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Guideline the 2017 Canadian Guideline for Opioids for Chronic The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain Main editor Publishing Information Jason Busse Associate Professor, Department of Anesthesia, Associate v4.10 published on 29.10.2018 Professor, Department of Health Research Methods, Evidence and Impact McMaster University, HSC-2V9, 1280 Main St. West, Hamilton, Ontario, Canada, L8S 4K1 [email protected] National pain center 1 of 106 The 2017 Canadian 2017 Guideline Canadian for Opioids for Chronic Non-CancerGuideline Pain - National painfor center Opioids for Chronic Non-Cancer Pain 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. Contact Jason Busse MDCL 2111, McMaster University, 1280 Main St W, Hamilton ON L8S 4L8 [email protected] 905-525-9140 x21731 Sponsors/Funding 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. 2 of 106 The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain - National pain center 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. 3 of 106 The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain - National pain center Sections Summary of recommendations...........................................................................................................................................................................................................................5 1 - About this guideline .......................................................................................................................................................................................................................................12 2 - Scope of the Guideline and How To Use the Guideline....................................................................................................................................................................13 3 - Background and methods............................................................................................................................................................................................................................15 4 - Initiation and Dosing of Opioids in Patients with Chronic Noncancer Pain............................................................................................................................21 5 - Rotation and Tapering of Opioids, for Patients with Chronic Noncancer Pain ......................................................................................................................68 6 - Best Practice Statements.............................................................................................................................................................................................................................77 7 - Expert Guidance..............................................................................................................................................................................................................................................78 7.1 - Risk mitigation....................................................................................................................................................................................................................................84 References ...............................................................................................................................................................................................................................................................90 4 of 106 The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain - National pain center Summary of recommendations 1 - About this guideline 2 - Scope of the Guideline and How To Use the Guideline 3 - Background and methods 4 - Initiation and Dosing of Opioids in Patients with Chronic Noncancer Pain Recommendation 1: When considering therapy for patients with chronic non-cancer pain Strong Recommendation We recommend optimization of non-opioid pharmacotherapy and non-pharmacological therapy, rather than a trial of opioids Recommendation 2: For patients with chronic noncancer pain, without current or past substance use disorder and without other active psychiatric disorders, who have persistent problematic pain despite optimized nonopioid therapy Weak Recommendation We suggest adding a trial of opioids rather than continued therapy without opioids. By a trial of opioids, we mean initiation, titration, and monitoring of response, with discontinuation of opioids if important improvement in pain or function is not achieved. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses. The mental illnesses identified in studies as risk factors for adverse outcomes were generally anxiety and depression, including ICD-9 definitions, as well as “psychiatric diagnosis”, “mood disorder”, and post-traumatic stress disorder. Recommendation 3: For patients with chronic noncancer pain with an active substance use disorder Strong Recommendation AGAINST We recommend against the use of opioids Clinicians should facilitate treatment of the underlying substance use disorders, if not yet addressed. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses. Recommendation 4: For patients with chronic noncancer pain with an active psychiatric disorder, whose nonopioid
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