What are the recommended guidelines to use when prescribing opioids for chronic non-cancer pain?

Busse J (ed). The 2017 Canadian guideline for opioids for chronic non-cancer pain. National Pain Centre, McMaster University. 2017. Guidelines

Why was this study conducted?

Opioids are a class of drugs that act on the nervous system to relieve pain and include such substances as heroin, oxycodone, hydrocodone, codeine, morphine and fentanyl. Opioid abuse is a growing problem; for example, the Public Health Agency of Canada estimates that almost 2,500 Canadians died from opioid-related overdoses in 2016. It is critical that this class of powerful drugs be used in a safe and effective manner to help the many Canadians (up to one in five adults) who are struggling with long-term or chronic non-cancer pain. This guideline was created at the Michael G. DeGroote National Pain Centre at McMaster University for those who may prescribe opioids for non-cancer chronic pain, regulators, patients, pharmacists and other healthcare providers. It does not address cancer-related pain, how to treat opioid addiction or opioid use disorder, acute or sub-acute pain (i.e., pain lasting less than three months), or the treatment of pain in palliative or end-of-life care. The focus of the review was on the use of opioids and there is only minimal discussion about medical cannabis.

What does this study add?

There is a strong recommendation that the first choice of treatment for a patient with chronic non-cancer pain should be a non-opioid medication, such as the cannabinoid nabilone (a synthetic cannabinoid), NSAIDs (Non-steroidal Anti-Inflammatory Drugs) or a tricyclic antidepressant (a class of medications that are primarily used to treat depression but may also relieve nerve-related or neuropathic pain), or non-pharmacological treatment such as physical activity Other recommendations were developed to guide practitioners and patients in the use of opioids for people who continue to have persistent pain, have an active or past history of substance use, or an active psychiatric disorder. Recommendations are also made on opioid restriction, rotation, and tapering.

Is there anything else I should know?

A very rigorous process was used to develop these guidelines. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to rate the quality of the evidence as high, moderate, low or very low. Using this information and input from the expert and patient group, the strength (“weak” or “strong”) and the direction (“for” or “against”) of the recommendations were determined.