New Guideline Recommends Opioids Only as a Last Resort

Liam Davenport

May 15, 2017

Canadian physicians are being advised to prescribe opioid medication only as a last resort for patients who have chronic pain that is unrelated to cancer.

The new clinical guideline focuses on harm reduction and incorporates evidence published since 2010, when the last national opioid use guideline was published.

Data show that Canadians are the second highest users per capita of opioids in the world and that rates of opioid prescribing and opioid-related hospital visits and deaths are rising rapidly.

"Canada is in the midst of an opioid epidemic. The guideline aspires to promote evidence-based prescribing of opioids for chronic noncancer pain," lead author Jason W. Busse, DC, PhD, Michael G. DeGroote National Pain Center, McMaster University, Hamilton, Ontario, Canada, said in a release.

The guideline was published online May 8 in the Canadian Medical Association Journal.

User-Friendly Format

The guideline was developed in accordance with the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system by a four-person steering committee in conjunction with a guideline panel and a clinical expert committee consisting of 13 clinicians each and a 16-member patient advisory committee.

The investigators reviewed the 2010 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, as well as six other recently published guidelines. They then conducted a systematic search of the AMED, CINAHL, Cochrane Library, Embase, MEDLINE, PsycINFO, and PubMed databases.

The groups then conducted a systematic review of the evidence, including an assessment of the risk for bias, and developed three categories of guidance: recommendations, which were supported by evidence from randomized controlled trials or observational studies; good practice statements, which were supported by indirect evidence; and expert guidance, which were supported by little or no published evidence.

After a public consultation on the Canadian National Pain Center website, which generated more than 500 comments, the draft guideline was reviewed by an external committee.

The final document comprises 10 recommendations, seven of which are concerned with harm reduction. The guidelines highlight five recommendations in particular, the first of which focuses on maximizing nonopioid treatment.

Specifically, they emphasize the importance of optimizing nonopioid pharmacotherapy and nonpharmacologic therapy, because adding opioids to nonopioids may achieve "modest improvements" at the expense of a "small but important risk of nonfatal and fatal unintentional overdose, very frequent physical dependence and frequent addiction."

The guidelines also recommend that a trial of opioids be conducted only in patients with chronic noncancer pain who do not have a current or past substance use disorder or other active psychiatric disorders and "who have persistent problematic pain despite optimized nonopioid therapy."

They strongly recommend that the prescribed dose when beginning opioid therapy be restricted to less than 90 mg morphine equivalents daily (MED). The guidelines also suggest that the dose be restricted to less than 50 mg MED, although they acknowledge that not all patients will be willing to accept the lower dose.

Finally, they recommend that for patients who are currently taking a dose of 90 mg MED or more, the opioids be tapered to the lowest effective dose, and possibly discontinuation, rather than continuing with the current dose.

In addition to being published in CMAJ, the guidelines were uploaded to the MAGICapp website, which is hosted by the Making GRADE the Irresistible Choice (MAGIC) nonprofit initiative, the aim of which is to optimize the presentation of guidelines.

Dr Busse told Medscape Medical News that MAGICapp is a multilayered format that allows users to "navigate through to the different recommendations quite quickly, without having to sort through a very large PDF.

"It includes decision aids that we believe will be helpful for clinicians to quickly convey important information to their patients to help them form their decision during the clinical encounter," he added.

The decision to host the guidelines on MAGICapp was made partly in response to the relatively poor uptake of the 2010 guidelines.

Dr Busse said that a qualitative survey of physicians indicated that they found that the presentation of the previous guidelines as a 160-page PDF was "suboptimal" and that it "simply was not practical to implement during the clinical encounter."

In addition to publishing the guideline online as an interactive document, "the other large initiative that really needs to be undertaken is a formal, national, knowledge transfer and implementation strategy.

"There really does need to be a formal plan put in place to push this guideline into practice, measure whether it's being taken up, test out different strategies to encourage utilization of the recommendations, and measure whether it's having an impact," said Dr Busse.

"We have started to look around for some funding to support this kind of initiative, but we haven't secured it yet."

Implementation "Always an Issue"

Commenting on the guideline for Medscape Medical News, Andrew J. Saxon, MD, Department of Psychiatry and Behavioral Sciences, and director, Addiction Psychiatry Residency Program, University of Washington, in Seattle, said that the new Canadian guidelines are "very similar" to those published last year by the US Centers for Disease Control and Prevention.

He pointed out that the implementation of guidelines "is always an issue."

"Guidelines get done, but oftentimes they sit in the shelf, and people don't refer to them, so that's always a problem," he said. Nevertheless, he noted, the "decrement in opioid prescribing" in the United States is a "positive trend."

However, he added, primary care providers "are in a real bind," because nonopioid pharmacotherapies and nonpharmacologic therapies are often not readily available, or they are more complicated to arrange.

He noted that physicians are used to "grabbing the prescription pad and writing a prescription," although nonopioid pharmacotherapies "sometimes don't help all that much," because some patients "don't have a great response" to them.

Dr Saxon believes that to tackle the opioid issue, efforts are required on several fronts, the first of which is to keep patients who have chronic pain from starting on the drugs in the first place.

"We can do some prevention by not compounding the mistakes of the past and starting those new patients on opioids, or, to paraphrase the guidelines, this would be your last resort.

"Also, as the guidelines say, they give some suggestions about who the high-risk patients would be that we would particularly want to avoid opioids in, and so we can also do some prevention that way, by selecting the patients more carefully if we were going to use opioids," he added.

Finally, he said that "we have this huge number of people who are already on them, [and] it's extremely hard to get off of them, because the opioids themselves change the brain." He noted that prolonged exposure increases the risk for hyperalgesia.

Buprenorphine, Methadone Underutilized

He agreed that for patients already receiving opioids, "the plan should be, as the guidelines say, to taper them down to lower and safer doses," although it is not always "realistic" and "doing the tapers requires a fair amount of skill."

Dr Saxon said that it requires a "partnership between the patient and the care provider, and it has to be done gradually, with the idea that if the patient's becoming destabilized, you don't just plunge ahead; you maybe stop things or maybe even increase the dose a little bit."

Emphasizing that "it's more like a 2-year plan or a 3-year plan than a 3-month plan," he said that there "hasn't been a lot of education about how to do the tapers properly."

One concern that Dr Saxon has about solving the opioid problem is the lack of accessibility and the underutilization of the two FDA-approved opioid medications, methadone and buprenorphine.

He said that physicians "have to take time out of their practice" to be trained to use the drugs, and that this "specialized skill doesn't provide any additional reimbursement for physicians.

"Physicians are not very much incentivized to do it. Thinking about it, it's easier for a physician to keep prescribing the opioids for chronic pain, even if the person has an opioid use disorder, and try and maintain them that way than it would be to say, 'You're misusing your medication, it's hurting you, I'm going to switch you to buprenorphine and prescribe that.' "

Dr Saxon noted that this issue is "very relevant to today," He pointed to comments made by new Health and Human Services Secretary Thomas E. Price, MD, at a meeting in West Virginia as part of his "listening tour" on the opioid drug crisis.

As quoted by the Charleston Gazette-Mail, Dr Price expressed doubts about medication-assisted programs, saying: "If we're just substituting one opioid for another, we're not moving the dial much.

"Folks need to be cured so they can be productive members of society and realize their dreams," he added.

Dr Saxon said that Dr Price's comments display "a lack of awareness of the different pharmacology of the treatment medications [and] the tremendous success that we've seen when we compare medication treatment to treatment without medication."

He characterized success in the "dramatic terms of actually saving lives, because people of opioid use disorder have very high mortality rates, largely from overdose but also from other medical conditions."

Safer, More Effective Prescribing

In an accompanying editorial, Andrea D. Furlan, MD, PhD, Toronto Rehabilitation Institute and Department of Medicine, University of Toronto, Canada, and Owen D. Williamson, MD, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia, note that the recommendations are backed by "strong, consistent evidence."

They add that the guidelines aim "promote safer and more effective opioid prescribing to the small proportion of patients with chronic non-cancer pain who may benefit from their use, and this may well be achieved."

However, they point out that it is unlikely that the guidelines by themselves will "solve either Canada's opioid crisis or the under-treatment of those living with persistent pain" and that their implementation may be "challenging" without a national pain strategy to support alternative treatments.

The guideline was funded by Health Canada and the Canadian Institutes of Health Research. The authors have disclosed no relevant financial relationships. A list of relevant financial reltionships. Dr Williamson has received nonfinancial support from Health Canada and personal fees and nonfinancial support from Purdue Pharma (Canada), Mundipharma International Ltd. and INVIVO Communications Ltd outside the submitted work. Dr Furlan has disclosed no relevant financial relationships.

CMAJ. Published online May 8, 2017. Full text, Editorial

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