'People are dying out there': New guidelines for prescribing opioids encourage doctors to put down the pad

Canadian doctors should only prescribe opioids to treat very specific cases of chronic pain and should try to wean their patients off the potentially addictive drugs, according to new guidelines published today in the Canadian Medical Association Journal.

The list of 10 recommendations for health-care providers represents a dramatic departure from the previous guidelines released seven years ago.

The message, according to Jason Busse, the principal investigator behind the list, is "opioids are not first-line therapy for chronic, non-cancer pain."

The new recommendations seek to minimize harm for a range of patients with chronic pain, including people with current or past substance-use disorders, other psychiatric disorders and those who suffer from persistent pain despite opioid therapy.

Chronic pain, like osteoarthritis, rheumatoid arthritis or lower back pain, is defined as pain lasting more than three months. About 20 per cent of Canadians suffer from this type of pain.

It's very necessary to get the prescribing in check. I mean, people are dying out there.-Chris Cull, member of patient advisory committee

The focus back in 2010, Busse says, was on how to prescribe opioids.

Seven years later, the focus is on reducing prescriptions.

"Our guideline has taken a step back and focused on a number of situations in which we feel the prescribing of opioids should be either carefully considered or not occur at all," said Busse, an associate professor of anesthesia at McMaster University in Hamilton.

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Canada has the second highest per-capita use of opioids in the world, and opioid-related deaths here are more prevalent today than 10 years ago.

"It's very necessary to get the prescribing in check," said Chris Cull, a former opioid addict who was part of a patient advisory committee that helped develop the recommendations. "I mean, people are dying out there."

The key recommendations are:

• For patients with chronic, non-cancer pain, before considering opioids use non-opioid pharmaceuticals like some anti-inflammatory medications (such as NSAIDs). Also, consider non-pharmaceutical therapy like physiotherapy or massage therapy.
• For patients who haven't responded to non-opioid treatment, and without substance use disorders, a trial of opioids is suggested.
• For patients beginning opioid treatment, the dose should be restricted to the equivalent of under 50 milligrams of morphine a day and no more than 90 milligrams a day. (The 2010 guidelines suggested a "watchful dose" of the equivalent of 200 milligrams of morphine a day.)
• For patients taking the equivalent of 90 milligrams of morphine a day or more, the guidelines suggest tapering to the lowest effective dose. 

Busse says some patients may be able to taper down quite a bit, or even discontinue taking opioids altogether. But he admits others will struggle and could suffer from severe withdrawal symptoms. In those cases, he says tapering could be paused, or abandoned.

"We don't want to have the recommendations applied in a very blunt fashion where everybody has to come below this threshold of 90 because not all patients are going to tolerate that."

Cull developed addiction issues at 21, first with Percocet, then OxyContin. He was on methadone for five years and has been drug-free since 2014. He says tapering is very difficult.

"Tapering is not easy by any stretch of the imagination. It took me over a year and a bit to taper off," said Cull, who now raises awareness about opioid abuse in Canada.

He said there's always a concern that patients could simply go elsewhere to get their opioids.

"If you're putting people into withdrawal by forcefully tapering them, they're going to find their stuff somewhere else," he said. "And that somewhere else might be on the street. And if it's on the street, it could be tainted drugs."

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Busse said implementation of the recommendations 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."

A commentary published in the journal says the new recommendations are welcome, but barriers to accessing safe, effective and affordable alternative pain treatments like physical therapies, psychological interventions and social supports limit their practical use.

"Until Canada has a realistic national strategy for the treatment of chronic disabling pain, physicians will continue using the only tool they have in their toolbox: their prescription pad."