Family Medicine Recommendation #13: Do not initiate opioids long-term for chronic pain until there has been a trial of available nonpharmacologic treatments and adequate trials of nonopioid medications.

Choosing Wisely Canada: What shared decision making strategies or tools have you implemented in your practice for this recommendation?

Dr. Meldon Kahan: Shared decision making (SDM), when initiating opioid therapy for long-term chronic pain, can be one of the most problematic and contentious experiences you have with a patient. Your patient is in considerable, perhaps even debilitating, pain that is impairing daily life. As a provider, you know chronic pain does not respond as dramatically to opioid therapy as acute pain does, and improvements will be modest. Side effects and harms often include gastrointestinal upset, constipation, sleep apnea, fatigue, and falls. Then you have to consider the rare but serious risks; your patient (or someone for whom the prescription was not intended) could develop dependency or opioid use disorder. These factors make decisions about opioid trials different than any other SDM conversation.

Before initiating opioid therapy, I explain to patients that we both have responsibilities we need to consider and stay committed to in order for the trial to be successful.

I inform my patient about potential harms and risks of opioids. To guide the conversation, I use resources from the Institute for Safe Medication Practices Canada. These tools ensure that patients are aware that potential side effects of opioids can outweigh the pain relief. It keeps their expectations realistic. Starting the conversation this way helps me during motivational interviewing in subsequent visits to identify if we are still on the right track with prescribing. Beyond considering their personal values, patients need to take responsibility for keeping opioids stored safely and commit to lifestyle change and exercise to help control their pain.

CWC: What makes SDM around this topic challenging or rewarding?

MK: Many patients’ lives are severely impaired by chronic pain. They are depressed, are not functioning well, and have exhausted other treatment options. For this population, opioids can play an essential role in helping lead a normal life. But opioids cannot be depended on alone to help with chronic pain. They are a considerable cause of morbidity and mortality and should not be used as first-line therapy.

The tremendous misinformation among the media, the medical community, and the public is challenging. Physicians are hesitant to prescribe opioids for fear of being penalized by regulatory bodies and are either not prescribing them at all or tapering them too aggressively. When this happens, patients suffer, and so does the patient-physician relationship we have worked so hard to foster. The SDM process is rewarding when the therapeutic goals of a trial are met and your patient is able to achieve a standard of life and functionality he or she has not seen in years.

CWC: Why is SDM around this recommendation or clinical topic essential to you?

MK: I have been practising family medicine for 34 years and I have been in addiction and opioid research since the late 1980s. I have watched the entire life cycle of this drug class. The demographic characteristics of opioid users in my professional lifetime have changed from a few marginalized patients, who were using heroin, to a vast number of patients of all ages and social classes using prescriptions like oxycodone, hydromorphone, meperidine, and fentanyl.

The marketing of Oxycontin was one of the biggest medical scandals in history. In the 1990s, we were told opioids were extremely safe and not addictive, and we used them as first-line therapy. Now, our knowledge has changed and we understand the risks better. As physicians with the ability to prescribe, we have to acknowledge that we have contributed to “the opioid crisis.” We were not being critical or evidence-based enough in prescribing opioids in the past. Now, I think we have a professional duty to only start opioid trials with chronic pain patients when all other nonpharmacologic and nonopioid therapies have proved ineffective. I have made it my life’s work to help patients who have developed opioid use disorder, often from what was initially well intentioned prescribing. Caring for these patients using evidence-based tools is how we can choose more wisely with our chronic pain patients.

This article first appeared in Canadian Family Physician. The interview was prepared by Dr Kimberly Wintemute, Primary Care Co-Lead, and Hayley Thompson, Project Manager, for Choosing Wisely Canada.