Debating the opioid guidelines: context

We wish to respond to the commentary of Dr Persaud¹ in the debate 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.²

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.³

Dr Persaud suggests that differences between the Canadian guideline and the Centers for Disease Control and Prevention (CDC) guideline⁴ are owing to bias. Dr Persaud might 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 (eg, insisting on studies with a follow-up of 1 year or more excluded every randomized controlled trial of treatment with opioids), suboptimal application of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) rating system to address evidence quality, excessive use of strong recommendations in the face of low-quality evidence, and vagueness in some recommendations.⁵ These factors, 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 2 guidelines.

The Canadian guideline is available here in an interactive, multi-layered format, with patient decision aids for all weak recommendations: 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.

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