Prescribe opioids as last resort for pain
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.”