Pre­scribe opi­oids as last re­sort for pain

The Hamilton Spectator - - FRONT PAGE - MOLLY HAYES

A team of doc­tors, re­searchers and pa­tients led by the Michael G. DeG­roote Na­tional Pain Cen­tre at Mac have re­leased new guide­lines around the use of opi­oids to treat chronic pain.

Cana­di­ans are the sec­ond high­est users per capita of opi­oids in the world. But as opi­oid pre­scrip­tion rates have con­tin­ued to rise over the years, so have re­lated hos­pi­tal vis­its and over­dose deaths.

“Opi­oids should not be first line ther­apy for chronic pain,” says McMaster pro­fes­sor and re­searcher Jason Busse, a prin­ci­pal in­ves­ti­ga­tor for the guide­line de­vel­op­ment, high­light­ing a key rec­om­men­da­tion from the re­port.

Sim­i­lar guide­lines for pain treat­ment were pub­lished in 2010 — but at that time, al­most all of the rec­om­men­da­tions en­cour­aged the use of opi­oids, he says.

To­day, in the face of an on­go­ing opi­oid epi­demic that is killing thou­sands of peo­ple every year, in­clud­ing more than 734 peo­ple in On­tario in 2015, the di­a­logue is shift­ing.

“You can­not pick up a news­pa­per with­out read­ing a story some­where about the opi­oid epi­demic and some­one who has been af­fected by an opi­oid over­dose,” Busse says.

How­ever, he notes there is still a di­vide in the med­i­cal com­mu­nity about the role of pre­scrip­tion drugs in this cri­sis.

The guide­lines — pub­lished Monday in the Cana­dian Med­i­cal As­so­ci­a­tion Jour­nal (CMAJ) — fo­cus on the treat­ment of pa­tients with chronic non-can­cer pain; not those with acute pain, or in pal­lia­tive care, who have spe­cific needs.

An es­ti­mated 15 to 19 per cent of Cana­di­ans are liv­ing with chronic (non-can­cer) pain.

The rec­om­men­da­tions in­clude try­ing non-opi­oid and even non­phar­ma­co­logic ther­a­pies first, when pos­si­ble — ac­knowl­edg­ing that op­ti­mal care op­tions such as phys­io­ther­apy and coun­selling are not read­ily ac­ces­si­ble in all com­mu­ni­ties.

For those who are deemed to re­quire opi­oid ther­apy, the guide­lines sug­gest re­strict­ing doses to a max­i­mum of 90 mg of mor­phine equiv­a­lents per day — in an ef­fort to re­duce the risk of over­dose. The pre­vi­ous guide­lines, re­leased in 2010, rec­om­mended a 200mg daily dose.

The ul­ti­mate goal should be to ta­per pa­tients down to a lower dose, Busse says, not­ing that for “legacy pa­tients” who may have been on opi­oids for quite some time, there could be ad­di­tional risks that could out­weigh the ben­e­fits of ta­per­ing.

Na­tional Pain Cen­tre Di­rec­tor Dr. Norm Buck­ley likens it to a pen­du­lum.

“Thirty years ago it was hard to get any­body to pre­scribe opi­oids. And then we be­came very pro­lific pre­scribers, and it may be the case that that wasn’t the right thing to do,” he says. “But at this point we have to rec­og­nize that what’s good (treat­ment) may vary be­tween pa­tients. We are try­ing to be more cau­tious with new pa­tients, with­out caus­ing dis­rup­tion or harm in the lives of ex­ist­ing pa­tients.”

The chal­lenge will be dis­sem­i­nat­ing the new guide­lines to physi­cians and pa­tients across Canada.

“The guide­lines are not self-im­ple­ment­ing. The fact that we have put to­gether a doc­u­ment that we be­lieve rep­re­sents a ro­bust ef­fort and cur­rent best ev­i­dence, does not mean it will au­to­mat­i­cally be­come ap­plied by ev­ery­body the day af­ter we pub­lish it,” Busse says.

“They’re not pre­scrip­tive. It’s up to the reg­u­la­tory bod­ies to cre­ate their stan­dards of prac­tice.”

But he is con­fi­dent, par­tic­u­larly given the on­go­ing opi­oid epi­demic, that the mes­sage will be re­ceived.

“I do think there is a very height­ened aware­ness around the is­sue. … I do think peo­ple are in­ter­ested, and it’s on their radar,” he says.

Lynn Cooper, pres­i­dent of the Cana­dian Pain Coali­tion, sat on a patient ad­vi­sory panel through the de­vel­op­ment of the guide­lines. She has been liv­ing with “per­sis­tent pain” as she calls it for 30 years as the re­sult of an of­fice ac­ci­dent, and hopes the new guide­lines will also spark con­ver­sa­tion about the re­al­i­ties of chronic pain — and the need for a mul­ti­dis­ci­plinary treat­ment ap­proach.

“There is an op­por­tu­nity, I be­lieve, right now to high­light the need for bet­ter ac­cess to pain man­age­ment in our coun­try,” Cooper says. “We re­ally need a na­tional strat­egy for pain.”

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