New guideline advises doctors not to give opioids as a first-line treatment

A new guideline is advising Canadian doctors to avoid giving powerful narcotics as a first-line treatment to patients with chronic non-cancer pain.

The guideline—published by the Canadian Medical Association Journal (CMAJ) on Monday—was developed by an international team of doctors, researchers and patients at McMaster University in Hamilton.

The recommendations include:

• Non-drug and non-opioid pharmacotherapy be considered first and optimized for patients with chronic non-cancer pain rather than a trial of opioids.
• A trial of opioids for patients who have not responded to non-opioid treatment and who do not have a current or past substance use disorder or other current psychiatric disorder.
• The suggestion that the dose be restricted to under 50mg morphine equivalents a day for patients starting opioid therapy, and the strong recommendation that the daily dose be under 90 mg a day. The previous guideline suggested a watchful dose of 200mg morphine equivalents a day.
• A trial tapering of opioids to the lowest effective dose, potentially to none, for patients currently using 90 mg morphine equivalents a day or more, recognizing there are some patients who may need tapering paused or abandoned.

“Canada is in the midst of an opioid epidemic. The guideline aspires to promote evidence-based prescribing of opioids for chronic non-cancer pain,” said Jason Busse, principal investigator for the guideline development, an associate professor of anesthesia of McMaster’s Michael G. DeGroote School of Medicine, and researcher for the Michael G. DeGroote National Pain Centre in a press release. “Opioids are not first line therapy for chronic non-cancer pain. There are important risks associated with opioids, such as unintentional overdose, and these risks increase with higher doses.”

Hamilton Paramedic Services says they responded to 23 emergency calls for opioid-related overdoses in April. That number is down slightly from a spike of 33 calls in March.

The McMaster guideline includes medical evidence published since a similar national opioid guideline was released in 2010.

“I applaud the work that has gone into updating the guideline, which equips prescribers with the latest recommendations for prescribing opioids,” said Jane Philpott, federal Minister of Health. “If we are going to solve the opioid crisis, health care professionals must be part of the solution, beginning with following the guideline.”

Busse says doctors must now learn about the new guideline and apply its recommendations in practice. He added that recent research has shown limited impact of the guideline published in 2010.

“The guideline isn’t self-implementing. We recognize implementation is a provincial responsibility, but we need dedicated funding for a national strategy to effectively ensure the guideline is used, and that we measure its impact,” said Busse.

An estimated 15 per cent to 19 per cent of Canadians live with chronic non-cancer pain, which is pain lasting more than three months and interfering with daily activities.

The guideline’s recommendations were developed over a two-year period and funded by Health Canada. It does not look at opioid use for acute pain, nor for patients with pain due to cancer or in palliative care, or those under treatment for opioid use disorder or opioid addiction.