There is no simple response to the opioid crisis and many family physicians face tremendous challenges in fulfilling our commitment to compassionate, high-quality care, while navigating the changes being spurred by the crisis itself.

The OCFP understands the important role of family physicians in effective pain management and in improving community safety around opioid prescribing. In the following discussion, Dr. Arun Radhakrishnan and Dr. Leah Skory address issues that are front and centre for family physicians, including the recent introduction of the 2017 Canadian Guideline for Opioids for Non-Cancer Pain.
Drs. Radhakrishnan and Skory are both family physicians and members of the OCFP's Collaborative Mentoring Networks, which include the Collaborative Mental Health Network, or CMHN, and the Medical Mentoring for Addictions and Pain Network, also known as MMAP.

Dr. Leah Skory: Why are we seeing new Canadian guidelines for prescribing opioids?

Dr. Arun Radhakrishnan: Canadians are among the highest consumers of opioids in the world and, along with this high level of use, sadly, we are seeing significant mortality among users. There are multiple factors behind the overuse of opioids and the tragic consequences we're seeing, and opioid prescribing, regardless of who does the prescribing, plays a part in the current crisis. Compared to the earlier guidelines, the new 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain places greater emphasis on the safety of patients when using opioids. Through this lens, the updated guidelines promote a better understanding of the evidence that exists around when we may not want to prescribe opioids and the relationship between dosages and safety.

LS: What are the most significant elements of the new Guideline?

AR: The new Guideline is meant to inform decision making in opioid prescribing. In the new framework, the focus has shifted to a stronger emphasis on the potential risks to patients from opioids. Three key concepts addressed in the guidelines are:

• Preference for non-opioid therapies: Optimization of non-opioid therapies is strongly recommended, over a trial of opioids, for patients with chronic non-cancer pain
• When to avoid opioid therapy: The Guideline suggests avoiding opioid therapy for patients with a history of substance use disorder or current mental illness, and avoided in cases of active substance use disorder
• Dosage guidelines: When starting a patient on opioid therapies for chronic pain, the Guideline suggests restricting dosages to below 50 mg morphine equivalents for most patients and recommends restricting doses to below 90 mg morphine equivalents for almost all patients. When considering increasing the dose to more than 90 mg morphine equivalents daily, the recommendation is to get a second opinion. For patients on dosages above 90 mg, consider an opioid rotation or tapering to the lowest effective dose.
  A good practice, as noted in the Guideline, is to acquire informed consent from the patient before initiating opioid use for chronic non-cancer pain. Based on a discussion of potential benefits, adverse effects and complications, the decision of whether to proceed with opioid therapy would be shared between you and your patient.

LS: Helping our patients to better understand chronic pain management and the issues around opioids is one way we can support efforts to deprescribe. Where can we find information that may be helpful to patients?

AR: Many organizations are working to help address the opioids crisis, including by providing resources for patients.

• Public Health: Some Public Health Units, for example, are undertaking specific strategies that include patient information, so you may want to check with your regional PHU to learn what education and support programs are available to the public in your community or region.
• OCFP: You may want to consider the resources compiled by the Ontario College of Family Physicians (OCFP) on the dedicated Opioid Management page of the OCFP website. The list includes tools and resources for providers and patients, and the page is updated as information becomes available.
• Centre for Effective Practice: Among the resources listed on the OCFP Opioid Management page is the Management of Chronic Non-Cancer Pain Tool, or CNCP, from the Centre for Effective Practice. The tool focuses on a multi-modal approach to pain management, including information that can help patients understand chronic pain and opioids, as well as explaining the value of non-opioid approaches to pain management and how to access them.
• Other internet resources: Patient resources around pain and opioids can be found online in many formats. Dr. Joel Bordman, a family physician with a focused practice in addictions and pain, and a Mentor in the OCFP's Medical Mentoring for Addictions and Pain Network, recommends the "Brainman" series to his patients. Here are links to the three videos in the series, Understanding Pain:

Brainman stops his opioids [video]
Brainman chooses [video]
Understanding pain in less than 5 minutes [video]

LS: A family physician who is concerned about harming their patient by deprescribing too aggressively, in following the guidelines, could end up above the dosing thresholds. We also know that prescribing habits are monitored by regulators. How can we, as family physicians, ensure we meet regulatory expectations AND continue to do what is best for our patients?

AR: It can be difficult to continue tapering a patient when you perceive a risk that tapering could push the patient to look for other, potentially harmful options. At the same time, family physicians are contending with revised expectations for lower dosages and frequency of prescriptions under the new guidelines.

The Guideline acknowledges that tapering takes time and can be very slow - it may even require years. Every patient is unique and the underlying expectation is for physicians to continue to do what's in the best interest of the patient. For some patients, dosages may not always go down steadily and the process may include some increases in dosages or pauses to allow patients to stabilize. In some cases, tapering may have to be stopped.

It is also important to be aware that deprescribing may destabilize an active substance use disorder or reactivate a substance use disorder in those with a history and caution is supported by the guidelines. In others, deprescribing may unmask new clinical features of an opioid use disorder (see CEP tool) or an exacerbation of their complex pain (including mental health features). In all cases, it is important to develop a good understanding of both your patient's substance use history and their complex pain - the latter being of particular importance - and if issues arise, seek out assistance from expert resources in your community or region, including consultation.

In short, the most important things for a family physicians to do are, first, to keep having conversations with the patient around deprescribing and, second, to document these discussions and the process itself. It may also be helpful to get support from colleagues who have faced similar challenges and who may be able to act as mentors.

LS: How can family physicians learn about and access other methods of pain control and non-opioid solutions?

AR: Family physicians play a pivotal role in helping patients manage chronic pain and opioids are one aspect of a pain management strategy. The new Guideline addresses the crucial need to optimize opioid prescribing. Effective pain management, however, often takes a multi-modal approach, including non-pharmacological as well as pharmacological tools. It's crucial that the family physician undertake a comprehensive assessment and where necessary use skills like motivational interviewing to engage with a patient and support them as they integrate different components of pain management.
One good resource and possible starting point is the Management of Chronic Non-Cancer Pain Tool, which I also mentioned as a resource for patients. The tool was published earlier this year by the Centre for Effective Practice to assist care providers in the development and implementation of a management plan for patients living with chronic non-cancer pain. (I helped develop the tool.) It takes a multidisciplinary and multidimensional approach. It emphasizes the importance and value of non-opioid-based therapies and how to integrate them into practice, and has recently been supplemented with compiled resources specific to each Local Health Integration Network (LHIN).

LS: What steps can a family physician take if a patient doesn't agree with being deprescribed?
AR: A patient, especially if he or she has been on the same dose of opioids for a long period, may resist undertaking a deprescription process. Beyond the increase in mortality rates, the evidence is that higher opioid doses can result in harms such as opioid-induced hyperalgesia, withdrawal mediated pain (both of which would cause an increase in pain for patients), depression, hormonal disturbances and sleep disturbances.

While these symptoms may worsen initially in deprescribing, over time, dose reductions may help reduce pain, increased function, improve sleep and stabilize mood.

Gradual dose tapering and multidisciplinary support are important aspects of deprescribing. It's also important that deprescribing is not punitive or judgmental, or perceived by the patient as such. Compassionate deprescribing includes engaging the patient in practical discussions so that, even though they cannot change the decision to deprescribe, they nonetheless have a voice and some control in how that process looks. It's important that discussion with the patient is ongoing and that the plan be iterative.

LS: How should we treat patients whose pain persists despite optimized non-opioid therapies?

AR: There is evidence that people with an active psychiatric disorder or active substance use disorder, or a history of substance use disorder are at risk for adverse outcomes from opioids. In these cases, the guidelines suggest continuing non-opioid therapy rather than a trial of opioids. Where this proves to be challenging it is important to engage with colleagues and expert resources in your community or region to support you.

LS: As Chair of the OCFP's Collaborative Mentoring Networks, can you explain how the Networks help physicians who are facing complex care issues around pain management, including managing the deprescribing process and the new guidelines?

AR: As family physicians, we are on the front line of this issue. The many considerations for deprescribing and the new Guideline itself highlight the difficult challenge we face in caring for patients with complex care issues, including chronic pain. The OCFP has two Collaborative Mentoring Networks (CMN) which respond to the current environment in mental health, pain and addiction. One of these groups, the Medical Mentoring for Addictions and Pain (MMAP) Network, connects family physicians with Mentors who are specialists or family physicians working in pain and addiction-focused practices.

From one perspective, the MMAP Network helps family physicians address the nitty gritty of caring for patients with complex pain issues - the decisions that must be made in daily practice. Participants exchange ideas and share information through the Networks - where to find the latest guidelines and new tools and techniques, and how to implement and integrate them. Mentees ask questions and get first-hand, timely input and suggestions from Mentors by email, telephone and online through a dedicated portal. The Networks also enable ongoing one-on-one relationships between Mentors and Mentees.

There are also opportunities for case-based learning which, like the Mentor-Mentee structure, may be especially helpful in building confidence and competence for physicians facing certain new, complex patient cases in their daily practice.

You can learn more about the OCFP's Collaborative Mentoring Networks, including how to join the Networks as a Mentor or Mentee, at ocfp.on.ca/mentoring or by using our contact form.