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New Guideline Tackles Undertreatment of Chronic Pain, Growing Misuse of Opioids

CMAJ. Published online May 3, 2010.

May 5, 2010 — A new Canadian guideline on opioid use in chronic noncancer pain (CNCP) has been issued to address the undertreatment of CNCP and the growing misuse of opioids.

The new guideline, a multi-institutional, collaborative effort, is available online at http://nationalpaincentre.mcmaster.ca/opioid/ and was published online May 3 in the Canadian Medical Association Journal. Canadian medical regulators formed the National Opioid Use Guideline Group in November 2007 to develop the guideline.

"Canadian physicians asked for clear, evidence-based guidance to safely manage opioid treatment for patients with [CNCP]," said Andrea D. Furlan, MD, PhD, from the University of Toronto in Ontario and lead author on the review article.

"The Canadian Guideline provides 24 recommendations based on evidence and consensus of experts, although it is not a policy or a standard of practice," she told Medscape Neurology.

According to Dr. Furlan, many physicians are reluctant to use opioids because of fear of adverse effects, complications, and risks of addiction, overdose, and misuse, but with appropriate precautions and monitoring, these problems can be avoided.

"[The guideline] provides advice for doctors, especially family physicians, and may be a useful resource for pharmacists, nurses, dentists, or other health professionals caring for patients with [CNCP]," she added.

The guideline was derived from a review of 184 studies (62 randomized controlled trials and 122 observational studies) that met the criteria for inclusion and were used to develop recommendations.

Clinical Questions Addressed

The Canadian Opioid Guideline addresses 4 clinical questions that physicians commonly consider when deciding to use opioids to treat CNCP, including:

* What should I do before writing a prescription for opioids?
* How do I titrate the dosage of opioids?
* What should I do to ensure patient safety?
* When do I stop a patient's opioid therapy?

To answer these questions, the 24 practice recommendations are organized into 5 clusters, as follows:

* Cluster 1: Deciding to Initiate Opioid Therapy
* Cluster 2: Conducting an Opioid Trial
* Cluster 3: Monitoring Long-Term Opioid Therapy
* Cluster 4: Treating Specific Populations with Long-Term Opioid Therapy
* Cluster 5: Managing Opioid Misuse and Addiction in CNCP Patients

Comparison With Other Guidelines

The new guideline follows in the wake of 2 other similar guidelines published in the United States in 2009, when development of the Canadian guideline was already in progress.

According to Dr. Furlan, the guideline of the American Pain Society/American Academy of Pain Medicine has additional recommendations not included in the Canadian guideline that pertain to treatment of breakthrough pain, management of adverse effects, selection of short-acting vs long-acting preparations, special issues with methadone, and awareness of state laws.

In addition, the Utah Department of Health guideline has compiled recommendations from 6 other guidelines on the management of CNCP with opioids. "There are no major discrepancies between the Utah and the Canadian guideline," Dr. Furlan noted.

An important point, Dr. Furlan said, is that the guideline recommends that before the first prescription is written, the physician and patient talk about the goals for therapy, and during the opioid trial phase these goals should be constantly checked.

"Sometimes patients have unrealistic goals; for example, that opioids will achieve 100% pain relief, whereas randomized trials indicate that the average improvement is only about 10 to 20 mm in a 100-mm [visual analog pain scale]. So, the patient needs to be informed of that before opioid is prescribed," she said.

The guideline also recommends a treatment agreement between the patient and the prescribing physician, as well as documentation. "The 'opioid manager' can be used as a chart insert to help physicians to monitor the important aspects on every visit," she said. This manager will be made available online at http://nationalpaincentre.mcmaster.ca/opioid/.

Knowledge Gaps

The Canadian Medical Association Journal article on the guideline cites several important gaps in knowledge regarding the use of opioids in noncancer pain. These include agents with alternative routes of administration (intramuscular, subcutaneous, transdermal, rectal, and infusion). Opioids need to be compared with nonopioid drugs, and in addition, more research is needed "on the treatment of fibromyalgia pain and chronic headache with opioids other than tramadol, and no useful literature exists on opioid treatment for chronic visceral pain," the authors note.

Other topics that need further research include long-term effects, opioid misuse, the effect of comorbidities, and the role of genetic factors in response and outcomes with opioids, the authors suggest.

In a related commentary, Roger Chou, MD, from the Oregon Health & Science University, in Portland, writes that more studies of high-risk populations with long-term follow-up are needed, as are studies on optimal methods for risk stratification, patient selection, opioid initiation, dose titration, monitoring, and discontinuation of therapy.

"Until these studies are completed, the new Canadian guideline offers clinically sound recommendations for making decisions regarding the use of opioids for treating non-cancer pain," he writes.

Dr. Furlan's disclosures are described in the Canadian Medical Association Journal article. She has received honoraria to write an expert opinion paper for the Workplace Safety and Insurance Board on opioid use for CNCP and has received grants from the Canadian Institutes of Health Research and the Ontario Association of Fundraising Professionals Innovation Fund to conduct research on opioids.

Crohn's 35

Inactive Account
I used to be able to get Oxycotin or Percocets, but no longer. I did not abuse them, I took enough to tolerate the pain, like maybe half a pill and food. The growing trend is that people are snorting them now and is a widespread problem. Our system is that when a doctor prescribes it, it goes into the computers (at least here) and no walk in clinics or or doctor on call will give them to you. People are abusing them and unfortunately the rest of the people who NEED them pay for it. Very addictive, and I am quite aware of that.