Opioid Prescribing for Chronic Pain

Care for People 15 Years of Age and Older

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Comprehensive Assessment
People with chronic pain receive a comprehensive assessment, including consideration of their functional status and social determinants of health.

Quality Statement 2: Setting Goals for Pain Management and Function
People with chronic pain set goals for pain management and functional improvement in partnership with their health care professionals. These goals are evaluated regularly.

Quality Statement 3: First-Line Treatment With Non-opioid Therapies
People with chronic pain receive an individualized and multidisciplinary approach to their care. They are offered non-opioid pharmacotherapy and nonpharmacological therapies as first-line treatment.

Quality Statement 4: Shared Decision-Making and Information on the Potential Benefits and Harms of Opioids for Chronic Pain
People with chronic pain, and their families and caregivers receive information about the potential benefits and harms of opioid therapy for chronic pain at the time of both prescribing and dispensing so that they can participate in shared decision-making.

Quality Statement 5: Initiating a Trial of Opioids for Chronic Pain
People with chronic pain begin a trial of opioid therapy only after other multimodal therapies have been tried without adequate improvement in pain and function, and they either have no contraindications to opioid therapy or have discussed any relative contraindications with their health care professional.

If opioids are initiated, the trial starts at the lowest effective dose, preferably below 50 mg morphine equivalents per day. Titrating over time to a dose of less than 90 mg morphine equivalents per day may be warranted in selected cases in which people are willing to accept a higher risk of harm for an improved pain relief.

Quality Statement 6: Co-prescribing Opioids and Benzodiazepines
People with chronic pain are not prescribed opioids and benzodiazepines at the same time whenever possible.

Quality Statement 7: Opioid Use Disorder
People prescribed opioids for chronic pain who are subsequently diagnosed with opioid use disorder have access to opioid agonist therapy.

Quality Statement 8: Prescription Monitoring Systems
Health care professionals who prescribe or dispense opioids have access to a real-time prescription monitoring system at the point of care. Prescription history is checked when opioids are prescribed and dispensed and every 3 to 6 months during long-term use, or more frequently if there are concerns regarding duplicate prescriptions, potentially harmful medication interactions, or diversion.

Quality Statement 9: Tapering and Discontinuation
All people with chronic pain on long-term opioid therapy, especially those taking 90 mg morphine equivalents or more per day, are periodically offered a trial of tapering to a lower dose or tapering to discontinuation.

Quality Statement 10: Health Care Professional Education
Health care professionals have the knowledge and skills to appropriately assess and treat chronic pain using a multidisciplinary, multimodal approach; appropriately prescribe, monitor, taper, and discontinue opioids; and recognize and treat opioid use disorder.

Resources Quality Statements Advisory Committee About

Setting Goals for Pain Management and Function

People with chronic pain set goals for pain management and functional improvement in partnership with their health care professionals. These goals are evaluated regularly.

Background

Health care professionals should work in partnership with people with chronic pain to establish realistic, specific, and measurable goals that focus on pain management, functional improvement, improvement in ability to perform activities of daily living, and any other improvements in quality of life that are important to the person with chronic pain. Family members should also be encouraged to be involved in the development of management goals. The goal of both opioid and non-opioid therapies for chronic pain will rarely be the total elimination of pain, but rather a meaningful reduction in pain intensity and/or a significant improvement in other patient-defined functional indicators, such as returning to social activities or employment.

Management goals should also consider the side effects of therapies for chronic pain and, wherever possible, minimize potential harms. Health care professionals should consider the potential impacts of physical dependence or inter-dose withdrawal from opioids on pain intensity and function when assessing progress toward pain management goals.

What This Quality Statement Means

For Patients

Your health care professional should work with you to set goals for managing your pain. This conversation should focus on goals that matter to you, including reducing your pain and improving your ability to function at work and at home.

For Clinicians

Work with people with chronic pain to set realistic, specific, measurable goals for improvement in pain and function, and evaluate these goals regularly. If you have initiated an opioid prescription, see the person with chronic pain for follow-up within 28 days.

For Health Services

Ensure resources and tools are available to allow clinicians to follow up with people prescribed opioids for chronic pain within 28 days and to evaluate management goals regularly.

Quality Indicators

Process Indicators

Percentage of people with chronic pain prescribed an opioid who have documented goals for pain management, functional improvement, and quality-of-life improvement

Denominator: total number of people with chronic pain who were prescribed an opioid and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator with documented goals for pain management, functional improvement, and quality-of-life improvement
Data source: local data collection

Percentage of people with chronic pain prescribed an opioid who were seen by the prescribing health care professional within 28 days of receiving an opioid prescription

Denominator: total number of people with chronic pain who were prescribed an opioid and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator who were seen by the prescribing health care professional within 28 days of receiving an opioid prescription
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System and the Ontario Health Insurance Plan (OHIP) Claims Database

Percentage of people with chronic pain prescribed an opioid whose documented goals for pain management, functional improvement, and quality-of-life improvement were reviewed within 3 months of initiating an opioid prescription

Denominator: total number of people with chronic pain who were prescribed an opioid and did not have an opioid prescription in the previous 6 months and who have documented goals for pain management, functional improvement, and quality-of-life improvement
Numerator: number of people in the denominator whose management goals were reviewed and assessed for progress within 3 months of initiating an opioid prescription
Data source: local data collection

Outcome Indicator

Percentage of people with chronic pain prescribed an opioid who experienced improved functional outcomes within 3 months of initiating an opioid prescription

Denominator: total number of people with chronic pain who were prescribed an opioid and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator with documentation of improvement in functional outcomes within 3 months of initiating an opioid prescription
Data sources: local data collection, Activities of Daily Living (ADL) Hierarchy Scale, Resident Assessment Instrument–Home Care (RAI-HC; for home care), Resident Assessment Instrument–Minimum Data Set (RAI-MDS; for long-term care)

Definitions Used Within This Quality Statement

Regular evaluation of goals

Management goals for pain and function should be documented and monitored over time. After initiating an opioid prescription, a health care professional should see the person with chronic pain for follow-up within 28 days. Progress toward goals should then be reassessed every 3 months.

Evidence to Improve Care