Will the new opioid guidelines harm more people than they help?

We wish to respond to the commentary of Dr. Persaud [1] regarding the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain [2].

Dr. Persaud takes our statement regarding controlled release versus short acting opioids out of context. The full statement is as follows:
“In patients with continuous pain including pain at rest, clinicians can prescribe controlled release opioids both for comfort and simplicity of treatment. Activity related pain may not require sustained release treatment and opioid therapy may be initiated with immediate release alone.
The benefit and safety of controlled release or sustained release over immediate release preparations is not clearly established. Some patients, when switching from immediate release to comparable dose sustained release, require larger doses in order to acquire a similar analgesic effect. The release profile of all sustained or controlled release preparations is not the same and may vary for the same drug among patients. Individuals misusing opioids favour immediate release opioid preparations, regardless of the route of administration.[3]”

Regarding the last point, a structured survey of 8304 individuals entering treatment for opioid use disorder found that only 4% selected extended release opioids as their preferred formulation, while 66% favoured short acting opioids; the remainder (30%) had no preference.

Dr. Persaud suggests that differences between the Canadian Guideline and the CDC Guideline are due to bias. Dr. Persaud may well be right: The CDC panel was largely restricted to experts who have been critical of opioid use for chronic noncancer pain. In addition, the CDC guideline, relative to ours, had limited involvement of patients, excessive restrictions on selection of evidence (e.g., insisting on studies with a follow-up of one year or more excluded every randomized controlled trial of treatment with opioids); suboptimal application of the GRADE rating system to address evidence quality; excessive use of strong recommendations in the face of low quality evidence; and vagueness in some recommendations.[4] These differences, in addition to bias as a function of restricting panelists largely to those who were already on record as being critics of opioid use, explain differences between the two guidelines.

The Canadian Guideline is available here in an interactive, multi-layered format, with patient decision aids for all weak recommendations: https://www.magicapp.org/public/guideline/8nyb0E

We reiterate our view that, if followed, the 2017 Canadian Guideline will promote evidence-based prescribing of opioids for chronic noncancer pain.

Jason W. Busse DC PhD, David Juurlink MD PhD, D. Norman Buckley MD, Gordon H. Guyatt MD MSc
Michael G. DeGroote Institute for Pain Research and Care (Busse, Buckley), Department of Anesthesia (Busse, Buckley), and Department of Health Research Methods, Evidence and Impact (Busse, Guyatt), McMaster University, Hamilton, Ont.; Departments of Medicine and Paediatrics (Juurlink), University of Toronto, Toronto, Ont.

References
1. Persaud N. Will the new opioid guidelines harm more people than they help? No. Can Fam Physician. 2018; 64(2): 102-104.
2. Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, Agoritsas T, Akl EA, Carrasco-Labra A, Cooper L, Cull C, da Costa BR, Frank JW, Grant G, Iorio A, Persaud N, Stern S, Tugwell P, Vandvik PO, Guyatt GH. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017; 189(18): E659-E666.
3. Cicero TJ, Ellis MS, Kasper ZA. Relative preferences in the abuse of immediate-release versus extended-release opioids in a sample of treatment-seeking opioid abusers. Pharmacoepidemiology and drug safety. 2017; 26(1): 56-62
4. Busse JW, Juurlink D, Guyatt GH. Addressing the limitations of the CDC guideline for prescribing opioids for chronic noncancer pain. CMAJ. 2016; 188(17-18): 1210-1211.