An updated version of the national guideline for opioid prescribing was published in the Canadian Medical Association Journal (CMAJ) on Monday May 8, 2017. The updated guideline aligns with the current evidence on opioid prescribing and harm reduction, while attempting to address the limitations of the College of Physicians and Surgeons of BC (CPSBC) standards.
Unlike the CSPBC standards and guidelines, this national guideline is not a regulatory requirement but offers recommendations for prescribers. The guideline includes 10 recommendations (7 of which are focused on harm reduction) and incorporates the following:
- The “strong recommendation” that prescribed opioid doses be less than 90mg morphine equivalents (MED) per day and a “weak recommendation” that doses be restricted to under 50mg MED per day for patients who are beginning opioid therapy
- The “weak recommendation” that trial tapering of opioids to the lowest effective dose (potentially to zero) for patients currently using 90mg MED per day or more, recognizing there are some patients who may need to stop or pause tapering
- The “strong recommendation” that non-opioid pharmacotherapy be considered first and optimized for patients with chronic non-cancer pain, rather than a trial of opioids.
- The “weak recommendation” for a trial of opioids for patients with “persistent problematic pain despite optimized non-opioid therapy” and who don’t have a current or past substance use issue or other active psychiatric disorders.
Around the issue of dosage, the guideline states that the suggestion “to restrict the prescribed dose to less than 50 mg MED acknowledges that some patients will be willing to accept the increased risks associated with doses exceeding 50 mg in order to potentially achieve improved pain control. Further, some patients may gain important benefit at a dose of more than 90 mg. Referral to a colleague (not necessarily a pain specialist) for a second opinion regarding the possibility of increasing the dose to more than 90 mg MED may therefore be warranted in some individuals.”
At the same time as the guideline was released, the CMAJ included a commentary piece by Dr. Owen Williamson and Dr. Andrea Furlan that discusses the updates. The commentary acknowledges the intention is to promote better, safer opioid prescribing, but notes that the recommendations are “unlikely to solve either Canada’s opioid crisis or the undertreatment of those living with persistent pain.” The commentary piece highlights the systemic barriers that can impact chronic pain patients – the lack of timely access to effective, affordable non-pharmacological treatments; long wait lists for multidisciplinary pain clinics and pain specialists; and the lack of community-bases resources, including self-management programs.
Furlan and Williamson echo the issue that Pain BC has raised many times – without a comprehensive provincial and national pain strategy, an updated guideline will not solve the opioid crisis or address the lack of “evidence-based alternative treatments for the one in five Canadians currently living with chronic pain” (Furlan and Williamson, 2017).
The recommendations included in the guideline were developed by a group of international researchers, patients, and clinicians. This team was funded by Health Canada and the Canadian Institutes of Health Research and lead by the Michael G. DeGroote National Pain Centre at McMaster University. The guideline applies to all professionals who prescribe opioids for chronic pain, including specialists, family physicians, and nurse practitioners.
Pain BC will continue to monitor the situation and to advocate for evidence-based, compassionate pain management approaches for people in pain. In the meantime, you can review the following useful links:
- The full updated guideline in the Canadian Medical Association Journal
- Furlan and Willamson’s commentary piece “New Canadian guidance on opioid use for chronic pain: necessary but not sufficient” in the Canadian Medical Association Journal
- McMaster University’s media release about the updated guideline
- A CMAJ podcast about the update guideline
- Canadian Journal of Pain article titled ‘“One Size Fits All” Doesn’t Fit When It Comes to Long-Term Opioid Use for People with Chronic Pain’about the opioid landscape and prescribing guidelines
- Pain BC’s responses to the CPSBC provincial opioid prescribing guidelines
 Furlan and Williamson (2017) explain that the strong recommendations can be viewed as ‘shoulds’, whereas the weak recommendations can be interpreted as “consider it”.
 The 2010 guideline suggested a ‘watchful dose’ of 200MMED per day