Canadian Opioid Prescribing Guidelines

Canada’s Opioid Prescribing Guidelines are used by clinicians to prescribe opioids to individuals, 18 years old or older, living with chronic non-cancer pain. The current guidelines are the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain that were developed by the Michael G. DeGroote National Pain Centre (MGD NPC), part of the Faculty of Health Sciences at McMaster University.

The guideline provides assistance to Canadian clinicians who prescribe opioids for chronic non-cancer pain management or create policies regarding opioid prescriptions. Chronic non-cancer pain is defined as any painful condition, not associated with a cancer diagnosis, persisting for three months or longer.

Canada’s Opioid Prescribing Guideline does not address opioid management for the following situations:

• Cancer related pain
• Opioid use disorder or addiction
• Acute or subacute pain (pain lasting less than 3 months)
• Pain or suffering associated with end-of-life care

2017 Canadian guideline opioid prescriptions to treat chronic non-cancer pain

The 10 recommendations in the guideline are categorized as strong or weak utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Strong recommendations indicate that all or almost all fully informed patients would choose the recommended course of action, and indicate to clinicians that the recommendation is appropriate for all or almost all individuals. Strong recommendations represent candidates for quality of care criteria or performance indicators.

Weak recommendations indicate that the majority of informed patients would choose the suggested course of action, but an appreciable minority would not. With weak recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and should assist patients to arrive at a decision consistent with their values and preferences. Weak recommendations should not be used as a basis for Standards of Practice (other than to mandate shared decision-making).

Initiation and dosing of opioids for patients with chronic non-cancer pain

Recommendation 1: When considering therapy for patients with chronic non-cancer pain (Recommendation level: strong)
Recommend optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids.

Recommendation 2: For patients with chronic noncancer pain, without current or past substance use disorder and without other active psychiatric disorders, who have persistent problematic pain despite optimized nonopioid therapy (Recommendation level: weak)
Suggest adding a trial of opioids rather than continued therapy without opioids.

Recommendation 3: For patients with chronic noncancer pain with an active substance use disorder (Recommendation level: Strong)
Recommend against the use of opioids.

Recommendation 4: For patients with chronic noncancer pain with an active psychiatric disorder whose nonopioid therapy has been optimized, and who have persistent problematic pain (Recommendation level: Weak)
Suggest stabilizing the psychiatric disorder before a trial of opioids is considered.

Recommendation 5: For patients with chronic noncancer pain with a history of substance use disorder, whose nonopioid therapy has been optimized, and who have persistent problematic pain (Recommendation level: Weak)
Suggest continuing non-opioid therapy rather than a trial of opioids.

Recommendation 6: For patients with chronic noncancer pain who are beginning opioid therapy (Recommendation Level: Strong)
Recommend restricting the prescribed dose to less than 90 mg morphine equivalents daily, rather than having no upper limit or a higher limit on dosing.

Recommendation 7: For patients with chronic noncancer pain who are beginning opioid therapy (Recommendation Level: Weak)
Suggest restricting the prescribed dose to less than 50 mg morphine equivalents daily.

Rotation and tapering of opioids

Recommendation 8: For patients with chronic noncancer pain who are currently using opioids, and have persistent problematic pain and/or problematic adverse effects (Recommendation Level: Weak)
Suggest rotation to other opioids rather than keeping the opioid the same.

Recommendation 9: For patients with chronic noncancer pain who are currently using 90 mg morphine equivalents of opioids per day or more (Recommendation Level: Weak)
Suggest tapering opioids to the lowest effective dose, potentially including discontinuation, rather than making no change in opioid therapy.

Some patients may have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused and potentially abandoned in such patients.

Recommendation 10: For patients with chronic noncancer pain who are using opioids and experiencing serious challenges in tapering (Recommendation Level: Strong)
Recommend a formal multidisciplinary program.

Best practice statements

• Informed consent. Health professionals should acquire an individual’s informed consent before introducing opioid use for chronic non-cancer pain. Knowing potential benefits, adverse side effects, and possible complications will assist the decision-making process about proceeding with opioid therapy.
• Monitoring. Clinicians should monitor patients using opioid therapy for non-cancer pain relief. They should monitor their response to treatment and adjust the opioid treatment appropriately.
• Contraindications: Clinicians prescribing opioids as a non-cancer treatment should exchange relevant information and potential contradictions with the patient’s general practitioner (if not the same as the clinician) and pharmacists.

Additional sources: Canadian Medical Association Journal and The College of Family Physicians