The new Guideline for Opioid therapy in Chronic Non-cancer pain was released earlier this week.  There was so much media coverage on Monday.  I heard it on the radio in the morning, on my way back from work and several times throughout emails, news coverage and social media outlets! Thanks to the opioid crisis. We really want everyone to be aware of the new guideline.  So what does it say about opioid prescribing?

There are 10 recommendations, 7 of the which pertain to the initiation and dosing of opioids whereas the remaining 3 recommendations focus on rotation and tapering of opioids. For the detailed guideline, please click here.
Below is my interpretation of the recommendations as well as my thoughts around them:
  1. Optimize the use of non-opioid options.
    • This is not a new recommendation but it’s worth re-emphasizing the need to optimize non-opioid options. These include non-drug measures such as physiotherapy, hot / cold pack, exercise and cognitive behaviour therapy.  Non opioid drug options include acetaminophen, NSAIDs, topical analgesics as well as treatment options for neuropathic pain (e.g. anticonvulsants [gabapentin, pregabalin], antidepressants [amitriptyline, duloxetine]).
  2. Always start opioid as a trial – initiate, titrate and diligent monitoring and discontinue if no improvement in pain or function.
    • This recommendation focuses on better practice to monitor opioid therapy.  Often patients may be prescribed an opioid prescription with good intention to help with acute / chronic pain. However without good follow up, some individuals may develop dependence.  It is important that opioid prescription always begin as a trial, titrate dose slowly and monitor for improvement in pain or function.  It also means quickly stopping the medication if improvement is not seen with adequate titration.
    • I think when it comes to this recommendation, I would suggest opioid prescription be written for a much shorter duration such as for 5-7 days with mandatory follow up prior to continuing or renewing more prescriptions.
  3. For individuals with an active substance use disorder, avoid using opioids.
    • There is no doubt that for an individual with an active substance use disorder including alcohol, there is an increased risk for opioid addiction to develop.  So I am not disputing the recommendation.  But what if these individuals do have chronic pain and require opioid treatment. What options do we have for them? I think it will be a challenge in real practice to balance what they may require vs. the potential risk with opioid addiction.
  4. For individuals with current serious psychiatric disorder, stabilize the psychiatric disorder before considering a trial of opioid.
    • Again, I agree with the context in how this recommendation has been developed. There is a higher risk of opioid addiction in individuals with serious psychiatric disorder and as such, the psychiatric disorder should be stabilized first before starting opioid. But life doesn’t always happen in this sequence. They may show up in emergency room with an active psychotic episode and also having a flare up of chronic back pain. Do we park aside the back pain and only address the psychosis? What about for psychiatric patients who are unable to verbalize their level of pain? It is a grey area and ultimately up to the clinician to determine the risks and benefits.
  5. For individuals with a history of substance use disorder where non-opioid therapy has been optimized, continue non-opioid therapy.
    • My thoughts are are the same as above. It is easier said than done. It will be a challenge.
  6. For long term opioid therapy, restrict prescribed dose of opioid under 50mg morphine equivalents daily if possible.
    • It is now formally recognized there is an optimal opioid dose which is under 50mg morphine equivalents daily.  This is roughly equivalent to hydromorphone 10mg/day or 12.5-25mcg/hr Fentanyl patch.  While it is a good guiding dose, the authors recognize that some individuals may need to go above this dose limit.
  7. Limit the max dose of opioid under 90mg morphine equivalents daily.
    • There is a maximum dose limit being endorsed now!  I remember many years ago being taught that there is no ceiling dose for opioids. But now, we recognize that as the dose increases, the effectiveness may not correlate but the risk of side effects, overdose and dependence will escalate.  In the community, there is a handful of individuals currently exceeding this dose limit. I wonder what strategies we have to systematically manage this population. It will be a project on its own to start the conversation to discuss the options to taper or rotate to a different opioid.
  8. If currently on 90mg morphine equivalents daily or more, try opioid rotation.
    • The guideline encourages opioid rotation. I have not tried very hard to switch my patients to different opioids but I do think this may be a reasonable option to try. For instance, if the patient does not respond to codeine, he or she may have better luck responding to morphine or hydromorphone. Likewise if the Fentanyl patch does not seem to offer much pain relief, it may be time to switch to other options.
  9. If currently on 90mg morphine equivalents daily or more, try tapering opioids to lowest possible dose including discontinuation.
    • Tapering opioid is not a new strategy but we definitely need to consider it more frequently in those who are on higher dose opioid, especially if they don’t seem to be receiving much benefits from therapy.  There needs to be a discussion on expectation. The opioid therapy will not eliminate pain completely but it may help to reduce pain to a level that allows for daily function or some quality of life. Here’s my other post on tapering opioids.
  10. If there are challenges in tapering opioids, consider formal multidisciplinary opioid reduction program.
    • While it isn’t explicitly discussed in the guideline, I think there should be more discussion around treatment for opioid dependence.  The only option we used to have was methadone few years ago.  Only pain or addiction specialists would prescribe the medication due to its long half life, risk of QT prolongation as well as other serious side effects. However, we now have available Suboxone which can be prescribed by any clinicians. However, many clinicians are still not comfortable to take on this responsibility. Perhaps the government should implement some incentives to encourage primary care physicians to learn about Suboxone therapy and take on patients who may benefit from it. There are free online education programs that are available. See my post on Suboxone therapy.
    • The other thought I have is around medical marijuana. As we try to taper individuals off opioid therapy, there is emerging evidence and some success with the use of medical marijuana.  Given there is also some evidence for pain (particularly with neuropathic pain), I do see this area to be a potential for further exploration. However, we also don’t have sufficient data to support the long term safety of medical marijuana. How do we know we are not replacing one toxin with another? I guess only time will tell.

What are your thoughts with the new opioid guideline for chronic non-cancer pain? Do you agree with the recommendations? Are they realistic? How do you see your practice changes as a result of the new guideline?

I look forward to hearing your thoughts.  Thank you for reading my post.

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