Managing opioids

One night, while I was working in the emergency department, I sutured a young man’s laceration. While doing so, the patient admitted to me that he had a narcotic addiction. I offered him assistance and then asked him, “You take such large doses of opioids every day. Isn’t it expensive?”

He replied, “I wouldn’t be able to afford it on the black market, but my grandfather has a prescription from his physician and I take some of his pills.”

I understood then that one of my colleagues was his “provider.”

When I first began practising, there were numerous conferences on pain management and several presenters would tell us that physicians undertreated pain. At the time, we rarely heard about addiction and abuse in the media or in our communities. But today it is a public health crisis. Although resellers have many supply sources, we know that the well-intentioned prescriptions of physicians and dentists contribute to the problem.

I recently received a request for a hydromorphone prescription renewal from one of my patients. I had been his family physician for a few years and I had never prescribed him any opioids. He had had problems with substance abuse in the past, but he had not used for years.

While he was visiting the emergency department for abdominal pain, he received a presumptive diagnosis of lymphoma after multiple adenopathies were discovered on a scan. I was concerned about the number of pills the patient was given relative to the type of illness he had. I reexamined him at my office. He was suffering so much that I requested he be hospitalized so that his diagnosis could be reevaluated and his pain quickly controlled.

The patient was hospitalized only very briefly before I saw him again at my office. He was suffering so much that he told me he would not be able to return home. He explained to me that the physician at the hospital did not want to give him too many opioids because of his history of substance abuse. I could well understand my colleague’s hesitation but, knowing my patient, I suspected something unusual was happening. I had him hospitalized again and he passed away a few weeks later from a rare form of sarcoma.

When managing opioids, the balance between pain relief and risk of abuse, addiction, and death can be very difficult to achieve.

The College of Family Physicians of Canada is a part of the Pan-Canadian Collaborative on Education for Improved Opioid Prescribing. It has collaborated on promoting the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain,¹ the Opioid Manager tool,² and other resources on the subject. The College has also produced a Self-Learning special issue on opioids that is available to all members for free and is working on other initiatives as well.

Nevertheless, regardless of what organizations are doing, it is truly our work on the ground that will make a difference. As family physicians, we must give ourselves the mandate to reduce the overall number of opioids we are putting into circulation while assisting our patients in effectively managing their pain.

I am confident in our ability to overcome this challenge. A recent Health Quality Ontario report has noted a decrease in opioid prescriptions by family physicians.³ This decrease is not sufficient, but it is a good start.

There is no magic formula and so our duty is to use 2 of family medicine’s greatest strengths to address this challenge: judgment centred on our comprehensive vision of patient health, and continuity of care for actively dealing with opioid management.

We know our science, the doctor-patient relationship is at the heart of our specialty, and we have our community’s well-being at heart. The only thing left to do is to apply the art of medicine.

• Copyright© the College of Family Physicians of Canada