I am a family physician practicing in North York. A few weeks before Christmas last year, I saw a patient who had been in a car accident. He was in significant pain, which he had been managing with anti-inflammatories. I asked about opioid use and he admitted that he also had been taking oxycodone (which he had purchased illicitly).
I asked a question about opioids knowing that I had not prescribed any to this patient because earlier that month I had reviewed the data available in my MyPractice Primary Care report —specifically the number of patients under my care who had filled a prescription for opioids in the past 6 months. I compared that data against my records and discovered that nearly 70% of those patients had received the prescription from someone else.
This prompted me to add a question about prescription and non-prescription opioid use in the EMR template I use when conducting periodic health exams.
It was a small change, but an effective one.
You can feel confident that you rarely prescribe opioids or that you do so responsibly. But that does not mean your patients are not receiving them from someone, or somewhere, else.
Much like asking about STIs, when you casually ask about opioid use you normalize the issue and patients are encouraged to open up. It leads to disclosure. Moreover, taking some time to review practice-level data (i.e., looking at your data when your patient isn’t in front of you) gives you the chance to review patients’ treatment plans and make decisions with clarity.
Knowing your data means you can start the conversation, ask the relevant questions, and have important discussions. You can ensure you do not prescribe conflicting medications. You can screen for risk of opioid use disorder. You can explore the availability of other pain relief therapies.
Another patient of mine recently had dental work and was prescribed a lot of Tylenol 3. Asking the question led to a discussion on safe storage (especially with adolescents in the house), the best way to dispose of unused medications (i.e., return to pharmacy), and the potential for drug interactions with the patient’s other medications.
Resources are available to help physicians navigate difficult conversations, a “soft” skill I feel is not always emphasized in medical school.
Is there a place for opioid use to manage chronic, non-cancer pain? Under the right circumstances, yes.
Dr. Joshua Tepper, CEO of Health Quality Ontario, echoed this sentiment in a tweet last fall: “The goal is not to eliminate opioid prescribing but to improve their safe use.”
Understanding risk can help ensure responsible care. One of my elderly patients with scoliosis has been managing her pain with Tylenol and Advil. She feels like these options are no longer effective. Another patient has end-stage vascular disease, with failed surgeries and no other potential for relief. Both would potentially benefit from an opioid.
In these cases, having a discussion about opioid use can offer the opportunity to do a risk assessment and, if appropriate, create an opioid contract to ensure two-way accountability and communication between the provider and the patient.
Screening for addiction can also help identify which patients may be misusing other substances. These individuals may be at higher risk of harms associated with some prescription medications.
Ten percent of the population could become addicted to anything. If you’re going to start a patient on a new medication like an opioid, you can mitigate the risk: do frequent check-ins and ensure the script is time-limited where appropriate, with no other narcotics prescriptions on the table. If a patient has been taking opioids long term, consider initiating a slow taper or rotating the medication.
A recent CIHI report confirmed that while the number of high-dose prescriptions of opioids is decreasing, the overall number of prescriptions is rising– an increase of almost 7% since 2012. Data show that 56% of patients who die of an opioid overdose were prescribed an opioid within 30 days of their death. Finally, a Health Quality Ontario public report reminds us, 1 in 7 Ontarians filled a prescription for opioids in 2015/16.
Numbers don’t lie, and data lend the weight of reality. National averages can capture the big-picture issue, but practice-level data can help position your role in addressing the ongoing opioid crisis and point you to areas that need improvement.
The data are available. What will you do?