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In this issue: December 2016

www.cpso.on.ca

Word from the Chair
CPSO closure
Methadone Q&A

CPSO Closure

Please be advised the College will close in the afternoon on Friday, December 23, 2016 and will reopen on Monday, January 2, 2017. Best wishes for a Happy New Year!

Methadone Q&A

Q. I have a new patient with confirmed degenerative disc disease (DDD) who has a prescription for Hydromorphone Contin as well as a prescription for immediate release Hydromorphone to treat breakthrough pain. He also meets the DSM V criteria for opioid use disorder. The patient advises me that his doctor is no longer able to prescribe opiates, so, he has been "cut off". His medication was running out early each month and he was getting some from a friend until his new prescription became available. He feels that methadone will help him deal with the withdrawal but also feels that he will need something more for pain. He asked that I continue his opioid prescriptions and, if he can tolerate it, taper them. Can I prescribe both medications for this patient? If not, how will he manage his pain?

A. Opiates/opioids should not be prescribed for patients who meet the criteria for opioid use disorder and who are beginning methadone treatment. Any existing prescriptions should be discontinued. These patients are considered to be unstable and should not be prescribed other opiates during the stabilization phase.

Methadone or buprenorphine is indicated for the treatment of opioid use disorder and can be prescribed for this condition. In this case, the continuation of other prescription opiates is not appropriate. Although this patient may take some time to stabilize (as do many others starting methadone treatment) it is important that the patient understands that the use of opiates/opioids is problematic. The patient does not require both methadone and the former prescriptions. However, the patient will likely complain of pain while stabilizing on the methadone dose. It is important to educate the patient about pain.

The prescription of opioids can create a paradoxical response where the patient becomes more sensitive to painful stimuli (opioid-induced hyperalgesia). It is also possible that the withdrawal the patient was experiencing as a result of running out of medications early has created more pain. While it is important to provide relevant education so that the patient understands that once the dose is stabilized there will likely be an improvement in the level of pain, it is also important to help him set realistic expectations with respect to pain management.

Patients suffering from addiction and chronic pain are unlikely to be pain free. In counselling the patient it is important to concentrate on improvement in function.

Patients can consider the following options to help relieve pain:

Add acetaminophen or Ibuprofen for pain relief.
Increase physical activities (water aerobics, walking, yoga).
Practise mindfulness.
Use meditation exercises.

With reassurance and education many patients find that their pain is significantly improved.

Depression and anxiety can contribute to an increased sensitivity to pain stimuli. Improvements in underlying mood issues can help reduce the patient’s perception of pain. In addition, the development of coping strategies can help patients with their pain and help them manage without other medications. If the patient is still experiencing pain once stabilized on methadone, there are a number of non-narcotic medications that can be added to treatment.

If patients with chronic pain are still receiving narcotic medications from their primary care physician or pain doctor while stabilizing on methadone, a discussion with the appropriate physician should occur early during stabilization about the increased risk of toxicity and tapering to a lower dose versus immediate discontinuation.

The decision to immediately discontinue narcotic medications versus tapering them over time will depend on the extent of the debilitation resulting from the chronic pain syndrome. If it is agreed that the primary care physician or pain doctor will continue to prescribe narcotics for severe pain syndrome, then, a controlled dispensing approach to narcotics (weekly or daily dispensing) should be put in place with a taper plan if feasible. Patients should be encouraged to stop taking narcotics altogether in order to be eligible for take home doses of methadone.

Q. During the past year, my patient was on full carries, but, they were discontinued 3 times due to relapses. Can I reinstate his carries at a rate of one carry per week as indicated in the guidelines?

A. Following a relapse and once the patient has stabilized, the guidelines recommend a carry reinstatement rate of one carry per week until the original carry level is reached (as long as it occurs within a one year period). However, in the case of recurrent relapses reinstatement of carries may be managed more conservatively. In the face of recurrent relapses, reinstating all carries within a short period of time does not allow the patient to properly demonstrate ongoing sobriety and may reduce the motivation to stay drug free. One suggestion is to reinstate carries following recurrent relapses at a slower rate of one carry every 2 weeks to 4 weeks. The rate should take into consideration any mitigating factors such as employment needs.

Q. My patient has 6 carries per week and has tapered down to 30 mg methadone. This patient is ready to stop taking methadone for 3 days and start a suboxone induction. Can I leave the carries at 6 carries per week, or do I need to reinstate the carries at the rate of one carry per week?

A. Patients making the transition from methadone to suboxone experience withdrawal in the first week. It is recommended that carries be withdrawn in the first week of suboxone treatment and only be reinstated once the patient achieves a suboxone dose level that is comfortable and at which there are no more withdrawal symptoms. Once the dosage is stable and urine samples are drug free, the patient then meets the criteria for ongoing clinical stability (N.B. – some patients may take more than a week to stabilize). It is then possible to reinstate the carries at the previous rate of 6 carries per week. A locked box should be recommended and there should be a carry safety agreement as well as education around the risk of diversion of suboxone. This should be documented. Some patients may have a prolonged relapse to other substances after transitioning to suboxone. A slower reinstatement of carries of one carry per week is indicated for these patients once they are drug free.

Diane Doherty, Chair

Word from the Chair

2016 is winding down and this will be our last newsletter for the year. I am pleased to have this opportunity to introduce the members of the 2017 Methadone Committee. I would like to congratulate and welcome Dr. Lisa Bromley on her appointment to the Committee. Dr. Bromley is a family physician from Ottawa, a seasoned methadone prescriber and a most welcome addition to the Committee. Returning members of the Methadone Committee for 2017 include Drs. Steven Bodley, Michael Franklyn, Trevor Gillmore, Kumar Gupta, and Meredith Mackenzie and Barb Lent. We say goodbye and thank you to Dr. Karen Jones.

The 16^th Annual Methadone Prescribers’ Conference held on November 25, 2016 at the Allstream Centre was well attended and I very much enjoyed the opportunity to speak with a number of the prescribers who participated. This year, over 320 participants representing prescribers, case managers, and pharmacists registered to hear presentations on a wide variety of relevant topics.

It was a pleasure to have keynote speaker Dr. Michael Kaufmann, from the OMA’s Physician Health Program reflect on the importance of civility in medicine in his talk, Five Fundamentals of Civility for Physicians.

Various presenters spoke about learning how to help a methadone patient safely and realistically manage pain and expectations for improvement. This process takes time and we heard very clearly from Dr. Mark Weiss that it may involve restructuring your practice to ensure you do a functional assessment and can take the time to engage in patient education. Efforts to communicate to patients that their pain may not go away, but, that you can help them manage it can be augmented with a wide array of resources and tools useful to both the physician and the patient. We also learned about the impact of neuroplasticity and rewiring the brain to adapt to pain; helpful information to share with patients to help them understand that much of the pain is often not in the bones but the brain.

Afternoon plenary session highlights:

Dr. Valerie Taylor talked about the relationship between methadone, use of psychiatric medications, and, weight gain. Dr. Taylor stressed the importance of assessing for an underlying sleep disorder or depression that contributes to weight gain; the relationship to socioeconomic status and weight gain and, for many disadvantaged clients, the challenge that they face because, geographically, they may have easier access to fast food than healthy food.
Dr. Paul Dungey provided the Coroner’s update on opioid deaths. He reported that opioid deaths resulting from overdose are now equal to the number of people killed in motor vehicle accidents (MVA). His key point is that MVA deaths are down as a result of targeted long term public prevention messages while, at the same time, the current ease of access to many opioids means that overdose deaths continue to rise.
Finally, Dr. Ruth Dubin presented on the role of Project Echo, an incredibly innovative distance educational format that has established two programs in Ontario – one on mental health and the other, in partnership with CAMH, on addiction.

Other workshop topics included:

Flexibility and Refusal Skills
Aging and Addiction
Non-pharmaceutical Management of Chronic Pain
Q&A: Current Clinical Scenarios and the MMT Standards and Guidelines
The Only Way to keep Opioids in the Toolbox
Advanced Issues in Trauma Informed Care
Update on the Health Canada project: Family Physician & Opioid Prescribing
Dialectical Behavior Therapy in MMT
Treatment of Opioid Use Disorders in the Youth Population

Materials from these sessions are available on the CPSO website.

Directly following the conference, on-line survey conference evaluation forms were emailed to all attendees. We encourage all participants to take the time to complete the survey. The results of this survey will assist us in planning for next year’s conference. As I mentioned in my opening remarks at the conference, this is the last year the conference will be organized by the College and we are in conversation with CAMH and the Ministry to assume ownership of the event. CAMH is a leader in education and research in the field of addiction treatment and well positioned to take on this important educational offering.

CPD certificates have been prepared and mailed to those members who attended the conference.

Reflections from the Methadone Committee on Physician Assessments

On behalf of the members of the Methadone Committee, I would like to draw your attention to recurrent themes we are observing in reviewing the assessment reports. Of note, we continue to recognize the need for more education and support available to physicians regarding adherence to the methadone standards and College policy in the following areas:

Dosing Issues:

Specifically, the importance of documenting the reasons for dose adjustments and more frequent appointments for patients after dose increases.
Approving accelerated take home doses with no documentation regarding the rationale.

General documentation issues including:

Lack of detailed documentation including clinical notes with insufficient detail to adequately tell the patient’s story and to provide the rationale for dosing levels and carries.
Transcription errors and lack of unique notes.
Reliance exclusively on pre-populated templates or using the “cut and paste” method for notes which can lead to dose errors.

In this respect we encourage prescribers to review the Guidelines on a regular basis and reach out to more experienced colleagues if you have questions about managing challenging situations.

Finally, the Methadone Committee wishes all our prescribers and the Methadone Program support staff a safe and happy holiday and we look forward to working and supporting this program in 2017.

Please send your comments and feedback to:

qmdnewsletters@cpso.on.ca