Rupa is a family physician who took over a family practice with a number of patients on high doses of opioids.
"I took over a high-opioid-prescriber practice about seven years ago, after the prescriber suddenly left. Some of the patients were on very high doses—the highest was 1,200 mg of morphine a day—and I knew I couldn’t continue those prescriptions. Luckily, I had some experience working up North where there was a high prescriber, and I had already done a lot of opioid tapering and de-prescribing."
"So my clinic began that process. We tapered probably 40 to 50 patients. We established a “no oxycodone” policy in our clinic, because that drug was known to be sold and used on the street. This was welcomed by many in our community, as my clinic was located in a vulnerable neighbourhood. Through routine urine testing, we found people who were diverting their prescriptions—their urine tests were repeatedly negative for opioids."
"We did slow opioid tapering, and I tried to figure out how people got on those meds. I would hear about really difficult, horrible childhoods or years of spousal abuse. Years of violence. Middle-aged women would talk about their pain, which was fibromyalgia, which they had never heard of. I was able to label that for them and talk about it."
"Tapering was not easy because when someone is dependent on opioids, their brain is demanding it. They would yell, scream, threaten all kinds of stuff. The important thing was to get those people down to a reasonable dose of the drug or actually get them off of it. And most of them have stuck with me. I am still their family doctor and I have learned a lot from them."
"Only one person fired me. Most of the others are doing really well—most are off opioids, some are on a lower dose of opioids, and a couple of people went on methadone."
"Early on, tapering was horrible. I had a really tough time. I had two years of feeling like people hated me, and for someone who was generally liked, that was really hard. I would walk into meetings and someone would say, “How are you doing?” and I would feel like crying. I think that the interaction around tapering and hearing all of the trauma stories—it was hard. I was quite burned out. But I think it made me a better doctor in the end. I got over the need to be liked, which in the end makes you a better doctor. I think the need to please distracts physicians from being objective in their care."
"Judith Herman is a psychiatrist who writes about the importance of disinterest when caring for complex PTSD patients. Her book Trauma and Recovery was really helpful to me. She writes about the fact that the physician actually has to have disinterest in order to encourage empowerment. One definitely needs to have compassion for people. You want them to get better, and to feel like you care about what happens to them. But the compassion shouldn’t come along with this rescuer thing. It should be compassion with a limit. “Compassionate disinterest” expresses that. You remain neutral in the sense that you are encouraging the person to take ownership of their health care, but they still know that you care about them. It is a fine line, because it’s really easy to care about them and take over, or be disinterested and not have the warmth."
"The ACE study was also really helpful for me. I think this is the most important study in medicine, as it looks at the association between childhood abuse and neglect and multiple chronic diseases. The quality of one's childhood experiences greatly impacts future health, and understanding this is very important."
"I have been accused of being opioid-phobic by pain specialists because I advocate opioid tapering."
"I think that anyone who wants to treat chronic pain needs to have some sense of how to recognize and deal with mental health issues. I have big problems with pain specialists and pain clinics that don’t want to deal with mental health issues and do not provide the full spectrum of care that is needed in the chronic pain population."
"That’s why I think family docs are actually best suited to manage patients with chronic pain. We can address both emotional and physical health issues."
"I think doctors forget the issue of somatization, the fact that mental health issues can sometimes manifest with physical symptoms. When someone has continual abdominal pain but all the investigations are normal, instead of asking, “Hmm, what’s going on in their life?” they give them medication. Interestingly, research has shown that higher opioid prescribers are male and women physicians take more time with their patients. So I do wonder if there is a bit of a gender thing there. Sometimes you have to listen to patients and not just reach for a prescription pad."
"You need to take time with certain patients. I tell my residents, “Most times family medicine is pretty straightforward. But you are going to meet certain people that you have to take the time with, pull up a chair and listen to get the story.” The ones who have medically unexplained pain—what is actually going on?"
"We’ve created pain as a disease entity on its own because it was in the interest of pharma to do that. More and more, physicians are being trained to find a pill for every problem, instead of looking at the underlying root causes of disease and actually offering something that is a bit more holistic and durable. Exercise actually works, you know?"
"I try to resist saying things like, “You should do this. I think this is good for you.” Instead, I say, “Here are some of the options that you could consider.” The language is always “What do you think?” “Do you want to see the physio, do you want to see how things go for now, or do you want to try this pain medication?” It is important to reframe things in order to encourage patients to take ownership of their health care. This is one of the principles of trauma-informed care."
"Also, the majority of chronic pain patients have anxiety and depression. So you have to deal with that. There is not enough psychotherapy in Ontario. I worked in New Zealand for several months, and people there who had traumatic childhoods or issues of abuse could access psychology, and that was really great. They also had an exercise prescription program, where three months of funding was offered. There was much more focus on prevention and mental health care there."
"Here, we don’t have adequate mental health care supports, although I think family docs who are interested can provide a lot of good services for that. When we started the opioid tapering, we created a list of free yoga and exercise programs throughout the city. But for many patients, access to psychotherapy and good cognitive behavioural therapy is non-existent. I live in a city where there is an academic teaching centre and even I can’t access CBT. We should fund it as a province."