Dialogue Volume 13 Issue 2 2017 - Page 27

Recommendation 7 For patients with chronic non-cancer pain who are begin- ning opioid therapy, it is suggested that the prescribed dose be restricted to less than 50 mg morphine equiva- lents daily. (weak recommendation) • Th  e weak recommendation to restrict the prescribed dose to less than 50 mg morphine equivalents daily acknowl- edges that there are likely to be some patients who would be ready to accept the increased risks associated with a dose higher than 50 mg in order to potentially achieve improved pain control. Recommendation 8 For patients with chronic non-cancer pain who are cur- rently using opioids, and have persistent problematic pain and/or problematic adverse effects, we suggest rota- tion to other opioids rather than keeping the opioid the same. (weak recommendation) • R  otation in such patients may be done in parallel with, and as a way of facilitating, dose reduction. Recommendation 9 For patients with chronic non-cancer pain who are cur- rently using 90 mg morphine equivalents of opioids per day or more, we suggest tapering opioids to the lowest ef- fective dose, potentially including discontinuation, rather than making no change in opioid therapy. (weak recommendation) • S  ome patients may have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused or potentially abandoned in such patients. Recommendation 10 For patients with chronic non-cancer pain who are using opioids and experiencing serious challenges in tapering, a formal multidisciplinary program is recommended. (strong recommendation) • I  n recognition of the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access ac- cording to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist and a psychologist). MD Explaining weak vs. strong recommendations Evidence was available to support only four “strong” recom- mendations and six “weak” recommendations. Strong rec- ommendations indicate that all or almost all fully informed patients would choose the recommended course of action, and indicate to clinicians that the recommendation is ap- propriate for all or almost all individuals. Weak recommendations indicate that the majority of informed patients would choose the suggested course of action, but an appreciable minority would not. With weak recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at a decision consistent with their values and preferences. Weak recommendations should not be used as a basis for standards of practice. Issue 2, 2017 Dialogue 27