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

Summary

This quality standard provides guidance on the prescribing, monitoring, and tapering of opioids to treat chronic pain for people 15 years of age and older in all care settings. It does not address opioid prescribing for acute pain or end-of-life care, nor does it address the management of opioid use disorder in depth.

Please refer to Health Quality Ontario’s Opioid Prescribing for Acute Pain quality standard and Opioid Use Disorder quality standard for detailed quality statements related to these topics.

Scope of This Quality Standard

The Opioid Prescribing for Chronic Pain Quality Standard Advisory Committee agreed that it is important to include adolescents between 15 and 17 years of age in the scope of this quality standard because of the increased risk of harm opioids pose to this population. Adolescents report higher rates of nonmedical opioid use and intentional poisonings, and suffer a disproportionately higher rate of opioid-related deaths than the general adult population. These higher rates of harm stress the importance of providing guidance on the careful and appropriate prescribing of opioids for chronic pain in youth.

While the scope of this quality standard includes adolescents between 15 and 17 years of age, it should be noted that the statements in this standard are based on guidelines whose evidence is derived primarily from studies conducted on adult (aged 18 years and older) populations. Health Quality Ontario’s Opioid Prescribing for Chronic Pain Quality Standard Advisory Committee members agreed that the guidance in this quality standard is equally relevant and applicable to people between 15 and 17 years of age. However, health care professionals should take into account that specialized skills and expertise may be required when providing treatment for special populations, including adolescents with chronic pain for whom opioid therapy hbeen prescribed or is being considered. If treatment of this or other special populations is beyond a health care professional’s expertise, the health care professional should consult or work with a health care professional with appropriate expertise.

This quality standard includes 10 quality statements addressing areidentified by Health Quality Ontario’s Opioid Prescribing for Chronic Pain Quality Standard Advisory Committee having high potential for improving the quality of care in Ontario for people with chronic pain who have been prescribed or are considering opioids.

Terminology Used in This Quality Standard

In this quality standard, the term “health care professional” is used to acknowledge the wide variety of providers who may be involved in the care of people with chronic pain. The term refers to physicians, nurse practitioners, nurses, dentists, pharmacists, and other allied health professionals involved in the assessment, monitoring, and treatment of chronic pain.

The term “prescriber” refers to physicians, nurse practitioners, and dentists who are authorized to prescribe opioids.

Why This Quality Standard Is Needed

Chronic pain is often defined pain that lasts longer than 3 months or past the time of normal tissue healing, and has been estimated to affect 1 in 5 Canadians. In Ontario, opioids are often prescribed to manage chronic pain, but opioid therapy can present a considerable risk of harm for what may be only a short-term benefit for some people. Over the past two decades, Ontario has witnessed a dramatic rise in the rate of opioid prescribing and concurrent rapid increases in the number of opioid-related deaths, hospitalizations, and emergency department visits, well an increase in the prevalence of opioid use disorder. In 2015/16, more than 9 million opioid prescriptions were written in Ontario, and 1.94 million Ontarians were dispensed opioids. This rate of opioid consumption is very high by global standards: Canada has the highest rate of opioid prescribing when measured by morphine equivalents dispensed, and the second-highest per capita rate of opioid prescribing in defined daily doses. In Ontario, the rate of prescriptions of stronger opioids, particularly hydromorphone, has also increased substantially over the last few years. Finally, there is a remarkable level of unexplained regional variation in the use of opioids across Ontario, with the percentage of people prescribed opioids for pain ranging from 11% to 18% across local health integration network (LHIN) regions.

Current clinical practice guidelines do not recommend opioids a first-line therapy for chronic pain. Evidence suggests that a multimodal combination of non-opioid therapies, delivered through a multidisciplinary approach, can often be effective opioids in managing chronic pain while presenting far less risk of harm. People with chronic pain should have access to appropriate treatment options that are selected with their health care professionals through a shared decision-making process. This process should include a discussion of the expected benefits and potential harms of both opioid and non-opioid therapies. Critically, the complexities of chronic pain require a biopsychosocial approach to treatment. However, many Ontario health care professionals caring for people with chronic pain—particularly in primary care settings—do not have ready access to other types of services or specialists needed to implement a multidisciplinary approach, such psychologists, addiction specialists, physiotherapists, and other health professionals.

While opioids may be an appropriate option for treating chronic pain in some circumstances, many people in Ontario are being prescribed high doses, defined here the equivalent of 90 mg of morphine per day or more. In 2016, the percentage of new opioid prescriptions started at a dose of 90 mg morphine equivalents or more varied between 2.0% and 4.6% across LHIN regions. High doses of opioids are associated with an increased risk of overdose, particularly when combined with other substances such benzodiazepines or alcohol. Patients taking high doses should be supported by their health care professionals to engage in shared decision-making and should receive continuous care during any trials of tapering or discontinuation of opioid therapy.

Appropriate opioid prescribing practices—including dose reduction and discontinuation—combined with an understanding of patient preferences and values, can help reduce the risk of people with chronic pain being subjected to opioid-related harms. Family physicians and nurse practitioners practising in primary care play a crucial role in supporting effective chronic pain management for patients. Primary care providers should be supported to develop skills to initiate the tapering and discontinuation of opioids for chronic pain, well to identify and treat opioid use disorder.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect, equity, and patient safety.

People with chronic pain who have been prescribed or are considering opioid therapy should receive services that are respectful of their rights and dignity and that promote shared decision-making.

People with chronic pain should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, linguistic, ethnic, and religious backgrounds), and disability. Equitable access to the health system also includes access to culturally safe care. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, in predominantly Anglophone settings, services should be actively offered in French and other languages.

Health care professionals should be aware of the historical context of the lives of Canada’s Indigenous peoples and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

A high-quality health system is one that provides appropriate access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

How Success Can Be Measured

The Opioid Prescribing for Chronic Pain Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that may be used to assess quality of care provincially and locally.

How Success Can Be Measured Provincially

Rate of opioid-related deaths
Urgent hospital use:

Rate of opioid-related emergency department visits
Rate of opioid-related hospital admissions

Prescribing:

Rate of people prescribed opioid therapy (proxy measure)
Rate of opioid prescriptions dispensed (proxy measure)

Proxy indicators are measures that approximate the intended indicator. In this case, the proxy indicators use data from a broader cohort (e.g., the population of Ontario), since data on the specific cohort of interest are unavailable (i.e., people with chronic pain).

How Success Can Be Measured Locally

You may want to assess the quality of care you provide to people with chronic pain when considering prescribing opioids. You may also want to monitor your own quality improvement efforts. It may be possible to do this using your own clinical records, or you might need to collect additional data. We recommend the following list of potential indicators, some of which cannot be measured provincially using currently available data sources:

Percentage of people with chronic pain with improved quality of life
Percentage of people with chronic pain with improved functional outcomes
Percentage of people with chronic pain who experience reduced pain
Percentage of people who are prescribed opioids for chronic pain and subsequently develop opioid use disorder

In addition, each quality statement within this quality standard is accompanied by one or more indicators. These indicators are intended to guide measurement of quality improvement efforts related to implementation of the statement.

What Does It Mean for Patients and Caregivers?

Someone who lived with chronic pain for more than 25 years, I have participated in a significant number of national initiatives related to promoting awareness of Canada’s epidemic of under managed pain, creating educational materials for people with pain and their families, and advocating for improved pain care. I am very aware of the opioid crisis that is taking place in Ontario and across Canada.

The development of this quality standard comes at a good time and it high potential to improve pain care and overall quality of life for people who struggle with the life-changing burden of under managed pain. It will help standardize care for people with chronic pain, particularly it relates to opioid prescribing; moreover, it recognizes the much-needed multidisciplinary approach to managing pain.

This quality standard encourages inclusive and non-stigmatizing care. I also appreciate that it is patient-centred, empowering patients and caregivers to become involved in pain management, goal setting, and decision making.

A great deal of collaborative work is required to make the high aspirations of these quality standards a reality, including changes to health policy and service delivery and improved education for health professionals and people living with pain. With these quality standards we have made a good start in the improvement of pain care in Ontario.

- Lynn Cooper, Opioid Prescribing for Chronic Pain Quality Standard Panel Member, Lived Experience Advisor

What Does It Mean for Providers?

There is an overwhelming concern about the use of opioids, which has permeated the public consciousness. I hope this quality standard will help providers and patients understand appropriate indications for opioid therapy and why opioids should not be first line therapy for chronic non-cancer pain. At the same time, this is a complex issue and there isn’t a one-size-fits-all approach: there can be significant barriers to accessing nonpharmacological treatment options, which is a policy issue, and some patients currently taking opioids may be harmed more than helped by stopping or tapering use. This quality standard will provide much-needed direction to ensure optimization of opioid therapy but will require consideration of each patient’s unique circumstances and risk factors.

- Jason Buses, co-chair, Opioid Prescribing for Chronic Pain Quality standard advisory committee

Timeline for This Quality Standard

This quality standard was completed in March 2018.

For more information, contact QualityStandards@HQOntario.ca.

Evidence to Improve Care