If you’re preparing for your CCFP exam, you’re keeping an eye out for new guidelines, and you’ve probably heard that this week the Canadian National Pain Centre just released its new guideline for opioid use in chronic pain.
The CMAJ publication made quite the splash in both the local and national Canadian media, as they were launched in the middle of the current fentanyl overdose crisis happening in every province (there were nearly 4 overdose deaths every day in BC in March).
You can bet that exam question writers have probably heard about this guideline.
In fact, if you attended the conference presentation by The Review Course faculty at the SRPC Rural & Remote conference last month, you would have already seen the draft guidelines before they were released nationwide.
SO... WHAT’S NEW?
1. CHOOSING TO USE OPIOIDS
2010: If you consider opioids for chronic non-cancer pain, do a “comprehensive assessment” and assess risk first. Using “non-opioid alternatives” first is only mentioned in the recommendation specific to adolescents.
2017: “We recommend optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids, for patients with chronic noncancer pain.” Only trial opioids if this fails.
2. MAXIMUM DOSE
2010: “Chronic non-cancer pain can be managed effectively in most patients with dosages at or below 200 mg / day” of morphine equivalent dose (MED)
2017: Recommended maximum prescribed dose is less than 90 mg MED, and a suggestion to stay even lower: 50 mg.
2010: “Opioids should be tapered and discontinued if the patient’s pain remains unresponsive after a trial of several different opioids” or if the patient is an adolescent, or pregnant. Several studies show that tapering results in improved mood and reduce pain.
2017: Taper if patients are already on 90 mg MED. “Tapering efforts should be individualized and should consider patients’ values and preferences.”
CLINIC TIP: See the official Patient info brochure
4. MENTAL HEALTH
2010: Document the patient’s psychiatric status and substance use history. “Titrate more slowly, and monitor closely” in patients with psychiatric diagnoses.
2017: If your patient has a history of substance use disorder, alcohol use disorder, or active mental illness, AVOID OPIOIDS
5. COMBINATION WITH BENZOS
2010: Consider a trial of tapering in patients using opioids and benzos. If not successful, titrate opioids more slowly.
2017: Don't combine them. Benzos and opioids should “very rarely” be prescribed together, according to expert opinion and standard of care (but surprisingly, the actual evidence on this – five studies - found conflicting results).
Be sure you are familiar with all ten recommendations from the new guidelines before you write your exam: Direct link to the 10 recommendations
EXAM TIP – Stay up to date with our comprehensive list of Canadian guidelines to know for the CCFP exam – available for free download at www.TheReviewCourse.com/guidelines
2010 Guidelines: http://nationalpaincentre.mcmaster.ca/opioid_2010/
2017 CMAJ article: http://www.cmaj.ca/content/189/18/E659.full.pdf