A female patient was prescribed hydromorphone for a herniated disk, after Tylenol No. 3 failed to control her pain. She took the medication for three weeks, at which point she tried to stop, and ended up in the ER with symptoms of withdrawal. Her pharmacist advised that strong opioids should be tapered, and suggested she revisit her doctor to discuss how to do this. Unfortunately, the earliest appointment was five weeks away. In the meantime, the patient was struggling with the discomfort of withdrawal: myalgia, nausea, restlessness, anxiety and weight loss.
The patient felt that the pain of withdrawal was worse than the pain from her herniated disc. A visit to a walk-in clinic ended in refusal to provide a bridging prescription to mitigate the withdrawal. The physician who initially prescribed the hydromorphone was leaving for vacation, which gave the patient a heightened sense of urgency. After four calls to the office, the physician issued a prescription for more hydromorphone, as well as for gabapentin (at the suggestion of the patient’s physiotherapist).
Unfortunately, the patient’s initiating physician had not discussed with her hydromorphone’s classification as a strong opioid, the risks associated with addiction, or the potential symptoms of withdrawal when stopping. Standards 2, 3 and 4 of Safe Prescribing of Opioids and Sedatives address the rationale for prescribing, discussing the treatment options and plan, and mitigating risk. The patient found a new physician who was able to institute a taper off the hydromorphone. Tapering medication should be done in a way to minimize discomfort to the patient. In this case, the tapering took 14 weeks, and required frequent follow-up and support from the health-care professionals involved, as well as her family. Eventually the patient was able to manage her pain without opioids, using other medications and treatment modalities.
The key message for physicians is to have a conversation with the patient to set expectations and address the risks versus the benefits of opioid treatment. Discuss potential complications, mitigate them from the start, and have a plan in place for if they happen. Opioids still have a role for treating pain. If they are the best option for the patient, the first priority is to prescribe safely when starting and stopping, and to have a plan in place for continuity of care during the process of weaning these medications.