Dialogue n't ready to go worldwide yet, so let's fix that r | Page 12

time, for the right patient, in the safest way. “We need to find the balance,” Dr. Mur- phy says, “just like any other medical tool.” Shifting to evidence- based prescribing “We need to give physicians the education to manage these patients properly.” Complicating matters is the popularity of the black mar- ket for opioids. Dr. Dungey shows a web page advertising illicit fentanyl, which he found in just a few clicks. Websites like these are troubling, but he rejects the argument that changing pre- scribing patterns won’t affect illicit drug traffic. Most people who suffer opioid abuse have their first exposure from prescribed (or diverted) products, he says. In other words, black market websites – as popular as they may be – are not most people’s introduc- tion to opioids. When you decide to prescribe opioids to someone, he says, you need to do so in cor- rect, non-escalating doses, with functional assessments, and with plans to wean people down. “It’s not happening often enough,” Dr. Dungey says. “We need to give phy- sicians the education to manage these patients properly.” The Canadian Guideline for Safe and Effec- tive Use of Opioids for Chronic Non-Cancer Pain (under the stewardship of the Michael G. DeGroote Institute for Pain Research and Care) is under revision to ensure it reflects evolving evidence and today’s envi- ronment. The updated guideline should be released in early 2017. The Canadian guide- line and the more conservative guideline from the U.S. Centers for Disease Control 12 Dialogue Issue 3, 2016 and Prevention are available at http://www.cpso.on.ca/ CPSO-Members/Continuing- Professional-Development/ CPD-Practice-Improvement- Resources/Medical-Expert- Role-Resources. But the dosages only tell part of the story. The dosage – whatever it is – is not the take home message, says Dr. Murphy. “We should be magnifying the functional score. If you’re using universal precautions and the guidelines, the watchful dose becomes irrelevant.” At his clinic, Dr. Murphy sees bad situ- ations at either end of the spectrum. For every patient who has a doctor who won’t prescribe anything for pain, there’s another patient who is taking 1000 mg of morphine but who has never had a functional assess- ment done. The pendulum should be in the middle, Dr. Murphy says. Underprescribing can be just as much of a problem as overprescrib- ing. “Safe prescribing is the answer,” he says. In a way, the current conversation about opioids reminds Dr. Dungey of a previous prescribing debate. “When I started practising in 1989, there was an overprescription of antibiot- ics for viral illnesses. It has taken us two decades to change that medical culture,” says Dr. Dungey. “Now we use best evi- dence on when to use antibiotics or not, and which are best. There’s a huge amount of evidence-based research in that field, and I kind of feel we’re in the infancy of that again on this issue.” MD