Foire aux questions

The information in this section is not a medical opinion. The answers to the questions cannot take the place of a medical consultation, diagnosis or treatment. If you have any questions about your medical condition, consult a physician or another health professional. Before starting, stopping, changing or adjusting your treatment, medication or dose, consult your health professional.

The information in this section is not a medical opinion. The answers to the questions cannot take the place of a medical consultation, diagnosis or treatment. If you have any questions about your medical condition, consult a physician or another health professional. Before starting, stopping, changing or adjusting your treatment, medication or dose, consult your health professional.

Chronic pain

A pain specialist physician answers your questions

1. I’m a family physician. When treating pain, at what dose of short-acting opioid can I switch to a long-acting opioid?

It’s not so much a matter of dose as type of pain. For acute pain, which shouldn’t last long and should be relieved fairly quickly, it’s appropriate to use short-acting opioids, with some prescribed on an as-needed basis. This way, treatment can be adjusted to the user’s rapidly evolving situation.

For subacute pain, which will probably last longer, it’s appropriate to provide baseline analgesia with a long-acting opioid.

2. I’m a user and I’m seeing a doctor at a pain clinic. Why can’t I chew some opioid tablets even though I think it makes the treatment more effective?

Some tablets are meant to release the medication over 12 and sometimes 24 hours. This is called extended-release medication and the goal is to provide long-lasting relief. Chewing or breaking the tablet can change how long the medication is effective for. You will not be relieved for the full length of time.

Extended-release tablets also contain more medication. They are designed to release the medication gradually over 12 or 24 hours. Breaking the tablet can release the medication all at once and increase the risk of respiratory depression and other serious side effects.

3. Are prescription opioids the most effective type of pain medication for all types of chronic pain?

Prescription opioids are effective for treating some types of pain, for example, pain after surgery or from an injury. They are not effective for functional pain such as migraine, fibromyalgia or irritable bowel. It’s important to know that other families of drugs can relieve pain. The choice of product is usually determined based on the type of pain you have. Your doctor may decide not to use an opioid because it is not an effective option for your medical condition.

4. I’m a family physician and I’d like to know if opioid medications can be prescribed for pain relief for a person who is on methadone treatment.

Yes, for acute pain, for example, postoperative pain, a fracture or tooth extraction. A user who is receiving methadone treatment often needs a higher-than-usual dose of opioid pain medication because of his higher tolerance and because the pain may not be relieved by the usual dose. The dose of the opioid will then have to be tapered to prevent withdrawal. In this type of situation, the patient may relapse and abuse the tablets prescribed for him. For all these reasons, a physician who prescribes opioid pain medication and the physician who prescribed the methadone should speak to one another.

For chronic pain, there are alternatives to prescribing opioids. Opioids may be less effective in the long term and there is a potential for abuse. Other approaches include increasing the dose of methadone or taking a non-opioid analgesic, for example, anti-inflammatories and co-analgesics. Alternative approaches, such as physiotherapy and psychotherapy, should also be considered.
 

5. Is Dilaudid® (hydromorphone) 2 mg less potent than morphine 5 mg?

If we’re talking about equianalgesic doses, hydromorphone 2 mg in tablet form is equivalent to 10mg of morphine in tablet form.

6. Why can’t I get my opioids for a month like the rest of my medication?

Opioid pain medications are controlled drugs that can be dangerous. Unfortunately, they are abused by many users. For safety reasons and to help users to take their medications as prescribed, the quantity of medications they can be given is often limited.

7. Do I absolutely have to follow my doctor’s instructions for my opioid medication? I could try to take less when the pain isn’t so bad …

If you’re taking short-acting opioids, you can take the medication as needed. However, if you’re taking a long-acting form, it’s important to follow your doctor’s instructions.

If you would like to reduce the dose of your long-acting opioid, it would be a good idea to talk to your doctor. You can also talk to your pharmacist and he can contact your doctor.
 

A nurse from the pain clinic answers your questions

1. I’m afraid to ask my pharmacist for help when my pain is worse than usual. I felt that my previous pharmacist suspected I was a junkie and I had to find a new pharmacy. And what if he was right ? Could I really have an addiction problem?

To find out if there’s a loss of control with the medication, check for the following behaviours:

  • Non-compliance with the dosage regimen prescribed by the doctor by taking the medication earlier than scheduled or by increasing the dose;
  • Using pain medication to relieve symptoms other than pain (for example, to relax);
  • Trying to bring forward the scheduled refill date at the pharmacy or using the quantity prescribed more quickly than scheduled;
  • Taking the medication compulsively despite wanting to comply with the prescribed dosage regimen.

If you have any doubts, it’s important to discuss them with your doctor or the health care team. There are other ways to treat pain than with opioids if they are a problem for you. Your doctor’s job is to help you manage the pain or a possible addiction problem.

It’s also important to develop a relationship of trust with your pharmacist so that you can tell him what you are going through and he can help you find solutions.
 

2. I’m a community pharmacist. What should I do when a user asks me to refill his opioid medication earlier than scheduled?

It’s important to find out why the user wants his medication earlier than scheduled. If he’s leaving on a trip and the refill is scheduled for when he is away, his request is legitimate.

There’s also a possibility that the user didn’t understand the prescription. So it’s important to check if he took his medication as prescribed, if he’s afraid of being in pain and is taking too much medication or, on the contrary, if he’s waiting too long, until his pain is unbearable, and then doubles or triples the dose.

You must also consider that the person might have an opioid use disorder and check the Québec Health Record to see if he consults other physicians to get medication.

Whatever the situation, the pharmacist must notify the prescribing physician about the situation and decide with him whether or not the medication can be dispensed earlier than scheduled.

A psychosocial worker from the pain clinic answers your questions

1. I’m a family physician and I’m treating a user who has rheumatoid arthritis. Could psychosocial support or psychotherapy help relieve her pain?

Yes. A person with chronic pain not only has to cope with pain but also with all the different ways it affects his daily life, at home or at work. This can cause a lot of psychological suffering and distress. The person is going through a difficult grieving process (grieving the loss of a healthy body, activities that he can’t do anymore, loss of income, etc.). He has a greater risk of developing a depressive disorder and so needs psychological support as much as he needs support for matters of a practical nature.

It has been scientifically proven that people who choose to undergo therapy to work on themselves in order to accept their pain not only see their quality of life improve, but also see their pain diminish.
 

2. My pain isn’t relieved by what my doctor prescribes for me. He’s tried everything but nothing works. I’ve heard that methadone is much more effective and that the effect lasts longer. I’m fed up taking so many pills. Can CRAN help me?

It’s important to explain to your doctor that your pain is not alleviated and that you have contacted CRAN. However, you must know that CRAN is a centre that specializes in the treatment of opioid use disorders and not in the treatment of chronic pain.

 
If you think you have an addiction problem, there are professionals at CRAN who can help you, either by supporting your doctor or by treating you if necessary. Ideally, CRAN should be able to discuss your situation with your doctor; teamwork and your cooperation are essential. You must also know that the requirements for methadone or buprenorphine treatment are very different from those for treatment at a pain clinic. You will have to go to the pharmacy every day to get your medication, go to many appointments at CRAN and have urine drug screening tests.

If the problem has more to do with inadequate pain relief, your doctor can refer you to a pain treatment clinic.

A community pharmacist answers your questions

1. Can I take my friend’s opioid pain medications? I hurt myself and I need some.

Opioid medications can be dangerous: the wrong dose could cause respiratory depression and death. Opioid therapy is always started with a low dose which is then increased gradually. Tolerance develops and the risk of respiratory depression decreases in a regular user.

If someone you know is taking a high dose of opioids and does not develop a respiratory problem, it means they have developed tolerance over time. If you take these medications and you weren’t taking them before, the dose might be too high and cause serious problems. Other side effects or drug interactions must not be underestimated either.

To make sure treatment is safe, opioids must be prescribed by a doctor. The doctor will also assess the cause of the pain. He may order examinations or tests in order to make a diagnosis. Also, the appropriate treatment may not be treatment with opioids at all, but with a medication from another family of drugs, surgery, physiotherapy, etc. Remember also that opioids only act on the pain, not on the cause of the pain.
 

2. What are the most common side effects of opioids? I’ve heard that people are always constipated when they’re on morphine …

The most common side effects are drowsiness, nausea and dizziness, especially at the start of treatment, and they are generally short lived. Constipation is common; it usually lasts for as long as the person is taking opioids. Healthy lifestyle habits are recommended, such as drinking enough water, making sure you have a high-fibre diet and exercising. A prescription for laxatives can also help.

Opioid use disorders

A physician from CRAN answers your questions

1. I’m a family physician. For the past two years, I’ve been following a user who takes opioids once or twice a week on average. He has to take his dose of methadone in front of a pharmacist four days a week. This user would like to have more take-home doses. What clinical parameters need to be considered?

The main criterion in deciding to allow take-home doses of methadone or buprenorphine is the user’s level of organization. A person who uses is not necessarily disorganized. It’s important to have an overall picture of his situation, which includes:

  • attendance at medical appointments;
  • the progress of treatment and behaviour with the health care team and at the pharmacy;
  • overall health and living environment;
  • ability to keep the take-home doses in a safe place;
  • understanding of the risks associated with the medication for himself and other people (for example, make sure the user clearly understands the risk of taking two doses in the same day and that a dose of methadone can be fatal for someone who doesn’t normally take opioids).
2. When can the first take-home dose of methadone or buprenorphine be prescribed?

According to the Collège des médecins du Québec guidelines, the first take-home dose can be prescribed three months after starting methadone treatment or two months after starting buprenorphine treatment (this medication is safer than methadone).

This length of time is given by way of indication only. It is a window that allows the physician or health care team to build a relationship of trust with the user and collect the necessary information.
 

3. I’m a family physician. A user has asked me to increase his dose of methadone: he complains that it doesn’t last 24 hours. However, during the consultation, he didn’t seem to be in withdrawal. When I went to see him in the waiting room, he was asleep in his chair. This seems to indicate that his dose is too high. What should I do?

Check what time he took the medication at and determine whether it is one of the following situations:

  • If the discomfort occurs within hours of taking the methadone, you must explore the user’s perception of the discomfort with him and point out to him that he even seems drowsy. You must also find out if he is using psychotropics, which could explain the drowsiness.
  • If the user’s discomfort occurs in the hours before he takes the methadone and he doesn’t feel drowsy in the hours after taking it, the dose can be increased. Drowsiness can also be caused by insomnia or some other reason unrelated to the methadone. That’s why it’s important to check what time it was taken at.
  • Users who metabolize the medication quickly may experience drowsiness post-dose and symptoms of withdrawal before the end of the 24-hour period. If this happens, it may be appropriate to split the dose in two.
     
4. I’m a family physician and I have a patient who has been on methadone treatment for five years. He has a generalized anxiety disorder that he refuses to take medication for. At first, my patient managed to reduce his heroin use significantly, but he gradually started taking the same amount as before, despite successive increases in the dose of methadone. He tells me that only heroin is able to relieve his anxiety. However, he really wants to stop using. Must I deduce that methadone treatment doesn’t work for this patient?

Some users have difficulty stopping using despite the prescribed methadone treatment. When this happens, it’s important to work in collaboration with other professionals to optimize the addiction treatment. This user would benefit from psychosocial support and acupuncture to learn how to manage his anxiety. To obtain these services, he can contact CRAN, his local community services centre (centre local de services communautaires – CLSC) for psychological support or a private acupuncture clinic. Acupuncture’s success in helping people with an opioid use disorder is scientifically recognized.

A nurse from CRAN answers your questions

1. I’m a community pharmacist. It’s Monday and I’m calling you because on Saturday, Mr. X came to the pharmacy after missing his doses at the counter four days in a row. He said that he hadn’t missed any because he had some of his own, that he had collected over time. Mr. X is currently on buprenorphine 16 mg. I decided not to give him any, without being able to confirm with you if this was the right decision because your services are closed on the weekend. Did I make the right decision?

Yes. A pharmacist should not provide buprenorphine after three missed doses even if the patient says he took his own medication. The same applies to methadone. It’s important to refer the patient to his health care team, which will have to reassess the patient before restarting the prescription. The dose will be lower, to be safe. The team will also look into the matter of the hoarded doses doses.

2. I’ve just started my treatment and I have to leave in six months for Western Canada. I’ll be spending three months in a place that’s a long way from any large urban centres. What are my options?

It’s important to clearly understand that opioid addiction treatment has a number of restrictions, including medication management. The Collège des médecins du Québec’s guidelines do not authorize more than one month of take-home doses for stable patients. You can change pharmacy provided the new pharmacy dispenses the medication and accepts prescriptions written in Quebec. As a last resort, you can be weaned off the medication. However, it would be an enormous challenge to apply this solution in such a short period of time.

3. I’m having methadone treatment and I’d like to transfer to buprenorphine, but I’m afraid to because I heard that if I have an accident such as a fracture, buprenorphine will make pain medication ineffective.

If the dose of buprenorphine is less than 8 mg, pain can be effectively relieved with opioid medications.

At a higher dose, buprenorphine’s properties effectively reduce the efficacy of other opioids in relieving pain. In this case, buprenorphine will be discontinued temporarily. It is recommended to plan to have a short-acting medication that will make up for the buprenorphine, while relieving the pain.

4. I’m a family physician and I’d like to know if opioid medications can be prescribed for pain relief for a person who is on methadone treatment.

Yes, for acute pain, for example, postoperative pain, a fracture or tooth extraction. A user who is receiving methadone treatment often needs a higher-than-usual dose of opioid pain medication because of his higher tolerance and because the pain may not be relieved by the usual dose. The dose of the opioid will then have to be tapered to prevent withdrawal. In this type of situation, the patient may relapse and abuse the tablets prescribed for him. For all these reasons, a physician who prescribes opioid pain medication and the physician who prescribed the methadone should speak to one another.

For chronic pain, there are alternatives to prescribing opioids. Opioids may be less effective in the long term and there is a potential for abuse. Other approaches include increasing the dose of methadone or taking a non-opioid analgesic, for example, anti-inflammatories and co-analgesics. Alternative approaches, such as physiotherapy and psychotherapy, should also be considered.
 

A psychosocial worker from CRAN answers your questions

1. How long will I have to wait for methadone or buprenorphine treatment?

The sooner you register, the sooner your name will be put on the waiting list. You can expect a wait time of around four to six weeks. To increase your chances of getting treatment quickly, we recommend that you apply at other places too: at the Hôpital Saint-Luc (Université de Montréal Hospital Centre), the Herzl Clinic at the Jewish General Hospital or the addiction rehabilitation centre (centre de réadaptation en dépendance – CRD) in your region.

You can call CRAN at 514 527-6939 any time to check the status of your application and to obtain psychosocial support in the meantime.

2. What should I do: go to detox or have methadone or buprenorphine treatment?

In general, a detoxification centre is recommended if

  • you have only been using opioids for a short while (less than a year);
  • you find the opioid addiction treatment program too restrictive because it requires a high level of commitment: daily visit to the pharmacy to get the medication and weekly appointments at CRAN at the start of treatment;
  • you would like to commit to short-term treatment rather than a medium- or long-term program, i.e., that spans several years, as is often the case with methadone or buprenorphine treatment.
     
3. I don’t live in Montreal. Can I still apply to CRAN?

You can, but people who live in Montreal will be given priority. It’s advisable to apply to the Hôpital Saint-Luc (Université de Montréal Hospital Centre), the Herzl Clinic at the Jewish General Hospital or the addiction rehabilitation centre (centre de réadaptation en dépendance – CRD) in your region at the same time.

4. Do I have to have psychotherapy if I’m admitted to CRAN?

No. The psychosocial worker in the health care team is there to offer support if you want it to help you cope both with psychological difficulties and in dealing with housing assistance, food banks, social assistance, tax returns as well as with the Court, the Régie de l’assurance maladie du Québec [Quebec health insurance board], etc.

You will be expected to see your psychosocial worker from time to time to maintain contact, without it being psychotherapy.

Medication cannot be the answer to all your concerns or difficulties. We believe that by accepting your psychosocial worker’s support, you will be giving yourself the best chances of succeeding.
 

5. I’m a user and I’ve heard about the NADA protocol. What is it?

The NADA protocol is an acupuncture technique that is used only in the ears. It is intended for people who would like help to cut down or stop using, alleviate withdrawal symptoms, improve their sleep quality and manage their anxiety. CRAN offers acupuncture on request and free of charge to users receiving treatment for opioid dependence.