It is argued that the opioid crisis we face today is a result of inappropriate prescribing rooted at the physicians’ offices. Some say it’s related to our social problem of poverty, distress and mental health with illicit drug use as a coping mechanism. Regardless of the cause, the opioid crisis is real and dear to us. Canada has been criticized for having the second highest consumption of opioids as compared to other countries. The exponential growth of incidents related to opioid overdose and the emergence of potent and illegal opioid compounds such as W-18 all lend strong evidence to an opioid crisis that is out of control and desperate for a solution.
In fact, Health Canada has recently granted a non-prescription status of naloxone, an antidote for opioid overdose to help address the rising number of opioid overdoses. Eric Hoskin, our provincial health minister has also confirmed and expanded the free access of naloxone in Ontario, in hope to allow efficient access of antidote to treat opioid overdoses. However, this is only a band-aid solution.
We need a more proactive approach to prevent individuals from developing dependance on opioids. The CDC (Centers of Disease Control and Prevention) in the US has released a new guideline on the use of opioids in chronic pain. It contains 12 recommendations group in three areas for considerations:
- Determining when to initiate or continue opioids for chronic pain
- Opioid selection, dosage, duration follow-up and discontinuation.
- Assessing risk and addressing harms of opioid use
Overall, I find these recommendations quite refreshing and rather significantly different from our current practice and maybe worth a closer look to adopt here in Canada.
Here are 10 key summary points that I like to highlight:
- Opioids are NOT indicated for first line treatment in chronic pain. Non-opioids (e.g. acetaminophen, NSAIDs, antidepressants, anticonvulsants) are first line treatments. Acetaminophen and NSAIDs have always been first line options for mild to moderate pain but antidepressants and anticonvulsants were previously classified as adjuvant therapies to be added when conventional options including opioids have failed. The CDC guideline definitely emphasizes on trying these medications before opioids.
- Also try non-drug measures such as exercise and CBT for chronic pain. These non-drug options are well established for the management of chronic pain. Their uptake, however, may be limited. The CDC guideline recognizes the barriers to these options including insurance coverage and accessibility. Yet it also includes suggestions for other low cost alternatives such as patient support, self-help and educational community based programs which can be conducive to stress reduction and other mental health benefits.
- Prescribe more immediate release formulation of opioids, less extended release formulaton. When starting opioid therapy for chronic pain, it is typical to start with an immediate-release opioid (e.g. Statex, Dilaudid). Yet the current thinking is to encourage dose titration based on response and can quickly escalate to using extended release formulation. The CDC guideline urges that extended release opioids be judiciously reserved when all else have “failed”.
- Focus on patient education and to define treatment goals in relation to function and pain. The CDC guideline encourages physicians to provide patient education before starting opioid therapy. Also it encourages a clear definition of treatment goals and realistic expectations around function and pain.
- Use the lowest effective dose and there is a “maximum” beneficial opioid dose. It is often believed that there is no universal maximum dose of opioid. The optimal dose is patient specific and depends on prior exposure, tolerance development and pain severity. However the latest CDC guideline on chronic pain has clearly established that there may be a significant increased risk of opioid overdose when taking greater than or equal to 50 morphine milligram equivalent (MME) per day. Given the benefits of high-dose opioids have not been established, prescribers are asked to carefully assess evidence of benefits and risks when increasing dosage to greater than 50 MME per day and should avoid increasing dosage to greater than 90 MME per day.
- Limit acute treatment of pain to 3 days is best, definitely not to exceed 7 days. Long term opioid use often begins with treatment of acute pain. Hence limiting treatment duration to 3 days is strongly encouraged. Further, many acute pain can be adequately managed with non-opioid options. Clinicians are also encouraged not to prescribe additional opioids in anticipation of longer duration of pain
- Clear guidelines for follow up – initial follow up within 1 – 4 weeks, chronic follow up every 3 months. When opioids are continued for more than 3 months, there is a substantial increase for opioid use disorder. As such, earlier follow up within first few weeks is important to detect potential concern. For methadone or transdermal fentanyl patch, it may be necessary to follow up after 3 days. Consistent chronic follow up every 3 months is also important to detect potential changes in the balance of benefits and risks over time and to identify opportunities for tapering when indicated.
- Introduce strategies to mitigate risk related to opioid overdose. If risk factors for opioid overdose are identified (e.g. history of overdose, substance use disorder, higher opioid dosages – greater or equal to 50MME/day), the clinician should consider naloxone to minimize opioid overdose. Urine drug testing may be done before starting opioid and annually to assess for prescribed medications and to rule out illicit drug use.
- Do not mix opioids with benzodiazepines. Concurrent use is likely to put patients at greater risk for fatal overdose. Benzodiazepines can be tapered by reducing dose by 25% every 1-2 weeks. CBT also increase tapering success rate.
- Offer to treat opioid use disorder. If the patient has been identified to have opioid use disorder, there are evidence-based treatments available (methadone or buprenorphine) and should be actively offered.
Based on the new CDC guideline, there is a significant change in how chronic pain should be managed. It will be interesting to see how it will be adopted both in Canada and the US. Maybe it is a good first step to managing the opioid crisis. But there is definitely more to do in the near future.