'People are dying out there': New guidelines for prescribing opioids encourage doctors to put down the pad

Canadian doctors should only prescribe opioids to treat very specific cases of chronic pain and should try to wean their patients off the potentially addictive drugs, according to new guidelines published today in the Canadian Medical Association Journal.

The list of 10 recommendations for health-care providers represents a dramatic departure from the previous guidelines released seven years ago.

The message,according to Jason Busse, the principal investigator behind the list, is "opioids are not first-line therapy for chronic, non-cancer pain."

The new recommendations seek to minimizeharm for a range of patients with chronic pain, including people with current or past substance-use disorders, other psychiatric disordersand those who suffer from persistent pain despite opioid therapy.

Chronic pain, like osteoarthritis,rheumatoidarthritisor lower back pain, is defined as pain lasting more than three months. About 20 per centof Canadians suffer from this type of pain.

It's very necessary to get the prescribing in check. I mean, people are dying out there.-Chris Cull, member of patient advisory committee

The focus back in 2010, Busse says, was on how to prescribe opioids.

Seven years later, the focus is on reducing prescriptions.

"Our guideline has taken a step back and focused on a number of situations in which we feel the prescribing of opioids should be either carefully consideredor not occur at all," said Busse, an associate professor of anesthesia at McMaster University in Hamilton.

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Canada has the second highest per-capita use ofopioidsin the world, andopioid-relateddeaths here are more prevalent todaythan 10 years ago.

"It's very necessary to get the prescribing in check," said Chris Cull, a former opioid addict who was part of apatient advisory committee that helped develop the recommendations. "I mean, people are dying out there."

The key recommendations are:

• For patients with chronic, non-cancer pain, before consideringopioids use non-opioidpharmaceuticals like some anti-inflammatory medications (such as NSAIDs). Also, consider non-pharmaceutical therapylike physiotherapy or massage therapy.
• For patients who haven't responded to non-opioid treatment, and without substance use disorders, a trial of opioids is suggested.
• For patients beginning opioid treatment, the dose should be restricted to the equivalent of under 50 milligrams of morphine a day and no more than 90 milligrams a day. (The 2010 guidelines suggested a "watchful dose" of the equivalent of 200 milligrams of morphine a day.)
• For patients taking the equivalent of 90 milligrams of morphine a day or more, the guidelines suggesttapering to the lowest effective dose.

Bussesays some patients may be able to taper down quitea bit, or even discontinue takingopioidsaltogether. But he admitsothers will struggle and could suffer from severewithdrawal symptoms. In those cases, he says tapering could be paused, or abandoned.

"We don't want to have the recommendations applied in a very blunt fashion where everybody has to come below this threshold of 90 because not all patients are going to tolerate that."

Cull developed addiction issues at 21, first with Percocet, then OxyContin. He was on methadone for five years and has been drug-free since 2014. He says tapering is very difficult.

"Tapering is not easy by any stretch of the imagination. It took me over a year and a bit to taper off," said Cull, who nowraises awareness aboutopioidabuse in Canada.

He said there's always aconcern that patients could simply go elsewhere to get theiropioids.

"If you're putting people into withdrawal by forcefully tapering them, they're going to find their stuff somewhere else," he said."And that somewhere else might be on the street. And if it's on the street, it could be tainted drugs."

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Bussesaidimplementation of the recommendations is a provincial responsibility, but "we need dedicated funding for a national strategy to effectively ensure the guideline is used, and that we measure its impact."

Acommentarypublished in the journal says the new recommendations are welcome, butbarriers to accessing safe, effective and affordablealternative paintreatments like physical therapies, psychological interventions and social supportslimit their practical use.

"Until Canada has a realistic national strategy for the treatment of chronicdisabling pain, physicians will continue using the only tool they have in their toolbox: their prescription pad."