New opioid guideline for chronic non-cancer pain focuses on preventing harm

A new guideline for prescribing opioids for people with chronic non-cancer pain is aimed at helping health care professionals in Canada limit use of these addictive and potentially lethal drugs. The guideline, published in CMAJ (Canadian Medical Association Journal) contains 10 recommendations, of which 7 are focused on preventing harm from opioid use.

"Opioids are not first-line treatment for chronic non-cancer pain, and should only be considered after non-opioid therapy has been optimized," says guideline lead Jason Busse, an associate professor of anesthesia at the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ont., and researcher for the National Pain Centre. "There are important risks associated with opioids, such as unintentional overdose, and these risks increase with higher doses."

Chronic non-cancer pain is defined as pain lasting more than three months that negatively affects quality of life and interferes with daily activities. An estimated 15% to 19% of Canadians experience this type of pain.

This guideline incorporates all new evidence published since the last guideline was issued in 2010. An innovative approach was taken in developing the guideline, with involvement from chronic pain patients across Canada, clinicians with expertise in pain management and diverse views on the role of opioids, as well as researchers.

The guideline does not address opioid prescribing for patients with pain due to cancer, or those with opioid addiction or opioid use disorder.

Canada has the second highest rate of opioid prescribing in the world, and the highest when measuring daily doses. Hospital visits for opioid overdoses as well as fatalities have continued to rise in recent years.

The recommendations for health care providers focus on minimizing harm in a range of patients with chronic non-cancer pain, including people with current or past substance use disorders, other psychiatric disorders, and persistent pain despite opioid therapy.

Key recommendations:

• Maximize non-opioid treatment: When considering therapy for people with chronic non-cancer pain, the guideline recommends optimizing non-opioid pharmaceutical as well as non-pharmaceutical therapy before considering opioids to avoid dependence, addiction and unintentional overdose.
• Pain despite optimimal non-opioid treatment: For people with chronic pain despite opioid therapy optimization and without substance use disorders or other psychiatric issues, the guideline suggests a trial of opioids.
• Opioid dosing: For people beginning opioid treatment, the guideline recommends restricting dosing to less than 90 mg morphine equivalents of opioids per day and ideally less than 50 mg, rather than having no upper limit for prescribing.
• Opioid tapering: For patients currently using 90 mg morphine equivalents of opioids per day or more, the guideline suggests tapering to the lowest effective dose, and possibly discontinuing. Tapering can be paused or discontinued in patients who develop a substantial increase in pain or decrease in function persisting more than one month after a dose reduction.

"Canadian physicians' awareness of and adherence to the 2010 Canadian guideline recommendations for use of opioids to manage chronic pain have been limited," write the authors. "We have formally explored barriers to implementation and used the findings (e.g., excessive length of guidelines) to guide design and format of the current guideline."

The guideline and related material may be found at http://nationalpaincentre.mcmaster.ca/guidelines.html. There is also an app available at https://www.magicapp.org/public/guideline/8nyb0E to help physicians and patients work through shared decision-making on the topic.

The new guideline is consistent with the 2016 United States Centers for Disease Control and Prevention (CDC) guideline's recommendations around dose escalation. It differs, however, in the involvement of clinical experts with diverse views toward opioids for chronic non-cancer pain, a dedicated patient advisory committee, restricting recommendations to only areas in which sufficient evidence exists, and in only allowing panel members without important financial or intellectual conflicts of interest to vote on recommendations.

"Guidelines are not self-implementing, and there is an important lesson to be learned from the limited impact of the 2010 guideline. Publication of the 2017 guideline must be accompanied by a dedicated knowledge transfer and implementation strategy if it is to play an important role in addressing Canada's opioid crisis," said Dr. Busse.

The guideline group is seeking funding to help communicate these opioid prescribing guidelines and ensure widespread uptake and application of the recommendations.

In a related commentary, Drs. Andrea Furlan, Toronto Rehabilitation Institute, and Owen Williamson, Monash University, Melbourne, Australia, write that the aim of the updated guideline " ... is to promote safer and more effective opioid prescribing to the small proportion of patients with chronic noncancer pain who may benefit from their use, and this may well be achieved."

However, the opioid crisis will not be solved without a national strategy that offers non-opioid pain relief for people with long-term pain.

"The updated guideline will not address the public health crisis related to opioids without support from a comprehensive national pain strategy to ensure evidence-based alternative treatments for the one in five Canadians currently living with chronic pain," write the commentary authors.