Max Deschner is a medical student at the University of Ottawa
Maaike de Vries is an epidemiologist & PhD candidate at the University of Toronto
Jonathan Gravel is an epidemiologist & resident physician at the University of Toronto
Pain is one of the most common reasons patients present to emergency departments and primary care clinics, as well as a common complaint among patients treated by subspecialty services. Physicians will agree that treating pain is vital. Yet despite grossly inadequate training in pain management – physicians are expected to offer multimodal pain management (including pharmacological, non-pharmacological and behavioural therapies). All too often, patients with acute or chronic pain also do not have a complete understanding of what options should be available to them and how to access them. Needless to say, an informed and bidirectional discussion between providers and patients about pain management before an opioid prescription is written is an all too rare occurrence.
The root of the opioid crisis in Canada is complex: past pharmaceutical marketing strategies, antiquated harm reduction policies, lack of addiction services, and, of course, social determinants of health such as poverty all play a part. Among the drivers is widespread licit (and usually well-intentioned) prescribing of opioids for both acute and chronic pain, which has contributed to a marked increase in opioid dependence and overdoses.
Shared decision-making is an established, evidence-based model to increase patient engagement in important decisions about healthcare. As part of patient-centred care, shared decision-making can make patients and healthcare providers more accountable when prescribing and using opioids. Using this model, the healthcare provider introduces available pain treatment options and frames these options into a choice which the patient must make. This choice is informed by the treatment goal (e.g. no pain versus tolerable pain during daily physiotherapy exercises). The provider describes the risks and benefits of the proposed pain treatment options, and supports the patient in coming to a decision that best aligns with his/her individual needs and overall treatment goals. Both patient and provider share responsibility in deciding how to move forward. Shared decision-making therefore, levels the playing field by coupling individual values and preferences with physician knowledge in the process of developing a pain treatment plan for the patient.
Patients should always know that symptom management with medications is not their only option, nor does it need to be the first one. Most treatment algorithms list lifestyle changes as the first step. It would be unimaginable to treat diabetes or hypertension pharmacologically without at least discussing diet and exercise. Similarly, treating depression or anxiety with no mention of psychotherapy would be misguided. And yet, the World Health Organization (WHO) starts its pain treatment ladder with medications.
Recently, a few studies have looked at the effectiveness of shared decision-making in optimizing opioid-managed pain. One study reported a 50% decrease in the number of opioids prescribed to women following caesarean delivery when a shared decision approach was used. Shared decision-making has also been shown to increase physician satisfaction in the treatment of chronic pain, as well as patient satisfaction following discharge from the emergency department for acute musculoskeletal pain. Even patients who are already dependent on opioids may benefit from shared decision-making in their efforts to cut back and stop opioids.
Shared decision-making does not end when the mode of treatment has been chosen. Once a patient has been prescribed an opioid, for instance, both provider and patient must understand the role that the medication will play. They must be prepared to re-evaluate their expectations on a regular basis: how much, how often and for how long? Opioids are far from benign and thus, shared-decision making must be a continual and dynamic process. Even when used as directed, prescription opioids can result in adverse events that range in severity from dry mouth and constipation to dependence and fatal overdose. Patients are responsible for understanding the risks inherent in managing pain with opioids, and providers must help them appreciate these risks and decide when opioids are needed to achieve their treatment goal. Just because it was prescribed, does not mean it must be taken.
Likewise, providers and patients share responsibility for ensuring opioids are handled safely. Patients often do not use all of the medication prescribed to them. To ensure that fewer opioids are available for diversion, physicians should avoid over-prescribing of opioids. It is important to emphasise that storing opioids in a locked cabinet and disposing them at pharmacies and municipal drop-offs are easy ways to ensure they aren't diverted to those who would misuse them. Patients should know, and acknowledge, the risks that come with keeping opioid medications at home. For example, young children of women prescribed opioids are at an increased risk of opioid overdose.
Work is currently under way across Canada to give patients and providers more effective tools that can increase knowledge about both opioids and non-pharmacological pain treatments, and prevent harms from medications. For example, the Institute for Safe Medication Practices (ISMP) created the Opioid Stewardship Program, and has committed to working with the Canadian Patient Safety Institute and Patient Safety Canada to prevent harms from opioid medications. Recently, this collaboration launched “5 Questions to Ask about your Medications,” which aims to empower patients and caregivers to start conversations with their health care providers so they can learn how to use their medications safely.
Striking a balance between reducing inappropriate prescribing, while also properly treating pain, is difficult. However, greater accountability and engagement among patients and healthcare providers can enhance patient-centered pain management and could help to prevent the tragic outcomes of opioid use that are becoming all too ubiquitous. Shared decision-making can empower patients to work together with providers to tackle Canada’s opioid crisis.