Reflecting an improved understanding of the risks and benefits of opioid therapy, clinical practice guidelines such as the Guideline for opioid therapy and chronic non-cancer pain1 support appropriate prescribing to reduce associated harms. Additionally, some regulatory authorities (Colleges) have issued policies to guide physicians in prescribing opioids safely.
Canada’s opioid crisis is having a significant impact on the healthcare system, with serious implications for patients, their families, and healthcare providers. Managing the care of patients on high-dose or long-term opioid therapy for chronic non-cancer pain is complex. And, the Canadian Institute for Health Information estimates that 25% and 17% of patients prescribed these drugs fall into these 2 categories, respectively.2 This context calls for a strategic, patient-centered approach that incorporates guidelines, validated tools, provincial and territorial resources, as well as support from a multidisciplinary team. Regulatory authorities (Colleges) are also offering guidance and direction. The situation is also challenging for CMPA members, who then seek medical-legal advice from the CMPA.
The CMPA analyzed 1,989 member telephone calls received between 2012 and 2017. The purpose was to identify the most commonly discussed medical-legal themes related to opioid management for patients in the community whose chronic non-cancer pain was already being managed by these drugs.
Unsurprisingly, over 85% of calls came from family physicians. Members called most often about the medical-legal risks they may face when attempting to effectively manage pain while minimizing opioid use or when dealing with aberrant drug-related behaviours. Physicians frequently called the Association with concerns that they might receive a College complaint related to opioid management or be subject to a potential investigation or restrictions on their opioid prescribing. Other common questions concerned their duty to report in a variety of situations related to opioid use and prescribing, and their duty to accept new patients on long-term opioid therapy, including when taking over another physician’s practice.
Questions on opioid tapering and alternatives
Physicians most often called the Association with questions on their medical-legal risks in managing the care of patients taking opioids for chronic non-cancer pain conditions in light of recent guidelines. Members’ concerns included: questioning the appropriateness of continuing to prescribe opioids to patients who are not responding to non-opioid alternatives; reconciling high-dose opioid regimens or other medications (e.g. benzodiazepines) with regulatory guidelines; and working with patients reluctant to accept referrals to pain management physicians or other specialists, or having difficulty accessing these specialists.
While the CMPA cannot advise on clinical standards of care, tapering too rapidly can result in a range of withdrawal symptoms. Reflecting this, the Association received many calls from physicians who expressed concerns about patients experiencing withdrawal when patients reported running out of or losing their medication, or when the member decided to stop prescribing opioids.
Pharmacists can help physicians decide on a tapering schedule or rotation of opioids. They can also provide patients with additional resources, counselling, and follow-up. When tapering, physicians should be familiar with titration protocols and consult addiction specialists for advice when needed. As outlined in recommendation 10 of the Guideline for opioid and chronic non-cancer pain, some patients may require a formal multidisciplinary program.1
Concerns about aberrant drug-related behaviours
Aberrant drug-related behaviours refer to behaviours that may signal misuse.3 Such behaviours can be particularly challenging for physicians. The most common behaviours that prompted member calls were: co-occurring alcohol abuse or use of illicit drugs or other unprescribed medications; threatening or coercive behaviour aimed at getting physicians to refill prescriptions early or increase opioid dosage; and illegal activity around obtaining or profiting from opioid prescriptions, including diversion of medication and forgery of prescriptions.
Interestingly, in some cases, members described patients’ family members or spouses displaying problematic behaviour when attending patient appointments or contacting the physicians’ offices. Many physicians observed this behaviour in the context of family members advocating for improved management of their loved one’s pain or, conversely, criticizing the physician for what they perceived as excessive prescribing; rarely members saw disruptive behaviour on the part of family members as a possible indication of diversion.
Members involved in these situations were typically concerned about how to navigate the physician-patient relationship. While these situations can be difficult to manage, physicians should consider whether it is possible to continue to provide appropriate care and not be intimidated into providing treatments they do not believe are in the patient's best interest.
Physicians are encouraged to explore conflict resolution strategies where possible before ending the physician-patient relationship. All decisions to end the physician-patient relationship should follow applicable current College guidelines.
Physicians can also contact the CMPA for additional resources and assistance on dealing with challenging behaviour. Some Colleges also offer mentoring programs that match family physicians with consultant physicians in addiction and pain management.
Concerns about receiving complaints
Members often sought advice on how to avoid patient complaints after they decided to stop prescribing opioids, or when they planned to taper and wean patients off their medications. Another scenario in which physicians expressed concern about receiving a complaint was when family members expressed concerns about a physician over-prescribing or failing to prescribe opioids.
Clear and compassionate communication with patients and families can go a long way in minimizing the risk of a patient complaint. It is also important to document all discussions and treatment decisions in the medical record. Being familiar with College guidance on opioid discontinuance can help guide decision-making when faced with a need to revisit the care plan.
Questions on reporting versus ethical, professional obligations
Questions surrounding the duty to report in the context of opioid use was another common source of calls. These questions most often concerned reporting suspected opioid abuse or illicit drug use to motor vehicle licensing authorities, child protective services, or professional regulatory authorities. Questions also concerned reporting suspected illegal activities, such as diversion or prescription fraud, to police. Members also called when they were contemplating reporting troubling opioid prescribing practices of other physicians to their College.
Physicians should be familiar with College policies and guidelines on reporting, as well as the relevant provincial or territorial legislation. The regularly updated CMA Driver’s Guide is a helpful resource for evaluating the potential effects of patients’ medication use on their driving capability. Members should call the CMPA if they are uncertain about their duty to report.
Questions from physicians taking over the care of patients
Over one-third of calls came from members in their first 10 years of practice. Many of these calls were from recently graduated or other physicians assuming new practices with patients who were receiving high-dose or long-term opioid therapy. Others sought advice on their medical-legal risks associated with accepting new patients taking these medications. Some locum physicians struggled with situations in which they disagreed or were uncomfortable with the current opioid prescriptions of the physician for whom they were covering.
Physicians should be aware that many College policies now state that physicians cannot decline to accept new patients solely due to opioid use. When meeting with prospective patients who are on opioid therapy, physicians should discuss the current chronic pain management guidelines, as well as their own approach to treating chronic pain. They should revisit the goals of opioid treatment, and also assess these patients’ pain, function, and risk for opioid misuse. Working with colleagues and relevant specialists is helpful for optimally managing the care of patients on long-term opioid therapy, including reduction strategies.
Opioid contracts, meant to be a useful tool in providing patients and physicians with clarity around opioid management, emerged as a distinct issue in calls to the CMPA. The most frequently asked questions related to the following:
- patients refusing to sign an opioid contract
- physicians seeking support in decision-making related to contract enforcement or offering second chances when patients breached the contract
- physicians wanting to stop prescribing opioids or terminate the doctor-patient relationship when contracts were breached
According to guidelines, these contracts or agreements often include clear descriptions of medication use and misuse, as well as the consequences for violating the contract. These provisions can aid in decision-making if the contract is breached.
The bottom line
Effectively managing chronic non-cancer pain and opioid therapy is complex. It requires patient-centered, compassionate care. Comprehensive guidelines, provincial programs (such as opioid monitoring systems), and guidance from Colleges support safer practice in this area. Members are encouraged to call the Association with medical-legal questions or concerns related to opioid management.
- Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8; 189(18): E659-E666
- Canadian Institute for Health Information. Pan-Canadian Trends in the Prescribing of Opioids, 2012 to 2016. Ottawa (CA): CIHI; 2017
- Passik SD, Kirsh KL. Assessing aberrant drug-taking behaviors in the patient with chronic pain. Curr Pain Headache Rep. 2004 Aug; 8(4): 289-94