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TORONTO REHAB TEAMS AIM TO TREAT PAIN WITH FEWER OPIOIDS

Many of the patients who arrive at Toronto Rehab have struggled with opioids for years. Fortunately, they leave with pain management strategies and a new lease on life.

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In 2011, Jason Herterich injured a muscle in his torso during a basketball game. Little did the Toronto-based athlete know that this injury would dramatically change his life. In 2014, while working as an energy consultant, the dull ache at the injury site, which had never gone away, got a lot worse. Herterich soon began experiencing intense full-body pain and fatigue, as well as depression and anxiety.

“The alarm system was going off in my brain,” he says.

He was diagnosed with severe fibromyalgia, a condition that often stems from an earlier trauma, and causes non-restorative sleep and chronic pain, and was prescribed several opioids by a family doctor. By 2017, Herterich was virtually bedridden, dizzy and extremely fatigued, and was losing his ability to speak and feed himself. “My parents thought I was dying,” he recalls.

At that time, Herterich was referred to Toronto Rehab by his family doctor, starting with a three-day in-patient stay. Doctors there quickly realized that the powerful drugs he was taking to manage his pain were causing his fatigue and low blood pressure. Over the following months, Herterich, now 29, was slowly weaned off his high-dose opioids. “It was very gradual,” he explains, which meant the side effects were minimized. “Six months later I could walk, drive and go to the swimming pool,” he says.

Safer use of opioids

It's the kind of outcome that Dr. Andrea Furlan, a senior scientist with the Toronto Rehabilitation Institute and its research arm KITE, and her team of fellow doctors aim to achieve with each patient. Their mission is to ensure safe, appropriate opioid use in Canada. Having watched with alarm the high rates of opioid prescriptions over the past decade, they're attempting to educate physicians about how to prescribe judiciously while assisting patients already on opioids to taper their doses.

The opioid issue in Canada is well documented. According to Dr. Furlan, in 2015, nearly two million Ontarians were prescribed opioids out of a total population of about 14 million, with many people given multiple prescriptions.

And often, doctors prescribe opioids when other medical and lifestyle modifications are available, she says. That leaves patients with many side effects. While initially they feel relaxed and pain free, over time, their dependence on the drugs grows, and they require higher and higher doses. Slowly, their quality of life diminishes as they begin to require other drugs for mood or sleep, explains Dr. Furlan.

That's when many seek the help of Toronto Rehab, where they meet Dr. Laura Murphy, the Institute's pharmacy clinical leader. Murphy works alongside a multidisciplinary team that includes physicians, a nurse, a physiotherapist, an occupational therapist and a social worker. They need this kind of wide-ranging support, as patients often take opioids while suffering from depression or other mood disorders, sleep issues and chronic pain.

Like with Herterich, they are assessed, and a program of tapering is recommended. “For many people, we may not stop their opioids completely,” says Murphy. “We help them get to the lowest effective dose.” She says she checks in with patients every two weeks or every month to ensure they're not having severe side effects, and to make changes to the plan if needed along the way. “They have to feel like we're going to partner with them,” she explains, adding that education around alternatives to opioids is a big part of the process.

“Over time, many people tell us their pain actually decreases and they can do things that they enjoy,” she notes. “They're happy to be free of the burden.”

Dr. Furlan says that although patients are successfully treated at Toronto Rehab, she wants to start at the source and change Canadian physicians' habits when it comes to prescribing opioids. She feels it's all too easy to write a prescription for the pain drugs – and much harder to wean patients off them. “People have to create the behaviours from the beginning,” she explains.

Better opioid management

Having helped develop the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain in 2010, Dr. Furlan is now co-chair of ECHO Ontario Chronic Pain and Opioid Stewardship — a project of the University Health Network — which she started in 2014.

It involves a weekly telementoring initiative in which an interdisciplinary team of pharmacists, nurses, addiction medicine physicians, psychiatrists, psychologists, physio and occupational therapists meet virtually with clinicians in remote areas of Ontario who verbally present complex opioid cases. The cases are then discussed by the team, and various drug management approaches are proposed.

Dr. Furlan is now focused on bringing Project ECHO to other provinces.

The success of the program, evidenced by positive feedback from clinicians, has led to a big uptake: About 30 professionals call in each week for guidance and consultation. “This builds a sense of community,” notes Dr. Furlan. “They feel supported.” And patients have their complex medication quandaries solved.

Herterich is one such patient who's felt supported by this approach to dealing with pain. “They have helped guide me to a solution,” he says. “I am now the master of my own body.”

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