I mean what do opioids have to do with everything? Well my suggestion to you is that opioid prescribing and is going to be the same whether someone is living with HIV or not. I mean opioids are sort of dear to us because of a couple things. That injection drug use is a route of acquisition of HIV, and HIV causes painful symptoms which have often been treated with opioids, even in the case of someone who has a past history of opioid use disorders. Opioids have long been and will continue to be part of our world. So what are opiates? Are they good? Are they bad? Are they safe and effective medications for chronic pain? Or dangerous medications that are killing people? I will posit that they are both of these things.

The pendulum has sort of swung back and forth. Yeah. Bonne chance. I’m gonna walk you through that road map today. So Health Quality Ontario has some great data. In terms of lots of us are getting opioids. Two million people in Ontario received an opioid prescription in 2015-16. So that’s one in seven people. So in this room… Right. Well that’s kind of… Look how many people in this room? That’s uh whatever, that’s a lot. We do know that there’s an association with with increased mortality the higher opioid dose a person is prescribed. I am going to pause on this slide for a moment, because I think this really tells a lot of the story. So this is from Public Health Ontario, and you know in the past couple years… Oh my god… Fentanyl, Fentanyl, Fentanyl… In the opioid agonist treatment world Fentanyl has broken everything. Right. Fentanyl is just kind of turned everything upside down and inside out.

But if you see… The the top orange line there, the past few years, that’s oxycodone and so for a long time oxycodone was the bad guy in terms of what opioids are present in death. Then oxyneo came along, you can see hydromorphone coming up. Methadone is there all along too so that really behooves us as methadone prescribers to be really careful in our methadone prescribing. And you know in the last few years of course that Blue Line fentanyl has really shot right up, in terms of opioids present at death, but I want to emphasize that there is a steady drumbeat of non fentanyl related opioid deaths all along. And we have to be mindful of that. Right. So big news a year and a half ago, the Canadian Opioid Guideline came out. Everyone familiar with that? Right.

I’m gonna walk you through it. And everyone kind of freaked out. Oh my god. You know 90 milligrams is now more is now the upper limit and blah blah blah. So when you really look at the guideline it does not say for the legacy opioid patient you have to get everyone down to 90 milligrams. It does not say that. Most of the recommendations have to do with the opioid naive patients, someone who you are considering initiating an opioid prescription on, and then you get basically two recommendations at the end on how to manage your legacy opioid patient, but what does the guideline actually say? So recommendations went to seven if you have a pain problem optimized non-opioid treatment, consider opioids if that doesn’t work. If a person has a current or past substance use disorder (SUD) or a psychiatric illness, it’s a weak recommendation to maybe stay away from opioids and keep the dose low, because most of the benefit is at that low end of the dose range. So far so good. The legacy opioid patient.

So here’s our eight and our nine. You could go look this up for patients who have chronic non-cancer pain, who are currently using opioids, and who have persistent problematic pain. So these are folks who no matter what their dose they’re not winning. They have pain problems. Change the opioid. Change it up. That can sometimes refresh things. Recommendation nine for those people who are above ninety, 90 milligrams morphine equivalent. Right. So you take if they’re on oxycodone or hydromorphone you sort of convert that how much morphine equivalent is that. If they’re above 90 well no matter how well or how poorly they’re doing, we’ll offer them to taper. You know you can offer it because you know opioids. We now have much better understanding that there are health risks associated with high doses. You know we suggest offering a taper rather than making no change. So offer. And you know specifically if they’re not doing well, if they’re not very adherent, if there are signs of substance misuse, maybe they had a close call, maybe the patient is you know interested to taper.

There’s no more hands off we’ll be prescribing. If you were a provider signing an opiate prescription, you are hands-on, you are addressing that person’s opioid use at almost every visit. How are you doing? How’s it going? Adverse effects, risks and so on. You know sometimes when a person been on opiates for a long time the benefits sort of may attenuate and they get some withdrawal relief with every dose, and that kind of it feels like the opiate is working and yet all they’re doing is really sort of treating that, introduce withdrawal. So you know it becomesa very cloudy picture. Okay. And here’s the important thing, don’t destabilize people because you cut, you do an aggressive taper or cut people off, that’s really destabilizing and increases their health risk. So please don’t do that. Some patients are likely to experience significant increase in pain or decrease in the function that persists. In that case you can potentially pause or abandon the taper okay.

So folks chronic pain and opioid use disorder, you know this is a complex relationship. Pain and addiction is sort of along the same scale, and sometimes because people don’t. Where’s the money-back guarantee that opioids always work for chronic non-cancer pain. No they don’t always work actually unfortunately I wish they did. We all kind of have a sense of folks who kind of take up our real estate in our minds about opioid prescribing. Opioids used to have some great guidelines. We have two guidelines CRISM the National Guideline and BC. Learn how to use buprenorphine. It’s a great tool. I mean that’s my total intellectual bias, I really like this molecule. It’s once a day, it’s good for pain, it’s a partial agonist, there’s some evidence that it’s protective against overdose.

I’m gonna breeze through these. The naloxone is there. Everyone gets messed up about the naloxone. That’s a deterrent to injection or nasal use of the tablet, and when it’s taken as intended. When naloxone does not get absorbed it doesn’t do anything. Oh my god, but I know buprenorphine is scary. If you’re a provider, it’s funny how many people say I don’t feel comfortable prescribing buprenorphine, and yet they feel comfortable prescribing buckets of hydromorphone. Right. So you know if you’re prescribing opioids put buprenorphine in your toolbox please. CPSO says if you’re a doctor you should know what you’re doing. Methadone it’s been around for a long time. The structured opioid therapy. If someone’s in trouble but they’re not in methadone or buprenorphine land, tear a page out of what we do in methadone buprenorphine and put a lot of structure. You know short dispensing interval, more urine tests, a little bit more hands-on, resources.

So now this is the home stretch so Laura can get up here. The natural pain center. Here’s the landing page. That’s what it looks like., this is a great resource for providers if you want to know how to treat opioid use disorder, or alcohol use disorder. Really great resources here. It’s a directory of the RAM clinics. Rapid Access Addiction Medicine clinics. TheWell health. Zero industry input here. Chronic non-cancer pain tool, opioid manager. This is what these things look like: opiate manager. MacHealth: a course on prescribing buprenorphine. This is what it looks like. It’s really simple. It’s really well done.

So the manufacture of suboxone has an industry supported course. A quick and dirty way, you wanted to know about how to use buprenorphine, you can go here and this is what the manufacturer says what you need to know about prescribing our product. E-Consult is a resource, it’s kind of spreading Ontario wide. Let’s you consult a specialist without having to actually send the patient there if you’re a physician or a nurse practitioner. I revealed my bias, I really like this program. The collaborative mentoring networks. You can join up and connect with a mentor, and talk about your problems, your clinical problems. May be your personal problems too, you know we’re friendly. Okay, there’s the landing page for Colaborative Mentoring Networks. There is help out there. We can help these folks. Thanks. [Applause]