Contraindications, forced tapering, and SOO tip
- Opioid tapering shouldn’t be “forced”
- Maximize non-opioid treatments first
- If that fails, “discuss a trial of opioids”…
- …but ONLY in low risk patients (e.g. those with NO history of: “psychiatric disorders,” overdose, or past or active substance use disorder)
The complete 2024 Canadian Opioid Prescribing Guidelines aren’t released yet (expected later this fall), but a sneak preview is now available. And, wow, are there some big changes.
The very top line of the summary states, “GOOD PRACTICE STATEMENT: Patients with chronic non-cancer pain (CNCP) prescribed opioids should not be engaged in forced/involuntary tapering.” It will be interesting to see the strength of the evidence used to support this statement, as it’s not indicated in the brief summary released so far.
Some other key points:
1. According to the guideline authors, opioid trials for CNCP are contraindicated if the patient has a history of:
other current or past psychiatric disorders
mental illness
opioid overdose
These will exclude a lot of patients; that being said, the guidelines suggest using shared decision-making to help determine the next steps. This helps ensure a balance of effective pain management with reducing the risk of harm.
2. If a trial is initiated, the maximum dose should be less than 80 mg morphine equivalents daily (MED), - see the calculator on their Opioid Manager tool, and “seldom if ever” more than 150 mg MED.
3. If the treatment isn’t working the authors suggest rotating opioids.
4. Finally, always (especially on a SOO) offer referral for multidisciplinary support, which can include input from other healthcare professionals like pharmacists, physical therapists, and mental health specialists. This collaborative approach can make all the difference in helping patients manage their pain safely.
What do you think? Join the discussion on our Preparing for the CCFP Exam Facebook Group at bit.ly/ccfpexam!
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