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

Opioid Use Disorder

People prescribed opioids for chronic pain who are subsequently diagnosed with opioid use disorder have access to opioid agonist therapy.

Background

The development of opioid use disorder is a risk associated with long-term opioid therapy for chronic pain. Clinicians concerned about a person with chronic pain developing opioid use disorder based on the person’s concerns, symptoms, or behaviours; findings in a prescription monitoring system; or the use of a risk-screening tool should have a discussion with the person about their opioid use in an open and nonjudgmental way and provide an opportunity for the person to disclose any concerns or problems related to opioid use. Clinicians should assess for the presence of opioid use disorder based on criteria from the current edition of the Diagnostic and Statistical Manual (DSM).

People with concurrent chronic pain and untreated opioid use disorder should be offered opioid agonist therapy with either buprenorphine/naloxone or methadone. People with concurrent chronic pain and opioid use disorder or another active substance use disorder should receive optimized non-opioid multidisciplinary pain management. Clinicians should continue to offer non-opioid therapies for chronic pain and consider consulting a pain or addiction specialist as needed.

For detailed quality statements related to the diagnosis, management, and monitoring of opioid use disorder, please refer to Health Quality Ontario’s Opioid Use Disorder quality standard.

What This Quality Statement Means

For Patients

There is a risk of becoming addicted to opioids. If you are taking your opioids more often or in higher doses than prescribed, or if you feel that opioids are having a negative impact on your life, talk with your health care professional. Your health care professional should not judge you. They should treat you with care and respect.

For Clinicians

Assess people for opioid use disorder based on current DSM criteria. If you diagnose opioid use disorder in a person taking opioids for chronic pain, ensure that they have access to opioid agonist therapy within 3 days of diagnosis.

For Health Services

Ensure systems and resources are in place to allow health care professionals to screen people at risk of opioid use disorder. Ensure pathways are in place that allow people diagnosed with opioid use disorder to access respectful, nonjudgmental, evidence-based treatment within 3 days of diagnosis. For further details, please refer to Health Quality Ontario’s Opioid Use Disorder quality standard.

Quality Indicators

Process Indicator

Percentage of people prescribed an opioid for the treatment of chronic pain diagnosed with opioid use disorder who received opioid agonist therapy within 3 days of diagnosis (aligned with Quality Statement 7 of the Opioid Use Disorder quality standard)

Denominator: total number of people prescribed an opioid for chronic pain and diagnosed with opioid use disorder
Numerator: number of people in the denominator who received opioid agonist therapy within 3 days of diagnosis
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System

Structural Indicator

Local availability of access to opioid agonist therapy (aligned with Quality Statement 7 of the Opioid Use Disorder quality standard)

Data sources: local data collection, ConnexOntario

Definitions Used Within This Quality Statement

Opioid agonist therapy

Opioid agonist therapy is the provision of an opioid agonist (typically a long-acting formulation) as part of a treatment program. Opioid agonist therapy eliminates the cycle of intoxication and withdrawal, reduces opioid cravings, and blocks the effect of other opioids. People with opioid use disorder who are stabilized on opioid agonist therapy are considered to be in recovery and typically experience a significant improvement in health and social function. They would have uncomfortable symptoms if they were suddenly to discontinue opioid agonist therapy, but they are no longer considered to have an active substance use disorder. In Ontario, opioid agonist therapy must be prescribed by a physician or nurse practitioner.

Opioid use disorder

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders defines opioid use disorder as “a problematic pattern of opioid use leading to clinically significant impairment or distress, occurring within a 12-month period.” The Manual lists 11 symptoms of opioid use disorder. The presence of 2 to 3 symptoms indicates mild opioid use disorder; 4 to 5 symptoms indicates moderate opioid use disorder; and 6 or more symptoms indicates severe opioid use disorder.

Evidence to Improve Care