Opioid Weaning program
Purpose and Rationale
The overall purpose of the Opioid Weaning Program (OWP) is to help non-cancer patients slowly reduce or eliminate their opioid use, as opioids poses many patient relevant issues for quality of life and safety.
- At its core this program is aimed at improving the quality of life and health of our patients
- The effectiveness of opioid therapy for chronic non-cancer pain is highly controversial. Tolerance and the possibility of hyperalgesia may mean that over time patients can eventually have either no change in their baseline pain, or even worse pain than if they had never started opiates
- Some people may be functional on their current chronic opiate regimes and attribute this to their opiate medications.
- However, pain levels can fluctuate over time. For instance, we know with low back pain that most people's pain will resolve on its own with time without surgeries or opioid medications.
- So, we may be able to taper opioid medications without increasing pain.
- Furthermore, with chronic opioid therapy physical dependence and other issues can develop. These can range from the very common and obvious, such as constipation, bowel dysfunction/abdominal pain, itching, fatigue and mental clouding, to more insidious, such as hypogonadism, depression, respiratory suppression, and disordered breathing in sleep
- Patients are at higher risk if they are older or have underlying medical conditions such as sleep apnea/other conditions that affect breathing, or affect the metabolism of the drug (renal impairment, or hepatic insufficiency). Also, if they take other high risk medications (especially those with sedative properties such as benzodiazepines, or anticonvulsants [e.g. gabapentin or pregabalin]).
- The use of other substances, such as alcohol or recreational drugs also substantially increase the risk of opioid medications.
- Addiction, misuse, or diversion directly affects the health and quality of life of patients and the community.
- Many other treatments, medications, and physical therapies can be used to control pain. We should periodically check if other treatment options may be more effective with lower side effect burden.
How the program works
The overall purpose of this clinic is to help non-cancer patients slowly reduce or eliminate their opioid use. This will be done through non-judgmental support to all who access this service, recognizing that each patient will have their own relationship with opioids, their own perception of the impact of this relationship and present in various stages on the continuum of use.
In addition, clinicians will continue to educate themselves with the goal of reducing the stigma that is often present when talking about opioid use. A strong emphasis will be placed on creating safety and rapport with patients, using non-stigmatizing language, and understanding that “people who use drugs are people”. The hope is to create an environment whereby patients feel confident in talking about and disclosing all substance use to manage pain.
An Opioid Weaning Program (OWP) that involves the pharmacy team and the MHW's (and is overseen/directed by the physicians). Similar, to how we refer to the memory clinic or to smoking cessation, PSFHT’s MDs could refer to the OWP.
Pharmacists developing a weaning plan for each individual patient and providing this in written format for the patient, their pharmacy and the chart. The MHW could provide periodic "check ins" to ensure the patients are coping.
All of this will be done with the Primary Care Physician heavily involved in the plan, and from a harm reduction perspective.
Initial focus will be on HIGH risk patients. In future, patients in medium or low risks will be addressed.
- Care Coordinator for each patient referred to the clinic
- Advise on proper opioid rotation and tapering protocols to achieve lowest effective dose
- Advise on adjunctive pharmacotherapy to reduce opioid need
- Support patients via close phone follow up while tapering opioids to manage withdrawal symptoms
- Coordinate with community pharmacies to optimize pain management plans
Mental Health Services:
- Support patients with clinical interventions identified to be contributing to ongoing challenges (ie: stress, anxiety , trauma , coping strategies, mindfulness, meditation)
- Linkages to resources for ongoing counselling support if needed
- Support patients through use of Behavior Therapy, Motivational Interviewing, and Relapse Prevention as used in Addictions Counselling frameworks
- Consult with team regarding harm reduction interventions and tapering plans
- Refers all patients to the clinic
- Works closely with the team, especially pharmacy, around tapering/de-prescribing
- Continues to be responsible for prescriptions for their patients
- Participates in virtual clinics as needed/available