Table 3.

Recommendations of the Canadian guideline for safe and effective use of opioids for chronic noncancer pain

Recommendation		Grade(s)	Tools available in guideline
Deciding to initiate opioid therapy
1	Comprehensive assessment Before initiating opioid therapy, ensure comprehensive documentation of the patient’s pain condition (Grade C), general medical condition and psychosocial history (Grade C), psychiatric status (Grade B), and substance use history (Grade B).	B, C	A description of components of a comprehensive assessment Guides to interviews on alcohol consumption and substance use The CAGE questionnaire
2	Screening for addiction risk Before initiating opioid therapy, consider using a screening tool to determine the patient’s risk for opioid addiction.	B	An example of a screening tool (i.e., the Opioid Risk Tool)
3	Urine screening for drugs When using urine drug screening to establish a baseline measure of risk or to monitor compliance, be aware of benefits and limitations, appropriate test ordering and interpretation, and have a plan to use results.	C	Advice on patient education about urine screening for drugs, sample collection and tampering Comparison of point-of-care versus laboratory urine testing A list of the pros and cons of routine urine screening for drugs A table of information about interpreting and acting on unexpected results A table comparing immunoassay and chromatography, including detection times
4	Opioid efficacy Before initiating opioid therapy, consider the evidence related to effectiveness in patients with chronic noncancer pain.	A	Summaries of findings from randomized controlled trials Examples of conditions related to chronic noncancer pain for which opioids were shown to be effective in placebo-controlled trials and examples of conditions that have not been studied in controlled trials
5	Risks, adverse effects and complications Before initiating opioid therapy, ensure informed consent by explaining potential benefits, adverse effects, complications and risks (Grade B). A treatment agreement may be helpful, particularly for patients not well known to the physician or at higher risk for opioid misuse (Grade C).	B, C	A summary of potential risks, benefits, adverse effects and complications of opioid therapy Information about actions by physicians and education of patients and families aimed at reducing risks of overdose, diversion, addiction and withdrawal A patient-information handout that can be customized to a physician’s practice An example of a treatment agreement, with suggestions about when such an agreement might be useful
6	Benzodiazepine tapering For patients taking benzodiazepines, particularly for elderly patients, consider a trial of tapering (Grade B). If a trial of tapering is not indicated or is unsuccessful, opioids should be titrated more slowly and at lower doses (Grade C).	B, C	Protocol for tapering benzodiazepines A table of benzodiazepine equivalence
Conducting a trial of opioid therapy
7	Titration and driving During dosage titration in a trial of opioid therapy, advise the patient to avoid driving a motor vehicle until a stable dosage is established and it is certain the opioid does not cause sedation (Grade C), and when taking opioids with alcohol, benzodiazepines or other sedating drugs (Grade B).	B, C	Advice about conditions under which driving should be avoided during titration A definition of “pharmacologically stable dose”
8	Stepped selection of an opioid During an opioid trial, select the most appropriate opioid for trial therapy using a stepped approach, and consider safety.	C	Guidance for selecting the most appropriate opioid while considering severity of pain and patient-safety issues
9	Optimal dose When conducting a trial of opioid therapy, start with a low dose, increase dosage gradually and monitor analgesic effectiveness until optimal dose is attained.	C	A definition of “optimal dose” A table showing suggested initial dosage and titration An example of how to assess change in pain intensity
10	Watchful dose Chronic noncancer pain can be managed effectively in most patients with dosages at or below 200 mg/d of morphine or equivalent (Grade A). Consideration of a higher dosage requires careful reassessment of the pain and of risk for misuse, and frequent monitoring with evidence of improved patient outcomes (Grade C).	A, C	Advice about actions to take when the morphine-equivalent dosage approaches or exceeds 200 mg/d
11	Risk of misuse When initiating a trial of opioid therapy for patients at higher risk for misuse, prescribe only for well-defined somatic or neuropathic pain conditions (Grade A), start with lower doses and titrate in small-dose increments (Grade B), and monitor closely for signs of aberrant drug-related behaviors (Grade C).	A, B, C	A description of patients at higher risk for misuse A tool for detecting aberrant drug-related behaviours Guidance on titration and monitoring in patients at higher risk for misuse
Monitoring long-term opioid therapy
12	Monitoring When monitoring a patient on long-term therapy, ask about and observe for opioid effectiveness, adverse effects or medical complications, and aberrant drug- related behaviours.	C	Information on elements of appropriate monitoring, including the value of physician–pharmacist collaboration An example of a tool to monitor functional improvement (i.e., the Brief Pain Inventory) Examples of tools for monitoring patients for aberrant drug-related behaviours An example of an opioid therapy record
13	Switching or discontinuing opioids For patients experiencing unacceptable adverse effects or insufficient opioid effectiveness from one particular opioid, try prescribing a different opioid or discontinuing therapy.	B	Guidance on initial doses when switching to a different opioid Protocol for tapering opioids A conversion table for opioid analgesics
14	Driving and opioid therapy When assessing safety to drive in patients on long-term opioid therapy, consider factors that could impair cognition and psychomotor ability, such as a consistently severe pain rating, disordered sleep and concomitant medications that increase sedation.	C	List of factors to assess that could impair cognition and psychomotor ability and thus prompt a report of “unsafe to drive” to a regulatory body
15	Revisiting steps of trial therapy For patients receiving opioids for a prolonged period who may not have had an appropriate trial of therapy, take steps to ensure that long-term therapy is warranted and dose is optimal.	C	A checklist to assist physicians with patients taking long-term opioid therapy who have not been through the steps of a therapy trial, to ensure nothing has been missed An outline of the process for revisiting diagnosis, screening, patient education, selection and dosage of opioid and ensuring opioid effectiveness
16	Collaborative care When referring patients for consultation, communicate and clarify roles and expectations between primary-care physicians and consultants for continuity of care and for effective and safe use of opioids.	C	Suggestions aimed at referring family physicians and consulting physicians on appropriate communication to ensure continuity of safe and effective care
Treating specific populations with long-term opioid therapy
17	Elderly patients Opioid therapy for elderly patients can be safe and effective (Grade B) with appropriate precautions (Grade C), including lower starting doses, slower titration, longer dosing interval, more frequent monitoring, and tapering of benzodiazepines.	B, C	An overview of risks, risk reduction and prescribing-related cautions for elderly patients Protocol for tapering benzodiazepines
18	Adolescent patients Opioids present hazards for adolescents (Grade B). A trial of opioid therapy may be considered for adolescent patients with well-defined somatic or neuropathic pain conditions when non-opioid alternatives have failed, risk of opioid misuse is assessed as low, close monitoring is available and consultation, if feasible, is included in the treatment plan (Grade C).	B, C	An overview of opioid use by and prescribing cautions for adolescent patients
19	Pregnant patients Pregnant patients taking long-term opioid therapy should be tapered to the lowest effective dose slowly enough to avoid withdrawal symptoms, and then therapy should be discontinued if possible.	B	A list of cautions related to delivery and postpartum
20	Comorbid psychiatric diagnosis Patients with a psychiatric diagnosis are at greater risk for adverse effects from opioid treatment. Usually in these patients, opioids should be reserved for well-defined somatic or neuropathic pain conditions. Titrate more slowly and monitor closely; seek consultation where feasible.	B	An overview of increased risks and prescribing cautions for patients with a psychiatric disorder
Managing opioid misuse and addiction in patients with chronic pain
21	Options for addiction treatment For patients with chronic noncancer pain who are addicted to opioids, three treatment options should be considered: methadone or buprenorphine treatment (Grade A), structured opioid therapy (Grade B) or abstinence-based treatment (Grade C). Consultation or shared care, where available, can assist in selecting and implementing the best treatment option (Grade C).	A, B, C	Indications for three treatment options for the opioid-addicted patient with chronic pain (i.e., methadone or buprenorphine treatment, structured opioid therapy, and abstinence-based treatment).
22	Prescription fraud To reduce prescription fraud, physicians should take precautions when issuing prescriptions and work collaboratively with pharmacists.	C	A list of precautions that could reduce prescription fraud
23	Unacceptable behaviour by patients Be prepared with an approach for dealing with patients who disagree with their opioid prescription or exhibit unacceptable behaviour.	C	A description of common sources of conflict between patients and physicians and how physicians can minimize these Advice on circumstances under which police should be contacted
24	Acute care prescription of opioids Acute or urgent health care facilities should develop policies to provide guidance on prescribing opioids for chronic pain to avoid contributing to opioid misuse or diversion.	C	Guidance for physicians in acute or urgent health care facilities on creating a policy on prescription of opioids