Canadian Medical Association's Guideline for Opioid Therapy and Chronic Noncancer Pain
Written by Editor   
Tuesday, August 01, 2017 07:30 AM

The harms associated with opioid therapy are substantial. Although the evidence supports dose limits for patients beginning opioid therapy, those currently receiving high-dose opioid therapy constitute a distinct population, and tapering efforts should be individualized and should consider patients’ values and preferences.

This guideline recommends:

  • Optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids, for patients with chronic noncancer pain.

  • Patients with chronic noncancer pain may be offered a trial of opioids only after they have been optimized on nonopioid therapy, including nondrug measures.

  • Avoiding opioid therapy for patients with a history of substance use disorder (including alcohol) or active mental illness, and opioid therapy should be avoided in cases of active substance use disorder.

  • For patients beginning opioid therapy, restrict to less than 90 mg morphine equivalents daily (MED) and suggest restricting the maximum prescribed dose to less than 50 mg MED.

  • Patients already receiving high-dose opioid therapy (≥ 90 mg MED) should be encouraged to embark on a gradual dose taper, and multidisciplinary support should be offered where available to those who experience challenges.

In developing this guideline, authors included innovative approaches for key standards such as patient involvement, panel and committee composition, and competing interest management. We performed systematic reviews and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to meet standards of evidence assessment and recommendation development. Health Canada and a grant from the Canadian Institutes of Health Research provided funding for this guideline.

This guideline provides prescribers and patients with a basis for decisions about using opioids to manage chronic noncancer pain. Prescribers, patients and other stakeholders — particularly regulatory agencies or the courts — should not view the recommendations in this guideline as absolute. No guideline can account for the unique features of patients and their clinical circumstances; this guideline is not meant to replace clinical judgment.

The guideline developed 10 recommendations, 7 of which focus on harm reduction, and makes strong recommendations to optimize nonopioid therapy (including nondrug therapies) before considering a trial of opioids, and to refer patients struggling to reduce their opioid dose for multidisciplinary care. 

Read the full report here.