When a family physician relocates or retires, pain patients are often left in great distress. The most egregious stories involve patients being rapidly tapered off their medications or even asked to leave a family practice when they cannot be weaned from their opioid medication. These patients struggle to find new care providers.
Registrants have pointed to the College practice standard Safe Prescribing of Opioids and Sedatives as justification for refusing to see patients with complex care needs that include opioid medications. It is time once again to be clear on this matter. The safe prescribing standard does not prohibit long term opioid medication, it makes it safer. In many situations, it comes down to primary prevention: it is not about getting all patients off long term opioid treatment (LTOT), but about preventing harm to patients as a result of LTOT. Abrupt tapering or discontinuation of LTOT is both inappropriate and potentially dangerous.
The practice standard obliges registrants to engage in ongoing discussions with patients about the risks of LTOT, and to establish and maintain a patient on the lowest effective dose of medication. Registrants must document evidence of both the need and benefit of LTOT. Discussions with patients must include conversations about non-pharmacologic and non-opioid treatments for chronic pain. When patients are on LTOT, registrants must discuss safe storage of opioids in the home and Naloxone kits for patients and their family members. Further, the management of a patient on LTOT may unmask an opioid use disorder or other substance use disorder, which must also be managed. This may involve management by the family physician and may require referral and co-management with an addictions specialist. In all cases, management of chronic pain with LTOT involves documented discussions, appropriate examinations and investigations, and pharmacovigilance strategies like PharmaNet checks and (where appropriate) urine drug screening and random pill counts.
Treating pain is a core competency for every registrant in clinical practice. The expectations outlined above are minimum practice standards that registrants are required to uphold. The CMA Code of Ethics and Professionalism states that: Physicians must not exclude or dismiss patients from their practice based on their current use of, or request for, opioids or sedatives, or a suspicion of problematic use of prescription medications.
In the event of a complaint, discrimination may be considered unprofessional conduct worthy of sanction. The College acknowledges that this is challenging medicine, but medicine is a demanding occupation. A family physician who can manage diabetes or COPD is more than capable of providing primary care for the one in five adults who live with chronic persistent pain.