Dialogue n't ready to go worldwide yet, so let's fix that r | Page 18
s cheduled rather than PRN dosing.
Prescribe small doses to be dispensed
frequently (as often as daily). With
frequent dispensing, you will not need
to renew the script if the patient runs
out early.
6 If timely referral to opioid substitu-
tion treatment is not available, you
may prescribe buprenorphine yourself,
following the product monograph and
buprenorphine guidelines. It is a very
safe medication and patients with an
opioid use disorder do much better on
buprenorphine than on potent opioids.
7 Contact an experienced methadone
prescriber if you are looking after a
hospitalized patient on methadone or
buprenorphine. Occasionally the dose
may need to be tapered (e.g., if the
patient has started sedating drugs while
in hospital.) If a patient on methadone
is going to jail, ensure they can remain
on their dose of methadone while in
jail. This can be done by arranging to
have their last dose before incarceration
witnessed, thus meeting the require-
ments in Corrections Services Canada
with respect to dose.
Opioid tapering in a patient without an
opioid use disorder:
Tapering is indicated for “opioid failures”
(severe pain-related disability and high pain
scores despite a dose of 90-120 mg morphine
equivalents per day or more). Tapering often
improves mood, pain and function in these
patients. Tapering is also indicated for pa-
tients who experience dose-related complica-
tions such as fatigue, sedation, dysphoria, or
18
Dialogue Issue 3, 2016
sleep apnea. Tapering should be done slowly,
over weeks or months. Daily dispensing is
usually not necessary, nor is complete cessa-
tion of the opioid – patients often feel and
function better at a lower dose (closer to 50
mg morphine equivalents per day).
Addressing an aggressive patient:
The College’s Ending the Physician-Patient
Relationship states that it is reasonable to
discharge a patient from your practice if
they are threatening or abusive towards you
or other staff, or if you have proof that they
are selling your prescription (e.g., a report
from the police). Ensure that you terminate
the relationship in accord with the Col-
lege’s policy. The policy states that physi-
cians have to provide notice, be helpful to
the patient in finding another provider and
give them a reasonable amount of time to
do that, and provide care in the interim,
including renewing prescriptions.
Becoming familiar with the risks of
abrupt cessation of opioids, strategies for
overdose prevention, and resources to guide
tapering and assessment of opioid use
disorder may mitigate risks associated with
reducing opioid prescribing.
MD
Dr. Meldon Kahan is Medical Director, Substance
Use Service, Women’s College Hospital
Dr. Pamela Leec e is a Clinical Associate,
Substance Use Service, Women’s College
Hospital
Dr. Sheryl Spithoff is a Staff Physician,
Department of Family and Community
Medicine, Women’s College Hospital