The role of prescribing practices in managing chronic pain with opioids

Norm Buckley and Jason Busse from the Michael G. DeGroote Institute for Pain Research and Care discuss prescribing practices, managing chronic pain with opioids, and the contribution of licit and illicit opioids towards the Canadian opioid crisis

Over the past 40 years, chronic pain treatment has ranged from pharmacotherapy, regional anesthesia techniques, graduated exercise, physiotherapy modalities, lifestyle modification, psychotherapy (e.g., cognitive behavioral therapy), and complementary therapies such as acupuncture, yoga, and Tai Chi.

Pharmacotherapy included the use of anticonvulsant drugs such as carbamazepine with their risks of liver dysfunction, non-steroidal anti-inflammatories with the risk of bleeding and renal injury, anti-depressants with serotonin, cholinergic and adrenergic actions, and complications including sedation and cardiac arrhythmia, and opioids.

Growing interest in managing chronic pain with opioids

Prior to 2000 and in the early 2000s, there was a growing interest in managing non-palliative chronic pain with long-term opioid therapy, possibly because of some successes in treating pain in palliative care with opioids. In 2000, the College of Physicians and Surgeons of Ontario supported the creation of a best practice advisory entitled ‘Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain.’ The resulting document contained suggestions on the judicious use of opioids, including sustained-release opioids, to facilitate their use in settings such as employment where repeated dosing might be inconvenient.

We have previously commented upon the growth of different opioid preparations, including sustained-release formulations, and the growing advocacy of using opioids for chronic non-malignant pain. Risks of addiction in patients experiencing chronic pain were believed to be low. ⁽¹⁾ With growing reports of the successful use of opioids for treating chronic nonmalignant pain ⁽²⁾ and industry advocacy ⁽³⁾, the use of opioids became more common.

As the number of patients prescribed grew, and the total dose prescribed at any one time also increased, it was observed that more prescription opioids were slipping from the therapeutic milieu into the area of illicit or recreational use.

Much attention began to be directed towards physician prescribing practice and strategies for ensuring that the therapeutic intentions did not go astray, creating a new public health problem. Ultimately, as we have seen, the public health problem has unfortunately grown in magnitude and severity.

Official guidelines for the prescription and management of chronic pain with opioids

In 2010, the Federation of Medical Regulatory Authorities of Canada (FMRAC), the national association of medical regulators, created a guideline for managing chronic pain with opioids – ‘The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non- Cancer Pain.’ The intent was to establish common practice amongst Canadian physicians in the use of opioids.

For chronic pain clinicians who were unable to return patients on opioids to their primary care practitioners, it was hoped that this guideline would encourage primary care physicians to manage opioid prescribing for their own patients. Many of the recommendations were nonspecific, and almost all supported the prescribing of opioids; the guideline provided few suggestions about when not to prescribe.

Opioid prescribing increased, and in 2013, Canadian data indicated that 13% of the population had received an opioid prescription. In 2015-16 in Ontario, 14% of the population received an opioid prescription. In 2016-2017, North American guidelines emerged that either recommended against opioids for chronic non cancer pain ⁽⁴⁾ or concluded they were not first-line care. ⁽⁵⁾

Since then, prescribing has diminished, and in 2018, the proportion of Canadians prescribed opioids was 12.6%, which further diminished in 2021 to 12.2%. In addition, fewer patients were starting opioid therapy, a reduction from 9.5% in 2013 to 8.1% in 2018. Many of these changes in prescribing may have been influenced more by public press and statements by influential individuals than they were by guidelines.

In fact, practice had begun to change before the release of the 2017 Canadian Guideline. Further, as opioid prescribing diminished, the rate of deaths due to opioid overdose rose tragically and is higher now than it has ever been. Causes are uncertain and likely multi-factorial; however, one possibility is that a strong recommendation by the 2016 Centers for Disease Control and Prevention guideline to avoid prescribing high dose opioids ⁽⁶⁾ resulted in aggressive, involuntary tapering for many chronic pain patients.

To mitigate withdrawal symptoms, some patients may have replaced their prescription opioids with illicit opioids, in some cases with devastating consequences. ⁽⁷⁾ The greatest proportion of opioid-related deaths are now associated with the use of illicitly manufactured synthetic opioids similar to fentanyl, of unknown but very high potency.

Opioid tapering

One of the controversies in prescribing practice is understanding the role of tapering patients currently on high dose opioids to lower doses. Tapering has been suggested to reduce the risk of dose-related side effects and events such as fatal and non-fatal overdose. It is also argued that some patients on long term opioids may be experiencing opioid induced hyperalgesia or continue to use opioids not because they provide specific analgesic benefits but are mitigating inter-dose withdrawal symptoms.

Tapering to lower doses has, in some observational trials, been associated with a reduction in opioid related side effects and sometimes a reduction in pain complaints. Several patients, however, report worsening quality of life brought on by ‘forced tapering’ or conflict with their prescribing physician around attempting a trial of tapering. Emerging evidence has shown support only for consensual, supported opioid tapering. ^{(8, 9)}

Continually reducing opioid related deaths

In summary, prescribing practices for opioid use in chronic pain care have changed considerably over the past 20 years. However, the relative contribution of high-quality guidelines and public pressure on physicians to address the terrible problem of opioid-related deaths is unclear.

Chronic pain care remains a very challenging issue. While pharmacotherapy is widely available, interventions promoted as first-line care, such as physical therapy and psychological measures, are not consistently available within provincial universal healthcare systems in Canada.

Further, education of health policymakers and healthcare professionals is still lacking concerning chronic pain, which has resulted in large variability in policies and practices. The opioid crisis is associated with prescription, illicit, and diverted opioids, and efforts to reduce harm must consider each of these areas. In the next article in this series, we will review some of the provincial and federal level activities of policymakers in Canada aimed at addressing the opioid crisis.

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