Opioid Prescribing Practices

1.      Careful patient selection:  The clinician should reserve opioids for patients who have not responded to non-opioid treatments, and who have pain conditions for which opioids have been shown to be effective.

2.      First-line opioids:  If opioids are to be considered for chronic pain conditions and after careful patient selection, then we would recommend starting with a step wise approach similar to the WHO Pain Ladder beginning with opioids of lower potency first, such as codeine and tramadol. Controlled trials have shown that they are effective, and they have a much lower risk of overdose and addiction than the more potent opioids. All opioids are potentially addictive and abusable. Long acting preparations are recommended with the avoidance of short acting preparations other than for the management of breakthrough pain

3.      Dose titration:  The harms of prescription opioids - overdose, addiction, trauma, sedation, and central sleep apnea – are dose related.  Furthermore, the effectiveness of high opioid doses relative to lower doses has not been demonstrated.  Therefore clinicians should titrate cautiously and slowly when treating CNCP.  The Canadian Guideline defines the optimal dose as one which improves function and reduces pain by at least 30% (on a 10 point scale), with minimal analgesic benefit from one or two additional dose increases.  In the great majority of cases, the optimal dose will be well below the recommended ‘watchful dose’ of 200 mg morphine equivalence per day.

4.      Overdose prevention:  The clinician should take steps to prevent overdose, including patient education on safe medication storage, cautious titration and dispensing, and avoidance of sedating medications.

5.      Screening for addiction risk:  Risk factors for opioid addiction include a past or strong family history of addiction to any substance, younger age, male sex, and an active psychiatric disorder.  Prior to initiating opioid therapy, the prescriber should take a history of current and past substance use and addiction, and a psychiatric history.  Screening questionnaires and urine drug screening may also be considered.  The predictive value of baseline history and screening measures is uncertain; therefore even in low or moderate risk patients, physicians should watch for indicators of opioid addiction, such as rapidly escalating dose, aberrant drug-related behaviours that are more suggestive of addiction (such as non oral route of use and obtaining of prescriptions from more than one source or illegally), and deterioration in mood and functioning despite increasing doses of opioids.

6.      Opioid tapering:  The opioid should be tapered and discontinued in patients who continue to have severe pain or disability despite a trial of several opioids, or who have major side effects or complications.  There is good evidence that tapering is associated with improved mood, pain and functioning in patients who have not responded to high doses.

7.      Management of patients at high risk for opioid addiction:   Opioids should be prescribed only to those with well-documented pain condition who have not responded to non-opioid therapies.  If opioids are prescribed, close monitoring is recommended, with regular urine drug screens and dispensing of small amounts.  Opioids with a higher abuse liability, such as oxycodone preparations, should be avoided if possible.  Since the euphoric effects of opioids are dose-related, the opioid should be titrated cautiously, and the maintenance dose should be kept well below 200 mg of morphine equivalent in the great majority of cases.  Patients who are currently addicted to cocaine, alcohol, or other substances should receive addiction treatment before being placed on potent opioids.

8.      Management of suspected opioid addiction.  Patients with suspected opioid addiction should not be maintained indefinitely on high doses of prescription opioids, even if they claim they need the opioids for their pain.  Ongoing prescribing increases their risk of overdose and other harms.  Furthermore, there is good evidence that patients with both pain and addiction experience improved pain, mood and function with methadone or buprenorphine treatment.  Abstinence-based treatment is also effective in some patients.

9.      Treatment options: 

a.      Structured opioid therapy.  A trial of “structured opioid therapy” may be considered, if the patient has a pain condition that probably requires long-term opioid therapy, and the patient does not access opioids from other sources or alter the route of delivery.  In structured opioid therapy, the dose is tapered if it is high, and it is dispensed frequently (as often as daily), with regular urine drug screens and monitoring for aberrant behaviours. Patients who are unable to comply with structured opioid therapy should be offered methadone or buprenorphine therapy.

b.      Opioid agonist treatment.  Patients with suspected opioid addiction should be referred for methadone or buprenorphine treatment if they regularly access opioids from other sources or alter the route of delivery, are addicted to other substances such as alcohol or cocaine, or have failed a trial of structured opioid therapy.

c.       Abstinence-based treatment.  Abstinence-based treatment involves medically assisted detoxification and intensive psychosocial counselling.  While not as effective as opioid agonist treatment, it is preferred by many patients.  Abstinence-based treatment can be successful in patients with strong social supports, a short history of opioid addiction, and no concurrent mental illness or addiction to other substances.

Public health recommendations

Education.  CSAM calls for a comprehensive educational strategy to address the opioid crisis.  A variety of methods should be employed, including workshops, long-distance clinical support systems (such as mentorship networks) and provider detailing.  The educational strategy should focus on high prescribers and on communities with a high prevalence of addiction and overdose.  The key messages of the strategy should be agreed upon and delivered in a coordinated manner by all relevant organizations. 

Overdose prevention.  Public health authorities should consider overdose prevention programs for patients at high risk for overdose.  These programs distribute naloxone kits and educate users on signs of overdose, how to use naloxone, and when to contact emergency services. 

Regulation and funding.  Provincial ministries should review the feasibility and effectiveness of regulatory and funding strategies to reduce the harms of prescription opioids.  Possible options include provincial prescribing data bases with real-time access for all primary care physicians, mandatory education of prescribers, de-funding 80 mg OxyContin tablets, and blocks on provincial funding for daily opioid doses above a certain limit. Removal of all codeine-containing preparations from being sold over-the-counter should also receive serious consideration.

Addiction treatment.  Methadone and buprenorphine treatment has been shown to reduce overdose rates and improve psychosocial outcomes in opioid-addicted patients. Unfortunately, many communities lack access to opioid substitution programs and to abstinence-based programs, particularly in rural and northern regions.  Waiting lists are often very long, and patients sometimes have to travel long distances to receive treatment.  Therefore CSAM recommends the following:

a.       Improve access to buprenorphine treatment.  CSAM strongly endorses improved access to buprenorphine treatment in Canada. Buprenorphine is of comparable effectiveness to methadone and has a substantially lower risk of overdose. Primary care providers should have access to on-site training on buprenorphine prescribing.  Provincial drug plans should provide coverage for buprenorphine for patients at higher risk for methadone toxicity, those with shorter duration of dependent opioid use, adolescent and young adults, and those who live in communities without a methadone clinic.  Coverage should not be restricted to physicians with a methadone exemption.

b.      Improve access to comprehensive methadone treatment.  Provincial ministries should adopt the findings of a recent policy review of methadone treatment in Canada, which recommended a continuum of MMT service delivery, coordination to ensure appropriate treatment matching, and a consistent funding system.

c.       Promote early identification of opioid addiction.  Emergency departments, hospitals, and pain clinics should have medical staff with expertise in the prevention, identification and management of prescription opioid addiction.