Grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Cluster 1: Deciding to Initiate Opioid Therapy
R01 Before initiating opioid therapy, ensure comprehensive documentation of the patient's pain condition, general medical condition, and psychosocial history (Grade C), psychiatric status, and substance use history (Grade B).
R02 Before initiating opioid therapy, consider using a screening tool to determine the patient's risk for opioid addiction (Grade B).
R03 When using urine drug screening (UDS) to establish a baseline measure of risk or to monitor compliance, be aware of benefits and limitations, appropriate test ordering and interpretation, and have a plan to use results (Grade C).
R04 Before initiating opioid therapy, consider the evidence related to effectiveness in patients with chronic non-cancer pain (Grade A).
R05 Before initiating opioid therapy, ensure informed consent by explaining potential benefits, adverse effects, complications and risks (Grade B). A treatment agreement may be helpful, particularly for patients not well known to the physician or at higher risk for opioid misuse (Grade C).
R06 For patients taking benzodiazepines, particularly for elderly patients, consider a trial of tapering (Grade B). If a trial of tapering is not indicated or is unsuccessful, opioids should be titrated more slowly and at lower doses (Grade C).
Cluster 2: Conducting an Opioid Trial
R07 During dosage titration in a trial of opioid therapy, advise the patient to avoid driving a motor vehicle until a stable dosage is established and it is certain the opioid does not cause sedation (Grade C); and when taking opioids with alcohol, benzodiazepines, or other sedating drugs (Grade B).
R08 During an opioid trial, select the most appropriate opioid for trial therapy using a stepped approach, and consider safety (Grade C).
R09 When conducting a trial of opioid therapy, start with a low dosage, increase dosage gradually and monitor opioid effectiveness until optimal dose is attained (Grade C).
R10 Chronic non-cancer pain (CNCP) can be managed effectively in most patients with dosages at or below 200 mg/day of morphine or equivalent (Grade A). Consideration of a higher dosage requires careful reassessment of the pain and of risk for misuse, and frequent monitoring with evidence of improved patient outcomes (Grade C).
R11 When initiating a trial of opioid therapy for patients at higher risk for misuse, prescribe only for well-defined somatic or neuropathic pain conditions (Grade A), start with lower doses and titrate in small-dose increments (Grade B), and monitor closely for signs of aberrant drug-related behaviors (Grade C).
Cluster 3: Monitoring Long-Term Opioid Therapy (LTOT)
R12 When monitoring a patient on long-term therapy, ask about and observe for opioid effectiveness, adverse effects or medical complications, and aberrant drug-related behaviours (Grade C).
R13 For patients experiencing unacceptable adverse effects or insufficient opioid effectiveness from one particular opioid, try prescribing a different opioid or discontinuing therapy (Grade B).
R14 When assessing safety to drive in patients on LTOT, consider factors that could impair cognition and psychomotor ability, such as a consistently severe pain rating, disordered sleep, and concomitant medications that increase sedation (Grade C).
R15 For patients receiving opioids for a prolonged period who may not have had an appropriate trial of therapy, take steps to ensure that long-term therapy is warranted and dose is optimal (Grade C).
R16 When referring patients for consultation, communicate and clarify roles and expectations between primary-care physicians and consultants for continuity of care and for effective and safe use of opioids (Grade C).
Cluster 4: Treating Specific Populations with Long-Term Opioid Therapy
R17 Opioid therapy for elderly patients can be safe and effective (Grade B) with appropriate precautions, including lower starting doses, slower titration, longer dosing interval, more frequent monitoring, and tapering of benzodiazepines (Grade C).
R18 Opioids present hazards for adolescents (Grade B). A trial of opioid therapy may be considered for adolescent patients with well-defined somatic or neuropathic pain conditions when non-opioid alternatives have failed, risk of opioid misuse is assessed as low, close monitoring is available, and consultation, if feasible, is included in the treatment plan (Grade C).
R19 Pregnant patients taking long-term opioid therapy should be tapered to the lowest effective dose slowly enough to avoid withdrawal symptoms, and then therapy should be discontinued if possible (Grade B).
R20 Patients with a psychiatric diagnosis are at greater risk for adverse effects from opioid treatment. Usually in these patients, opioids should be reserved for well-defined somatic or neuropathic pain conditions. Titrate more slowly and monitor closely; seek consultation where feasible (Grade B).
Cluster 5: Managing Opioid Misuse and Addiction in CNCP Patients
R21 For patients with CNCP who are addicted to opioids, three treatment options should be considered: methadone or buprenorphine treatment (Grade A), structured opioid therapy (Grade B), or abstinence-based treatment (Grade C). Consultation or shared care, where available, can assist in selecting and implementing the best treatment option (Grade C).
R22 To reduce prescription fraud, physicians should take precautions when issuing prescriptions and work collaboratively with pharmacists (Grade C).
R23 Be prepared with an approach for dealing with patients who disagree with their opioid prescription or exhibit unacceptable behaviour (Grade C).
R24 Acute or urgent health care facilities should develop policies to provide guidance on prescribing opioids for chronic pain to avoid contributing to opioid misuse or diversion (Grade C).
Canadian Guideline Recommendation Grading
Grade A: Recommendations are supported by evidence from randomized controlled trials.
Grade B: Recommendations are supported by:
- Evidence from controlled trial(s) without randomization, or
- Evidence from cohort or case-control analytic studies, preferably from more than one centre or research group, or
- Evidence from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments could be included here.
Grade C: Recommendations are supported by consensus opinion of the National Advisory Panel.