Dialogue Volume 13 Issue 2 2017 - Page 26

2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain Summary of recommendations Recommendation 1 When considering therapy for patients with chronic non- cancer pain, optimization of non-opioid pharmacother- apy and non-pharmacologic therapy, is recommended, rather than a trial of opioids. (strong recommendation) Recommendation 2 For patients with chronic non-cancer pain, without current or past substance use disorder and without other active psychiatric disorders, who have persistent problem- atic pain despite optimized non-opioid therapy, adding a trial of opioids is suggested, rather than continued therapy without opioids. (weak recommendation) • A trial of opioids means initiation, titration and moni- toring of response, with discontinuation of opioids if im- portant improvement in pain or function is not achieved. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol abuse and dependence, and narcotic abuse and dependence, and sometimes referred to International Classification of Diseases, 9th revision (ICD-9) diagno- ses. The mental illnesses identified in studies as risk factors for adverse outcomes were generally anxiety and depres- sion, including ICD-9 definitions, as well as “psychiatric diagnosis,” “mood disorder” and post-traumatic stress disorder. Recommendation 3 For patients with chronic non-cancer pain with an active substance use disorder, the use of opioids is not recom- mended. (strong recommendation) • C  linicians should facilitate treatment of the underlying substance use disorders, if not yet addressed. The studies that identified substance use disorder as a risk factor for adverse outcomes characterized the conditions as alcohol 26 Dialogue Issue 2, 2017 abuse and dependence, narcotic abuse and dependence, and sometimes referred to ICD-9 diagnoses. Recommendation 4 For patients with chronic non-cancer pain with an active psychiatric disorder whose non-opioid therapy has been optimized, and who have persistent problematic pain, it is suggested that the psychiatric disorder be stabilized before a trial of opioids is considered. (weak recommendation) Recommendation 5 For patients with chronic non-cancer pain with a history of substance use disorder, whose non-opioid therapy has been optimized, and who have persistent problematic pain, it i