Opioid Wisely

Don’t use withdrawal management as a stand-alone treatment for opioid use disorder.

High rates of relapse to opioids after withdrawal management is well established and results in an increased risk of overdose death, blood-borne illness infections, and non-fatal overdoses associated with significant long-term morbidity. Therefore, withdrawal management as a stand-alone treatment should be avoided, and patients must be carefully counselled regarding the significant risks of pursuing this course. Opioid agonist therapy is the gold standard for the management of opioid use disorder. Addiction Medicine Recommendation #1

Don’t prescribe benzodiazepines for opioid withdrawal symptoms.

There is limited evidence to support the use of benzodiazepines to manage opioid withdrawal symptoms during the induction of opioid agonist therapy. Moreover, concurrent opioid and benzodiazepine use is associated with an increased risk of respiratory depression, hypotension, and cardiac arrest. Benzodiazepines should not be routinely used for the treatment of opioid withdrawal. Addiction Medicine Recommendation #5

Don’t routinely discontinue buprenorphine peri-operatively or in the context of acute pain requiring additional opioid analgesia.

Given the lack of evidence supporting improved outcomes with the discontinuation of buprenorphine in the context of acute pain and the high mortality risk associated with untreated opioid use disorder, buprenorphine should not be routinely discontinued in the context of acute pain or surgery. Addiction Medicine Recommendation #8

Do not administer opioid analgesics to patients with burn injuries without considering the co-administration of adjunctive agents, and psychological as well as physical strategies. 

Reliance on opioids as the dominant or only analgesic is associated with harms including not only higher opioid requirements and significant side-effects e.g. nausea, constipation, drowsiness, but also dependence, diversion, and overdose.  One should implement a multi-modal analgesic strategy including acetaminophen and NSAIDS if there are no contra-indications. One should also consider medications directed at neuropathic pain (e.g. gabapentin, pregabalin, duloxetine, amitriptyline), as well as physical (e.g. positioning) and psychological (e.g. distraction, relaxation, meditation) interventions to optimize mental health, reduce anxiety and promote effective sleep. Burns Recommendation #5

Do not administer analgesia and sedation (e.g. opioids and benzodiazepines) without regular titration, interruption or dose reassessment of the administered agents.

Don’t continue opioid analgesia beyond the immediate postoperative period or other episode of acute, severe pain. 

The immediate postoperative period or acute episodes of pain typically refers to a time period of three days or less, and rarely more than seven days. Prescribe the lowest effective dose and number of doses required to address the expected pain. This recommendation does not apply to individuals already on long term or chronic opioids or opioid agonist treatment. Family Medicine Recommendation #12

Don’t initiate opioids long-term for chronic pain until there has been a trial of available non-pharmacological treatments and adequate trials of non-opioid medications.

Depending on the pain mechanism and patient co-morbidities, this can include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclics and gabapentinoids. Other non-medication modalities for managing acute, subacute and chronic pain may include exercise, weight loss, cognitive-behavioural therapy, massage therapy, physical therapy and/or spinal manipulation therapy.  An opioid trial should be guided by clear criteria for monitoring the success of an opioid trial and a plan for stopping opioids if criteria are not met. Family Medicine Recommendation #13

Prolonged use of opioid analgesia beyond the immediate postoperative period or other acute pain episode is not recommended.

Opioid use poses considerable health risks to patients including opioid use disorder, overdose, and side-effects such as psychomotor impairment. While opioid analgesia may be appropriate in select circumstances, prolonged use of opioids beyond the immediate postoperative period and for chronic non-cancer pain is not recommended. Instead, clinicians and patients should consider alternative therapies, such as non-opioid pharmacologic therapy or non-pharmacologic therapies. If opioid analgesia is required, the lowest effective dose, potency, and number of doses required to address the acute pain episode should be prescribed. General Surgery recommendation #7

Don’t prescribe opioid analgesics or combination analgesics containing opioids or barbiturates as first line therapy for the treatment of migraine.

Non-steroidal anti-inflammatory drugs and triptans are recommended first line treatments for acute migraine therapy. Opioids may produce increased sensitivity to pain and increase the risk that intermittent headache attacks will become more frequent and escalate to a chronic daily headache syndrome (medication overuse headache), particularly when opioids are used on 10 days a month or more. Opioids may impair alertness and produce dependence or addiction syndromes. Headache Recommendation #2

Don’t use opioids for post-operative dental pain until optimized dose of NSAID/Acetaminophen has been used.

For post-operative dental pain, the dose and frequency of a non-opioid (ibuprofen and/or acetaminophen) analgesic should be optimized.  If this is not sufficient for managing pain then an opioid may be considered. If an opioid analgesic is appropriate consider limiting the number of tablets dispensed. Hospital Dentistry Recommendation #1

Don’t initiate or escalate opioid doses for chronic non-cancer pain before optimizing non-opioid pharmacotherapy and non-pharmacologic therapy.

Evidence shows that opioids are not more effective than other analgesics for certain chronic pain conditions. Furthermore, evidence is mounting that the risks of opioid treatment, including opioid use disorder, overdose, and other previously under-recognized side effects (e.g., hyperalgesia, psychomotor impairment [which can increase the risk of fractures], myocardial infarction, sexual dysfunction) support the use of non-opioid therapy.

Thorough patient-centred discussion about risks, benefits, and expectations is essential. Hospital Pharmacy Recommendation #6.

Don’t use opioids long-term to manage abdominal pain in inflammatory bowel disease (IBD).

While opioids may be used to manage abdominal pain in select acute settings in IBD patients, their prolonged use may mask the symptoms of active IBD or its complications (e.g., bowel perforation or megacolon). Chronic opioid use has been proven ineffective for non-malignancy associated chronic pain and is associated with excess mortality. Moreover, because of their potential risk for dependence, their long-term use for managing IBD-related abdominal pain should be avoided especially in the context of the opioid crisis in North America. Inflammatory Bowel Disease Recommendation #2

Don’t initiate therapy with opioids for patients with chronic non-cancer pain unless non-opioid pharmacotherapy and other non-pharmacological options have been optimized.

Several non-opioid therapies (including both drug and non-drug alternatives) may achieve a similar magnitude of improvement in pain and function more safely without the potentially serious side effects of opioid therapy (e.g. harms related to dependence, addiction and overdose). Internal Medicine Recommendation #6

Don’t choose opioids or cannabinoids as the first choice of treatment for neuropathic pain.

Opioids and cannabinoids have weak or inconclusive evidence in effective treatment of neuropathic pain. The well documented risks of opioid and cannabinoids include nausea, sleepiness, impairment, dependence, and development of substance use disorders. With impairment comes further risks to oneself and others in altered judgement in the workplace or while operating a vehicle. Opioids come with an additional risk of decreased respiratory drive and fatality with overdose. Neuropathic pain can be treated effectively using agents with demonstrated efficacy and significantly less risks compared to opioids and cannabinoids. Neurology Recommendation #3

Don’t use opioids for treatment of migraines.

Opioids are not adequate for pain control for patients with migraines. The risk for harm, including impairment, dependence, tolerance, medication overuse headaches, and opioid use disorder with opioids is greater than the documented benefit. Additionally, opioids may worsen nausea and vomiting associated with the migraine. Prescription opioids for migraines would have minimal to no benefit with the excess of risk, and contribute to the opioid crisis. Neurology Recommendation #6

Don’t prescribe opioids for management of osteoarthritis before optimizing the use of non-opioid approaches to pain management.

The use of opioids in chronic non-cancer pain is associated with significant risks.  Optimization of non-opioid pharmacotherapy and non-pharmacologic therapy is strongly recommended. Treatment with opioids is not superior to treatment with non-opioid medications in improving pain-related function over 12 months in patients with moderate to severe hip, knee or back pain due to osteoarthritis. Orthopaedics Recommendation #4

Don’t use meperidine for labour analgesia due to its long-acting active metabolites and negative effects on neonatal behaviours.

Meperidine (Demerol) as an opioid analgesic relieves pain of labour but there are superior agents. Furthermore it passes to the fetus and has a particularly long time before elimination. It persists in the neonate and thus interferes with adaptation to extrauterine life and adversely affects breast feeding. Because there are superior choices for analgesia without these adverse effects, meperidine should not be used if alternatives are available. Obstetrics and Gynaecology Recommendation #5

Don’t prescribe opiates for the treatment of acute or chronic non-cancer pain without first assessing side effects, work status, and capacity to drive a motor vehicle.

Increases in opioid prescribing have been accompanied by simultaneous increases in abuse, serious injuries, and deaths from overdose. Compared to those on no, or lower opiate doses, those prescribed higher opiate doses have increased disability risk and duration. The use of opiates can result in effects such as euphoria, drowsiness or inability to concentrate. Cognitive and psychomotor ability are essential functions for driving a motor vehicle and other complex work tasks. Those who prescribe opiates may be obligated to report a patient’s inability to drive safely. Occupational Medicine Recommendation #2

Don’t recommend the use of over-the-counter medications containing codeine for the management of acute or chronic pain. Counsel patients against their use and recommend safe alternatives.

There is no evidence to support the use of low-dose codeine pain medication over non-opioid analgesics. Codeine is an addictive opioid with potential for abuse and dependence. Over-the-counter codeine products are often supplied in combination with non-opioid analgesics (i.e., NSAIDs and acetaminophen). In addition to concerns regarding codeine abuse and dependence, misuse of these codeine-containing combination analgesics may also result in serious adverse effects due to high doses of the simple analgesics (ibuprofen, acetaminophen or aspirin). Effects of high doses of simple analgesics may include liver toxicity, gastric perforation, haemorrhage and peptic ulcer, renal failure, chronic blood loss anaemia and low blood potassium (with potential fatal heart and neurological complications). Pharmacist Recommendation #2

Don’t order prescription drugs for pain without considering functional improvement.

Prescription pain medications have been shown to be effective for pain relief. However, a number of adverse events have been established. While pain reduction is an important outcome measure for patients, they also highly value improved function and quality of life. The addition of prescription pain medications does not always improve functional outcomes, or even pain. There is also a significant risk of long-term addiction. It is imperative that providers work with patients to establish treatment goals, regularly reassess pain and function, and taper or discontinue medications as able or if patients experience harm. Physical Medicine and Rehabilitation Recommendation #3

Don’t prescribe codeine for post-tonsillectomy/adenoidectomy pain relief in children.

Codeine has been associated with a high rate of adverse drug reactions in children. This includes life-threatening respiratory depression. Appropriate dosing of codeine is challenging due to the genetic heterogeneity amongst patients for the CYP2D6 enzyme, which is responsible for codeine metabolism. Genetic screening of CYP2D6 is not routinely performed and can not reliably identify variations in codeine metabolism rates amongst patients. As such, children who are ultra-fast metabolizers of codeine are placed at increased risk of severe adverse drug reactions. Alternative analgesia should be used post-tonsillectomy/adenoidectomy. Pediatric Otolaryngology Recommendation #6

Don’t prescribe opioids for management of chronic rheumatic disease before optimizing the use of non-opioid approaches to pain management.

Opioids in chronic non-cancer pain are associated with substantial risks.  Optimize non-opioid pharmacotherapy and non-pharmacologic therapy. Opioids are not superior to non-opioid medications for pain-related function over 12 months in moderate to severe hip or knee osteoarthritis, or mechanical back pain. Opioids should only be prescribed by physicians skilled in their use. Rheumatology Recommendation #6

Don’t use an opioid analgesic medication as first-line treatment for acute, uncomplicated, mechanical, back-dominant pain.

Over 90% of acute low back pain is a mechanical problem that is often self-limiting and can be controlled with physical treatment and non-narcotic medication. The most common entry point to prescription opioid addiction is through opioids prescribed for back pain. Adequate pain control using opioids is frequently not achieved and patients face the added risks of physical dependence and withdrawal hyperalgesia, which can lead to continued use.
Spine recommendation #6

Don’t treat post-operative back pain with opioid analgesic medication unless it is functionally directed and strictly time limited.

Using post-operative opioid analgesics creates problems with constipation, nausea and dizziness while interfering with early mobilization and, in some patients, promoting long term use. It should be used only in a strictly limited manner and with well-defined parameters. Alternate pain management regimens offer improved pain control, enhanced rehabilitation and fewer complications. Spine recommendation #7

Don’t use opioid analgesic medication in the ongoing treatment of chronic, non-malignant back pain.

There is no clear evidence for the benefits of long-term opioid medication on pain, function or quality of life. There is a clear correlation with a range of adverse effects including falls, fractures, testosterone suppression, hyperalgesia and depression. It increases the risk of dependence, addiction and overdose. Long-term use either before or following spine surgery is associated with increased medical costs and a reduced rate of return to work.
Spine recommendation #8

Don’t prescribe opioids as first line treatment for acute or chronic non-cancer musculoskeletal pain.

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Although acute inflammatory tendinopathies (i.e., tendinitis) exist, most patients seen in primary care will have chronic symptoms (tendinosis). Multimodality options (e.g., relative rest, activity modifications, physical or athletic therapy, etc.) should be considered as the first line treatment of tendinopathies. Opiates should not be used in the initial phase of treatment. Sport and Exercise Medicine Recommendation #2