Laura Murphy (BScPhm, ACPR, PharmD)
Clinical Leader, Department of Pharmacy
Toronto Rehab, University Health Network, Toronto, ON
Feng Chang (BScPhm, PharmD)
Associate Professor, University of Waterloo, School of Pharmacy Waterloo, ON
Shelita Dattani (BScPhm, PharmD)
Director, Practice Development and Knowledge Translation
Canadian Pharmacists Association, Ottawa, ON
Beth Sproule (BScPhm, PharmD)
Clinician Scientist, Pharmacy Department
Centre for Addiction and Mental Health, Toronto, ON and
Leslie Dan Faculty of Pharmacy, University of Toronto
Canada is currently experiencing an unprecedented opioid epidemic (1). Widespread use of increasing doses of prescription opioids to treat chronic pain in the past two decades has been a significant contributor to current opioid-related morbidity and mortality (2). Nearly half of all patients with chronic pain (approximately 20 per cent of Canada’s population) still receive inadequate analgesia (3). So, we know that we have not yet struck the right balance between safety and efficacy in the management of chronic pain.
Pharmacists across all practice settings encounter people with chronic pain who also use opioids. These interactions are important opportunities for pharmacists to act as opioid stewards. Further, in the context of the current opioid crisis, people with chronic pain are often concerned about making decisions regarding opioid use. Their pharmacists are well positioned to support them in these decisions.
“The Canadian Guideline for Opioids for Chronic Non-Cancer Pain,” hereafter referred to as “the Guideline,” was published in May 2017 to address the use of opioids to manage chronic pain in adults (4). The full Guideline is available through MAGICApp online and through the National Pain Centre based at McMaster University.
To assist pharmacists in navigating this guideline and implementing it in practice, our paper, “A pharmacist framework for implementation of the Canadian Guideline for Opioids for Chronic Non-cancer Pain” was published in the Canadian Pharmacists Journal in January 2019 (5). Here, we provide a brief summary:
WHAT DID THE GUIDELINE RECOMMEND?
The Guideline includes 10 evidence-based recommendations related to initiation of opioid therapy, opioid dosing and opioid rotation and tapering. These are outlined in Box 1. The GRADE system was used to create the Guideline and applied a rating of the strength of each recommendation (strong or weak). If a recommendation is “strong,” all or almost all individuals should receive the intervention. If a recommendation is “weak,” pharmacists and other clinicians should recognize that different choices are appropriate for individual patients and acknowledge the need to support them in arriving at a decision that is in line with their own values and preferences. In other words, we need to understand what balance of risks and benefits is meaningful to our patients.
Best practice statements, informed by indirect evidence, were included as well as expert guidance statements to address areas where evidence was very limited or absent. As evidence emerges, these guidance statements may evolve into recommendations, or may no longer be applicable.
PHARMACIST FRAMEWORK TO IMPLEMENT THE GUIDELINE
Pharmacists must assess all patients initiating opioid therapy and provide ongoing monitoring of effectiveness (pain and function), safety (dose, adverse effects, long-term consequences of opioids, aberrant behaviours) and adherence as part of their care plan.
Recognizing the many challenges pharmacists could face implementing the Guidelines in daily practice, we proposed a Framework (sample of the Framework is shown in Table 1) to help pharmacists put all of this together.
The development of opioid-related policy changes, in response to the opioid epidemic, has led to patients perceiving increased stigma and a loss of autonomy related to their opioid use (6). For many patients, how the conversation about opioids is initiated is key to their engagement in a discussion about tapering. This is similar to other conversations about behavior change but complicated further by stigma and also fear relating to uncontrolled pain and opioid withdrawal. Thus, initiating this conversation can be daunting for pharmacists, requiring a motivational approach. Our framework and its suggested approach to engaging patients was reviewed by people with lived experience of chronic pain and opioid therapy.
Education should be tailored to the individual, ensuring they have information that is important to them. Patients using opioids are often surprised by the concept of opioid-related hyperalgesia, when opioids cause pro-nociceptive or sensitizing effects(7). Pain may increase with opioid dose. Once understood, this may be motivating for people to want to decrease opioid doses. Listening to patients is an essential component of providing individualized education.
APPLYING THE FRAMEWORK
Arthur is a 68-year-old widower and grandfather of three with chronic low back pain and degenerative disc disease. He has used oxycodone extended release (ER) for the last 20 years and his current dose is 40mg twice daily (MED = 120mg). Arthur reports that his pain is getting worse over time and he doesn’t get the same relief as he used to. His other medications for pain include acetaminophen and duloxetine. He asks you, his pharmacist, can his dose be increased for better relief of his pain?
For opioid doses >90mg MED, taper to the lowest effective dose, and potentially discontinue (weak recommendation) Arthur’s dose is already above the recommended threshold of 90mg MED. However, the recommendation to taper when above this dose is classified as “weak,” so Arthur’s pharmacist should support him in reaching a decision that is right for him. Hearing that his pain is not as well controlled may mean that he has developed tolerance, and he may be experiencing some opioid-related hyperalgesia, which he perceives as worsening pain. Increasing the dose would exacerbate those circumstances. To support him in his decision, the pharmacist can help him set functional goals by asking, “what would living well with chronic pain look like?” They can also discuss adverse effects or complications he might be experiencing (e.g. sleep apnea, low testosterone, mood changes, constipation, falls) which could be important to him as he makes his decision about opioids. The pharmacist can recommend a referral for a sleep study, lab work or a mood assessment if needed to inform the discussion. His pain response and functional goals can be monitored over time using a tool such as the Brief Pain Inventory (8).
If he decides he would like to taper, his pharmacist can make recommendations on how to safely decrease his dose to the lowest effective dose. Working with Arthur to reassess his non-opioid and non-pharmacological therapy, his pharmacist can ensure other pain management and coping strategies are optimized.
Anita, a 45-year-old wife and mother of a teenage son, has chronic, widespread pain throughout her body. She has tried many medications since her diagnoses of fibromyalgia five years ago, but she hasn’t been able to tolerate any of them after only a few days because of terrible side effects. She is currently using a transdermal fentanyl patch, 50mcg changed every three days (MED=200mg). She is confined to her home much of the time because of pain and spends most of her day in bed. She is interested in cutting back on her dose because of terrible constipation and sleepiness during the day, but she feels hopeless because the last time her prescriber decreased her dose, her pain had a severe flare.
Optimize non-opioid drugs and non pharmacological therapies (strong recommendation). Physical exercise reduces pain in fibromyalgia (4). Meditation and good sleep hygiene are also recommended (9). Anita’s pharmacist can recommend these and refer her to other clinicians or programs if needed for further support. Unfortunately, Anita has not tolerated non-opioid medications in the past. Opioids have poor clinical response in fibromyalgia and may worsen pain because of increased risk of opioid-induced hyperalgesia (10).
For persistent problematic pain and/or problematic adverse effects, rotation to other opioids rather than keeping the opioid the same (weak recommendation). Anita is already using opioids at a high dose (MED >90mg), is experiencing intolerable side effects, and still her function is quite limited. Anita can be empowered to achieve her goal and taper her opioids gradually as the other strategies are put into place. Recommending an opioid rotation to a different drug may improve her pain management, and also facilitate the taper as the dose can be lowered when switching by up to 50 per cent to address incomplete cross tolerance. Further decreases may be possible in smaller increments. The pharmacist can support Anita to pause or slow down the taper as needed.
Michael is a 56-year-old single man with chronic neuropathic pain in his legs and feet where he has constant burning, tingling pain and also some numbness. He uses capsaicin topically and nortriptyline 100mg at bedtime which provides some relief but overnight pain still interrupts his sleep. His medical history is significant for diabetes, insomnia, and alcohol use disorder. His doctor has prescribed hydromorphone 2-4mg to take at bedtime (MED=10-20mg) to help with the pain overnight.
If there is history of substance use disorder, continue non-opioid therapy rather than adding an opioid (weak recommendation). Michael’s pharmacist should engage him in a discussion to ensure he has the information he needs about his increased risk of opioid-related problems considering his history of alcohol use disorder. There are non-opioid therapeutic alternatives he can consider for neuropathic pain (e.g. duloxetine, pregabalin, topical lidocaine) before opioids.
WHERE TO BEGIN
Pharmacists are formally recognized in the Guideline for making important contributions to the inter-professional team, particularly with respect to their role in opioid tapering. An important first step is identifying patients with high opioid-related risk in their practice (e.g. opioid doses >90mg MED), with concurrent use of benzodiazepines and opioids, and with aberrant behaviours. The next step is partnering with them to discuss the Guideline. Working with patients and prescribers to recommend and monitor changes to therapy (e.g. opioid rotations, opioid tapers, optimizing non-opioid pain medications) are opportunities where pharmacists are highly-valued, ensuring safety and support to patients when they need it most.
BOX 1. EVIDENCE-BASED RECOMMENDATIONS
Recommendations for when to INITIATE opioid therapy:
- Optimize non-opioid and non-pharmacologic therapy first (strong).
- For patients who experience persistent, problematic pain despite optimized non-opioid therapy, consider a trial of opioids if no past or current substance use disorder or other active psychiatric disorders (weak).
Recommendations against initiating opioid therapy:
- Do not use opioids in patients with an active substance use disorder (strong).
- Suggest avoiding opioid therapy in patients with a history of substance use disorder, or other active psychiatric disorder (weak).
Recommendations for DOSING when starting opioid therapy:
- Restrict doses for patients beginning opioid therapy to <90mg MED (strong).
- Restriction to <50mg MED is suggested (weak).
Recommendations for opioid ROTATION and TAPERING:
- Rotate to a different opioid if patients using opioids have persistent problematic pain and/or adverse effects (weak).
- Taper to the lowest effective dose (and potentially discontinue) if patients are using ≥90mg MED daily (weak).
- Provide multidisciplinary support for patients struggling to reduce their opioid dose (strong).
Table 1. Sample of the Framework for Implementation of Guideline Recommendations
|Ask||Assess||Canadian Opioid Guideline Recommendation||Recommend and Document|
|What benefits do you see related to your opioid therapy?
What do they help you to do in your day?
What are some of the downsides that you see from your opioids?
|Track objective measures of pain and function (Brief Pain Inventory), adverse effects, long-term consequences
(e.g. sleep apnea, hypo-gonadism, aberrant behaviours)
Assess readiness for change.
|For >90mg MED: tapering to the lowest effective dose, potentially discontinuation (WEAK)
For persistent pain and/or adverse effects: Rotate to other opioid rather than keeping the opioid the same (WEAK)
|Document calculations and endpoints from monitoring parameters.
Engage patient and prescriber in discussion about tapering or rotation. Document patient goals and preferences, and readiness for change.
|There are several strategies that we have to help lower your dose – which of these sound like they would be a good fit for you?||Create a plan for rotation, account for incomplete cross tolerance in calculations.
Consider rotation as a strategy to decrease dose when appropriate.
Educate patient about expectations for the taper, especially the temporary withdrawal pain and symptoms.
Document patient progress over time.
Follow up with patient frequently.
Note: MED=morphine equivalent daily
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2. Gomes T, Khuu W, Martins D, Tadrous M, Mamdani MM, Paterson JM, et al. Contributions of prescribed and non-prescribed opioids to opioid related deaths: population based cohort study in Ontario, Canada. BMJ. 2018;362:k3207.
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Conflict of Interest: None of the authors have conflicts of interest to disclose.
Financial Acknowledgement/Industry Sponsorship: This article has not received any funding or industry sponsorship.