Addressing inaccurate claims about the Canadian opioid guideline

The commentary by Dr Clarke and colleagues published in the September issue of Canadian Family Physician, “Canada’s hidden opioid crisis: the health care system’s inability to manage high-dose opioid patients,”¹ includes several inaccuracies regarding the 2017 “Guideline for opioid therapy and chronic noncancer pain,”² including some we have already addressed after 3 of the article’s authors made the same misrepresentations in a different journal.^3,4

Clarke and colleagues suggest that the 2017 Canadian opioid guideline led to regulatory investigations of doctors who prescribe high doses, yet the reference they provide makes clear this investigation began in November 2016, 6 months before the guideline was published.⁵

Clarke and colleagues state that the 2017 Canadian opioid guideline directs physicians to taper patients taking stable opioid doses equivalent to 120 mg of morphine, and who report good pain relief, improved function, few side effects, and no aberrant behaviour. It does not. Recommendation 9 (which suggests tapering opioids to the lowest effective dose for patients with chronic noncancer pain using ≥ 90-mg morphine equivalents of opioids per day) is a weak recommendation, meaning that most informed patients would choose the recommended course of action, but an appreciable minority would not.² With weak recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at decisions consistent with their values and preferences. The final decision to attempt a trial of opioid tapering rests with the patient. The patients described by the authors would likely choose not to taper.

Clarke and colleagues state that the “Canadian opioid guidelines estimate the prevalence of OUD [opioid use disorder] in patients with chronic noncancer pain who were prescribed an opioid to be 10%.”¹ It does not. The studies we reviewed provided evidence of moderate certainty for a 5.5% (95% CI 3.91 to 7.03%) risk of OUD among patients prescribed opioid therapy for chronic noncancer pain.² The authors discuss the potential harms that might result among patients with OUD who are tapered as recommended by the guideline; however, the guideline does not apply to this population. As the guideline outlines very clearly, it is not intended to address the use of opioids in patients with the following:

• cancer-related pain;

• OUD or substance use disorder;

• acute or subacute pain (pain lasting < 3 months); and

• pain or suffering associated with end-of-life care.²

Clarke and colleagues suggest that recommendation 10 (a strong recommendation for a formal multidisciplinary program for patients with chronic noncancer pain who are using opioids and experiencing serious challenges in tapering) is impractical. We agree that this recommendation is resource-dependent, which is why the guideline provides the following associated remark:

In recognition of the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist, and a psychologist).²

The 2017 Canadian opioid guideline is available at www.magicapp.org/public/guideline/8nyb0E in an interactive, multi-layered format, with patient decision aids for all weak recommendations.

If followed, the 2017 Canadian opioid guideline² will promote evidence-based prescribing of opioids for chronic noncancer pain.

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