White Coat, Black Art

Meet the doctor who's become an expert in "de-prescribing" opioids

Dr. Andrea Furlan is an expert in pain management. Lately much of her practice revolves around "de-prescribing" patients with chronic pain. She believes doctors need to do the hard work with patients who want off the drugs, rather than pulling out the prescription pad.
Dr. Andrea Furlan is an Associate Professor in the Department of Medicine at the University of Toronto and a Staff Physician and Senior Scientist at the Toronto Rehabilitation Institute. (Twitter)

Dr. Andrea Furlan is an expert in pain management. The Toronto MD and researcher has spent years treating patients with chronic pain, and often that meant prescribing them opioids.

But lately, she's relying on her prescription pad less and less.

"These days have been different. I think I became an expert in de-prescribing opioids," she tells Dr. Brian Goldman, host of White Coat, Black Art. 

Dr. Furlan says she has a team made up of a nurse, a pharmacist, and a nurse practitioner who work with patients to taper their use of opioids.

She says many of her colleagues are sending their patients her way. 

"Nobody was taught how to de-prescribe, so they started sending their patients to me," she says.

Dr. Furlan led the team that wrote the 2017 Canadian Guideline for Opioid Therapy. She also put out a book and an ​app called  My Opioid Manager to help people taper themselves from opioids.

She says every patient on opioids is different, and the most difficult cases require a lot of attention.

"They require... a lot of motivation. We need to call these patients at home, it's difficult," she says. 

Dr. Furlan says  around 10 percent of the patients she sees are still in a lot of pain despite being on incredibly high doses of opioids, a phenomenon known as opioid-induced hyperalgesia. 

She believes those patients, and others, deserve the chance to get off opioids. 

"Every patient on long-term opioids deserves a trial of tapering," says Dr. Furlan.

To do that, she uses a number of techniques, including meditation, cognitive behavioural therapy, stretching, hypnosis and exercise. She also switches patients to a different opioids to control pain while tapering, allowing them to decrease their dosage. Using Suboxone is also an option.

She says the problem is that everyone wants a quick fix, and getting off opioids takes time. 

"I tell my patients that for every year that you have been on opioids, let's give one month to do the taper."

She says she's managed to get patients who've been using prescription opioids for 15 years to taper off the drugs. 

I think out society has become addicted to quick fixes. "

The work is difficult, and it takes time.- but she believes it's something more doctors need to offer their patients. 

"They don't need to keep prescribing (patients) opioids for the rest of their lives...You have to rethink and try to lower the dose and see what happens." 

The letters she gets from happy patients tell her it's worth the hard work.

"They say 'I didn't believe lowering the dose or stopping these opioids would make anything better. Now I can think clearer, my bowels are not a trouble anymore. I can concentrate, my hair has grown again...I feel like myself again.'" 


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