Manitoba doctors face delicate balance when prescribing opioids

The word opioid is becoming more synonymous with the massive drug crisis sweeping North America however opioids have also been used safely for decades in surgery and to manage pain.

“Opioids specifically refer to medications that act on opioid receptors, which are receptors that are found throughout the body,” Dr. Ryan Amadeo, medical director for the WRHA’s pain program and the acute pain service program at the Health Sciences Centre, said.

He explained opioids are most often used as part of an anesthetic in a surgical setting, or for pain management.

“About 30 years ago, you would have only prescribed these medications – outside of an anesthetic – for somebody who had cancer or at end of life,” Dr. Amadeo said.

Tweet This Click to share quote on Twitter: "About 30 years ago, you would have only prescribed these medications - outside of an anesthetic - for somebody who had cancer or at end of life," Dr. Amadeo said.

“In the late 90’s, there was a movement to consider pain as the fifth vital sign. And there was another movement that said we should treat the treatment of pain almost as a basic human right. And that drove people to want to use these medications – I’ll say more liberally, but more widespread prescribing – for patients who no longer had just end of life illness.”

The transition from using opioids for a very small number of patients to using it for far more people with varying degrees of pain meant doctors began writing prescriptions more frequently.

“Now, in the past five years, we’ve started to change that,” Dr. Amadeo said.

“We’ve taught a generation of prescribers – doctors, nurses, pharmacists – to prescribe these medications very early in care, and now we’re moving back towards the idea that probably these medications don’t do as much as we thought they did on the benefits side.”

Tweet This Click to share quote on Twitter: "We've taught a generation of prescribers - doctors, nurses, pharmacists - to prescribe these medications very early in care, and now we're moving back towards the idea that probably these medications don't do as much as we thought they did on the benefits side."

“We are the highest users of opioids in the world – Canada’s second only to the United States,” Dr. Erin Knight, medical director of the Health Sciences Centre‘s Addictions Unit echoed.

“Anybody who’s on prescribed opioid medications long-term is going to develop both tolerance and physiological dependence to those medications,” Dr. Knight said.

She said this is true regardless of whether or not someone is addicted to their medication. But there are a number of red flags that indicate it’s time for doctors to ask a few more questions about how their patient is handling the prescription.

LISTEN: The number of Manitobans diagnosed with opioid addictions is still increasing.

“Some of the things that make us start thinking there might be a problem with the medication use is things like running out of medication early, lots of asking for early refills or having things happen where patients are coming in and saying that their medications were stolen or lost multiple times,” Dr. Knight said.

“Things like chewing pills rather than swallowing them, crushing them and snorting them or even injecting them.”

Tweet This Click to share quote on Twitter: "Things like chewing pills rather than swallowing them, crushing them and snorting them or even injecting them."

Dr. Knight said the best thing for patients with an opioid use disorder is to get on replacement therapy as soon as possible.

“Detoxification from those medications, so tapering off of those medications, for somebody who truly has a diagnosis of opioid use disorder, is not recommended,” she said. “That’s because there’s a very high risk of relapse, and when somebody’s come off of those medications they lose that tolerance very, very quickly, so if they go back to using their medication – or the illicit opiate, if it’s illicit opiates – they’re at very high risk of overdosing.”

“We know that when people have an opioid use disorder, if they go through a detoxification process from that opioid, their risk of morbidity and mortality actually increases significantly,” Dr. Knight said.

Tweet This Click to share quote on Twitter: "We know that when people have an opioid use disorder, if they go through a detoxification process from that opioid, their risk of morbidity and mortality actually increases significantly," Dr. Knight said.

She explained Manitoban doctors have predominantly used methadone in cases of opioid addiction, but Suboxone, a combination of buprenorphine and naloxone, is increasingly viewed as the gold standard for treating opioid use disorder.

But the goal is to see better pre-prescription screening preventing addictions from happening in the first place.

“Every patient to whom I’m about to prescribe opioids to, I say we should do everything other than this,” Dr. Amadeo said.

Tweet This Click to share quote on Twitter: "Every patient to whom I'm about to prescribe opioids to, I say we should do everything other than this," Dr. Amadeo said.

Doctors run through a risk assessment checklist when considering whether patients would benefit from a course of opioids, and Dr. Amadeo said the importance of being vigilant has increased in this day and age.

“We look at a personal history of struggling with other substances, we look at a current or a past history of untreated mental health issues – not that that would preclude prescribing but we would want to put a priority on managing their mental health in addition to their pain,” Dr. Amadeo explained.

He highlighted the need to identify risks to the patient, which do include addiction. Dr. Knight said studies find the chance of someone getting addicted to their opioid prescription at about 10 per cent – though some have even gone as far as to estimate the figure at 25 per cent, which she considers a bit high. But still, “it’s not insignificant.”

Both note opioids aren’t just risky for those to whom they are prescribed.

“We know that unused prescription opioids find their way into the wrong hands, and can cause harm,” Dr. Amadeo said.

Tweet This Click to share quote on Twitter: "We know that unused prescription opioids find their way into the wrong hands, and can cause harm," Dr. Amadeo said.

Dr. Knight reiterated someone prescribed opioids has built up a tolerance to a certain dose and said that should someone else take that same dose, it has the potential to cause possibly significant amounts of harm.

She said it’s a good idea to buy a lockbox to store medications in if you’re prescribed opioids, so you can be sure no one else has access to the drugs.

As the risks of these kinds of prescriptions become increasingly well known, people are beginning to ask questions when opioids come into the discussion.

“People are concerned and I think some of that concern is good – if it’s caution, I think it’s good – and sometimes it’s a matter of sitting and talking about the goals and the objectives – what we can expect from these medications,” Dr. Amadeo said.

WATCH: Opioid prescriptions have gone up in certain parts of the country, such as Manitoba. (Nov. 2017)

1:21 ‘Prescription trigger happy’: Opioids being dispensed at alarming rate

He finds the main question from patients deals with the sedation aspect, as someone on a course of opioids can be nauseous and feel foggy and fatigued.

One thing both Dr. Amadeo and Dr. Knight said is key to managing prescribed opioids is how the drugs are dispensed.

The medications prescribed in quantities covering one month maximum. This helps keep a closer eye on how the patients are handling the prescription and sets a limit to the amount received in one go and minimizes the potential for harm and abuse.