The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain

Main Editor Jason Busse Associate Professor, Department of Anesthesia, Associate Professor, Department of Health Research Methods, Evidence and Impact McMaster University, HSC-2V9, 1280 Main St. West, Hamilton, Ontario, Canada, L8S 4K1 bussejw@mcmaster.ca
Language en
Last Update Oct 29, 2018
Published Date Oct 29, 2018
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Disclaimer

The draft recommendations in this guideline are presented to encourage public review and comment. The direction (‘for’ or ‘against’) and strength (‘weak’ or ‘strong’) of each recommendation has been established by a 15-member guideline panel of clinicians, methodologists and patients, and are unlikely to change unless compelling evidence emerges that was not considered by the panel. All feedback received regarding the wording of recommendations and associated text, and/or important considerations (please see Feedback Form), will be carefully considered by the guideline steering committee and used to inform the drafting of the final guideline document.


This guideline was an investigator-initiated study, supported by grants from the Canadian Institutes of Health Research and Health Canada. The funders had no role in the design and conduct of the study; collection, analysis, and interpretation of the data; or preparation, review, or approval of the guideline. Health Canada personnel provided non-binding feedback during the study. Final decisions regarding the protocol and issues that arose during the guideline development process were the purview of the guideline steering committee. This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License.

Sponsors This guideline was an investigator-initiated study, supported by grants from the Canadian Institutes of Health Research and Health Canada. Health Canada personnel provided non-binding feedback during the preparation of the guideline. The funders had no other role in the design or conduct of the study; collection, analysis, and interpretation of the data; or preparation, review, or approval of the guideline. Final decisions regarding the protocol and issues that arose during the guideline development process were solely the responsibility of the Guideline Steering Committee.
Abstract

Guideline Panel Members:

Jason W. Busse (Chair), McMaster University, Canada
Gordon H. Guyatt, McMaster University, Canada
Alonso Carrasco, American Dental Association, USA
Elie Akl, American University of Beirut, Lebanon
Thomas Agoritsas, University Hospitals of Geneva, Switzerland
Bruno da Costa, Florida International University, USA
Per Olav Vandvik, Innlandet Hospital Trust-Division Gjøvik, Norway
Peter Tugwell, University of Ottawa, Canada
Sol Stern, private practice, Canada
Lynn Cooper, Canadian Pain Coalition, Canada
Chris Cull, Inspire by Example, Canada
Gus Grant, College of Physicians and Surgeons of Nova Scotia, Canada
Alfonso Iorio, McMaster University, Canada
Nav Persaud, University of Toronto, Canada
Joseph Frank, VA Eastern Colorado Health Care System, USA

Guideline Steering Committee: Gordon H. Guyatt (Chair), Norm Buckley, Jason W. Busse, David Juurlink
Clinical Expert Committee: Norm Buckley, Donna Buna, Gary Franklin, Chris Giorshev, Jeff Harris, Lydia Hatcher, Kurt Hegmann, Roman Jovey, David Juurlink, Priya Manjoo, Pat Morley-Forster, Dwight Moulin, Mark Sullivan
Patient Advisory Committee:* Bart Bennett, Lynn Cooper, Chris Cull, Ada Giudice-Tompson, Deborah Ironbow, Pamela Jessen, Mechelle Kane, Andrew Koster, Sue Mace, Tracy L. Mercer, Kyle Neilsen, Ian Tregunna, Jen Watson
* 3 members did not provide written consent to be listed
Evidence Synthesis Team: Samantha Craigie, Jason W. Busse, Li Wang, Rachel Couban, Vahid Ashoorion, Mahmood AmniLari, Yaping Chang, Kayli Culig, Kyle De Oliveira, Anna Goshua, Justin Ho, Patrick Hong, Alka Kaushal, Regina Li, Veena Manja, Curtis May, Yasir Rehman, John Riva, Stephanie Ross, Nicole Vogel, Raad Yameen, Yuqing Zhang
External Review Committee: Paul Glasziou (Chair), Pablo Alonso Coello, Miranda Langendam
Acknowledgements: The authors acknowledge Arnav Agarwal, Fazila Aloweni, Justin Bhullar, Linn Brandt, Paul Bruno, Jasmine Chahal, Iván D. Flórez, Farid Foroutan, Andrea Furlan, Mehdi Ghasemi, Daniel Gottlieb, François-Camille Grolleau, Robert Hauptman, Alan Kaplan, Luciane Lopes, Lyubov Lytvyn, Doug McEvoy, Isabel Ng, Marie Nikkanen, Sureka Pavalagantharajah, Loren Regier, Behnam Sadeghirad, and Naomi Scott for their contribution to this work.

PICOS
PICO 4.0
P: Patients with chronic non-cancer pain, without current or past substance use disorder and without other current serious psychiatric disorders, whose therapy is optimized with non-opioids with persistent problematic pain
I: Trial of opioids.
C: Continue established therapy without opioids.
O:

PICO 4.0
P: Patients with chronic non-cancer pain considering first line therapy for pain
I: Trial of opioids.
C: Optimization of therapy with NSAIDs.
O:

PICO 4.0
P: Patients with chronic non-cancer pain considering first line therapy for pain
I: Trial of opioids.
C: Optimization of therapy with anticonvulsants.
O:

PICO 4.0
P: Patients with chronic non-cancer pain considering first line therapy for pain
I: Trial of opioids.
C: Optimization of therapy with mexiletine.
O:

PICO 4.0
P: Patients with chronic non-cancer pain considering first line therapy for pain
I: Trial of opioids.
C: Optimization of therapy with nabilone.
O:

PICO 4.0
P: Patients with chronic non-cancer pain considering first line therapy for pain
I: Trial of opioids.
C: Optimization of therapy with tricyclic antidepressants.
O:

PICO 4.0
P: Patients with chronic non-cancer pain with an active substance use disorder whose non-opioid therapy has been optimized
I: Trial of opioids
C: Continue established therapy without opioids
O:

PICO 4.0
P: Patients with chronic non-cancer pain with a history of substance use disorder, whose non-opioid therapy has been optimized, who still experience persistent problematic pain
I: Trial of opioids
C: Continuing established therapy without opioids
O:

PICO 4.0
P: Patients with chronic noncancer pain with an active psychiatric disorder whose non-opioid therapy has been optimized, and who still experience persistent problematic pain
I: Trial of opioids
C: Continue established therapy without opioids
O:

PICO 4.0
P: Patients with chronic noncancer pain beginning opioid therapy
I: Limit opioid dose to a particular maximum dose
C: No maximum opioid dose
O:

PICO 5.0
P: Patients who want to taper opioids who are above the threshold dose
I: Multidisciplinary Program
C: No Multidisciplinary Program
O:

PICO 5.0
P: Patients with chronic non-cancer pain on opioids with persistent problematic pain
I: Tapering of opioid
C: Keeping the dose of opioid the same
O:

PICO 5.0
P: Patients with chronic non-cancer pain with persistent problematic pain and/or problematic side effects
I: Rotation to other opioids
C: No change in opioid therapy
O:

PICO 7.0
P: Patients with chronic non-cancer pain on long-term opioid therapy with clinical and biochemical evidence of hypogonadism.
I: Hormone replacement therapy while maintaining current opioid dose.
C: Taper opioids to treat hypogonadism.
O:

PICO 7.0
P: Patients with chronic non-cancer pain prior to starting long term opioid therapy
I: Urine drug screening for baseline substance use.
C: No urine drug screening for baseline substance use.
O:

PICO 7.0
P: Patients with chronic non-cancer pain prior to starting long-term opioid therapy
I: Formal structured treatment agreements.
C: No formal structured treatment agreement.
O:

PICO 7.0
P: Patients with chronic non-cancer pain prior to starting long-term opioid therapy.
I: Provide take-home naloxone along with opioid prescription.
C: Do not provide take-home naloxone along with opioid prescription.
O:

PICO 7.0
P: Patients with chronic non-cancer pain prior to starting long-term opioid therapy
I: Controlled release opioids
C: Immediate release opioids
O: