Pubdate: Mon, 21 Nov 2016
Source: Toronto Star (CN ON)
Copyright: 2016 The Toronto Star
Contact:  http://www.thestar.com/
Details: http://www.mapinc.org/media/456
Author: Dr. Peter Selby
Page: E6

SUDDEN STOP NOT THE ANSWER FOR OPIOIDS

Canadians have one of the highest rates of prescription opioid use in
the world - five times higher than in the U.K., for example. This is a
tragedy because we don't do any better at reducing chronic pain - just
at creating addiction and an epidemic of overdose death.

Many reasons have caused this, including the influence and marketing
tactics of the pharmaceutical industry, the willingness of Canadian
insurers to pay for drugs like OxyContin, as well as mistaken
assumptions about opioids by prescribers and dispensers.

Despite this, I'm not advocating we ban certain types of prescription
drugs outright. Knee-jerk decisions could leave people in pain, push
those addicted to use more dangerous types of opioids, or increase use
of illicit opioids such as heroin.

Instead, we need to slow down the tap of opioid supply. We need to
prescribe opioids less often, for shorter periods, with lower doses.
We need to look at other pain management options like physical rehab
and even meditation.

What we cannot and should not do, is stop it completely.

Here's just one example of how the best intentions to curb the opioid
epidemic can backfire if we don't think it through: When Ontario
acknowledged just how addictive OxyContin was in pill form, it removed
it from public drug plans. A tamper-proof alternative, OxyNeo, was
introduced, but under restricted access, leaving more potent opioids
easily accessible on its public drug plan.

It appears that overdose deaths have increased, in part, because of a
switch by prescribers to the more potent hydromorphone and fentanyl.
Plus, street drugs such as heroin and illicitly produced fentanyl have
also replaced OxyContin.

A core problem is the lack of access to alternative chronic pain
treatments. And that problem has deep roots in the Canadian
health-care system.

Not enough doctors and pharmacists learn about pain management during
their training. So it is not surprising that prescribers in both
hospital and community settings are ill-prepared to manage their
patients' pain or addiction, despite their best intentions. Indeed,
surveys of Canadian family physicians and pharmacists have found
significant gaps in their knowledge and use of evidence-based pain
management and safe opioid prescribing guidelines.

That's why it's important for patients to educate themselves about the
dangers of prescription opioids and the alternatives to their use.

Until 20 years ago, we didn't use opioids for chronic pain, like bad
backs or arthritis.

We managed it with physiotherapy and other effective tools like
mindfulness-based meditation - the way doctors in most other countries
manage it now.

So now what?

We need to make sure the remedy does not make a bad situation worse.
As a start, follow these suggestions:

Ask the prescriber for alternatives to opioids, especially for the
management of chronic pain.

Do not accept more than three to four days' worth of pain medications
for acute injuries or post-operatively.

Do not start with long-acting opioids if you haven't first tried
short-acting versions of the drug.

Store opioids safely and out of reach of others, especially
teenagers.

Do not alter the pills in any way (i.e. do not crush them). Doing so
will alter the time-release mechanism and enhance the risk of overdose.

Do not combine with alcohol or sleeping pills.

Have a naloxone overdose kit if taking opioids.

Let family members know you are taking these pills and how to use the
naloxone kit.

If addicted, get help as soon as possible.

If dependent, do not stop opioids suddenly - you will experience
withdrawal, including worse pain. Consult your doctor or ask for a
referral to an addiction specialist.

==============================================

Dr. Peter Selby is a professor in the departments of Family and 
Community Medicine, Psychiatry and Public Health Sciences. He is also a 
clinician-scientist in the addictions division and the director of 
medical education at the Centre for Addiction and Mental Health. 
Doctors' Notes is a weekly column by members of the U of T Faculty of 
Medicine.
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MAP posted-by: Matt