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

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.

Background

Tapering should be offered to all people on long-term opioid therapy every 3 to 6 months, especially to those on doses of 90 mg morphine equivalents per day or more. Health care professionals should discuss the potential benefits and harms of opioid tapering and work with people with chronic pain to taper to the lowest effective dose or to taper to discontinuation in situations in which patients:

Are not experiencing improvements in pain or function
Are not adhering to their prescribed dose
Have aberrant drug screening results
Are experiencing adverse effects
Are prescribed both opioids and benzodiazepines
Request a dose reduction or discontinuation

People taking both benzodiazepines and opioids require tapering to reduce the risk of overdose and death. The concurrent tapering of both drugs is preferred, but it may be more practical to taper one drug at a time depending on adverse effects and risk of harm.

During tapering, other non-opioid therapies for chronic pain should be offered with frequent follow-up. Gradual dose reductions of 5% to 10% every 2 to 4 weeks with frequent follow-up is the preferred method of tapering for most people. Health care professionals should work with patients to individualize the tapering strategy for each person’s unique needs and, where appropriate, offer referrals to addiction medicine, psychiatry, or other multidisciplinary programs that provide care for people taking high doses of opioids, those who have previously experienced withdrawal, and those who have complex comorbidities. As there are cost and availability issues associated with formal multidisciplinary opioid reduction programs, clinicians should endeavour to offer an alternative coordinated multidisciplinary collaboration that includes several health care professionals.

Some people might experience an increase in pain or a decrease in function that lasts more than 1 month after a dose is tapered. In such cases, tapering may be paused or stopped.

What This Quality Statement Means

For Patients

Your health care professional should talk with you about cutting down or stopping your opioid medication when:

You have been taking opioids for 3 months or longer
Your pain is not getting better
You are having problematic side effects
You are on a high dose of opioids
You want to cut down or stop taking opioids

Cutting down or stopping your opioid medication may have benefits for you, including lowering your risk of overdose and improving your pain.

But, cutting down or stopping opioids can be difficult. Your health care professional should work with you to make this decision together. If you cut down or stop too quickly, you may experience uncomfortable physical symptoms such as trouble sleeping, muscle aches, diarrhea, upset stomach, and vomiting. Your health care professional will work with you to make a plan to help you cut down or stop taking opioids safely. When you are cutting down, you might find it helpful to try other ways to manage your pain, like physical therapies, psychological therapies, or cultural or spiritual practices that are important to you.

For Clinicians

For people on long-term opioid therapy, discuss opioid tapering and offer tapering to discontinuation every 3 to 6 months. Strongly encourage tapering to people who:

have been prescribed a dose of 90 mg morphine equivalents or more per day
are not experiencing adequate improvement in pain and function
are experiencing problematic side effects
have been prescribed both opioids and benzodiazepines

For Health Services

Develop opioid tapering protocols and ensure health care professionals have the knowledge and skills needed to taper and discontinue opioid therapy safely.

Quality Indicators

Process Indicators

Percentage of people with chronic pain who were offered a trial of tapering every 6 months while on opioids

Denominator: total number of people with chronic pain who were prescribed an opioid
Numerator: number of people in the denominator who were offered a trial of tapering to a lower dose every 6 months while taking an opioid
Data sources: linked administrative databases, including the Narcotics Monitoring System

Percentage of people with chronic pain prescribed an opioid dose of ≥ 90 mg morphine equivalents per day who received a trial of tapering to a lower dose

Denominator: total number of people with chronic pain who were prescribed an opioid dose of ≥ 90 mg morphine equivalents per day
Numerator: number of people in the denominator who received a trial of tapering to a lower dose
Data sources: linked administrative databases, including the Narcotics Monitoring System

Definitions Used Within This Quality Statement

Multidisciplinary opioid reduction program

Formal multidisciplinary opioid reduction programs and coordinated multidisciplinary collaborations consist of treatment provided by several health professionals. Possibilities include, but are not limited to, primary care physicians, nurses, pharmacists, physical therapists, chiropractors, kinesiologists, occupational therapists, psychiatrists, and psychologists.

Adverse effects

Possible adverse effects of opioid therapy include cognitive impairment, constipation, depression, falls, hypogonadism, nausea and vomiting, opioid-induced hyperalgesia, sleep apnea, unintentional overdose, opioid use disorder, and death.

Evidence to Improve Care