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

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.

Background

Given the risk of harms involved, opioid therapy for people with chronic pain should be considered only after other multimodal therapies have yielded inadequate improvement in pain and function and after people with chronic pain have had a documented, informed discussion of the potential benefits and harms of opioid therapy with their health care professionals. Additional caution should be applied when considering prescribing opioids for people with relative contraindications to opioids, such as a history of mental health disorder or substance use disorder.

Because there is evidence of a dose–response relationship for overdose and death related to opioid use, if a trial of opioids is warranted, it should start at the lowest effective dose and be titrated as needed, preferably less than 50 mg morphine equivalents per day. In selected cases in which a higher dose is required for effective pain management and the person with chronic pain has discussed the increased risk of overdose and death with their health care professional, the dose may be titrated up to 90 mg morphine equivalents per day. If considering titrating to a high dose of 90 mg morphine equivalents per day or more, a referral to a colleague for a second opinion may be warranted before making a decision. People beginning opioid therapy should be assessed within 28 days of initiation to evaluate benefits and harms, and stable doses should be re-evaluated every 3 months.

If opioids are prescribed, opioid therapy should be combined in a multimodal approach with non-opioid pharmacotherapy and nonpharmacological therapies for chronic pain (see Quality Statement 3).

What This Quality Statement Means

For Patients

Before you start taking opioids, you should know about the potential risks of opioids. If you currently have a drug or alcohol addiction or if you did in the past, or if you currently have a mental health condition, the risk of becoming addicted to opioids or overdosing is higher. Your health care professional should discuss these risks with you.

If you and your health care professional decide that treatment with opioids is right for you, your starting dose should be as low as possible to improve your pain and ability to function. Your health care professional should monitor your use of opioids carefully and help you stay on the lowest possible dose.

When your pharmacist gives you opioids, they should explain to you how to safely store your medication and how to safely dispose of any unused medication you no longer need.

For Clinicians

Prescribe opioids for chronic pain only after other multimodal therapies have been attempted without adequate improvement in pain and function, after you have discussed the potential harms of and alternatives to opioids with the person with chronic pain, and if the person has no absolute contraindications to opioids. For people with relative contraindications, discuss the potential risks they pose.

Initiate opioid therapy at the lowest effective dose, ideally less than 50 mg morphine equivalents per day. Titrate over time to a dose of between 50 and 90 mg morphine equivalents per day only when necessary and only after ensuring the person with chronic pain is aware of the potential harms and is willing to accept a higher risk of harm for improved pain relief.

For Health Services

Develop and adopt protocols and policies to assist prescribers to educate patients on the potential harms associated with opioids through a shared decision-making process and to initiate and monitor a trial of opioids for chronic pain. Put processes in place to help people with chronic pain access non-opioid and nonpharmacological therapies.

Quality Indicators

Process Indicators

Percentage of people with chronic pain prescribed an opioid who received non-opioid pharmacotherapy and/or nonpharmacological therapies prior to starting opioid therapy (aligned with an indicator for Quality Statement 3)

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 received non-opioid pharmacotherapy and/or nonpharmacological therapies prior to starting opioid therapy
Data source: local data collection

Percentage of people with chronic pain prescribed an opioid with documentation of receiving information about the benefits and harms of opioid therapy prior to starting opioid therapy (aligned with an indicator for Quality Statement 4)

Denominator: total number of people with chronic pain who are 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 receiving information about the benefits and harms of opioid therapy prior to starting opioid therapy
Data source: local data collection

Percentage of people with chronic pain prescribed an opioid at an initial dose of greater than 50 mg morphine equivalents per day

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 prescribed an initial dose of greater than 50 mg morphine equivalents per day
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System

Percentage of people with chronic pain starting opioid therapy who were seen by the prescribing health care professional within 28 days of receiving an opioid prescription (aligned with an indicator for Quality Statement 2)

Denominator: total number of people with chronic pain who were initiated on opioid therapy 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 OHIP Claims Database

Percentage of people with chronic pain starting opioid therapy who were evaluated by the prescribing health care professional every 3 months while on opioid therapy

Denominator: total number of people with chronic pain who were initiated on opioid therapy and did not have an opioid prescription in the previous 6 months
Numerator: number of people in the denominator who were evaluated by the prescribing health care professional every 3 months while on opioid therapy
Data sources: local data collection or linked administrative databases, including the Narcotics Monitoring System and the OHIP Claims Database

Definitions Used Within This Quality Statement

Adequate improvement in pain and function

Adequate improvement in pain and function occurs when a person with chronic pain is moving toward or meeting their goals for pain management and function (see Quality Statement 2). Clinically meaningful improvement should be focused on function and quality of life. Because there is no clear consensus on patient-important thresholds for pain relief, a number of options may be considered, such as an appreciable reduction in baseline pain (e.g., 20%, 30%, or 50%); reaching a desired pain state, such as “no worse than mild pain”; or a combination of the two.

Contraindications

Absolute contraindications
Long-term opioid therapy should not be prescribed for chronic pain to people:

With an active substance use disorder, including alcohol use disorder
Who are giving or selling their medication to others
With a confirmed allergy to opioid agents

Relative contraindications
Additional caution should be applied when considering prescribing opioids for chronic pain for people:

With a history of substance use disorder
With an active mental health disorder that is not stabilized; for example, mood disorders, such as anxiety or depression, or post-traumatic stress disorder
Who perform safety-sensitive jobs
Who are pregnant
With chronic obstructive pulmonary disease (COPD) or sleep apnea
Taking any other co-prescribed medications that increase the risk of overdose and death when combined with opioids

If contraindications present after long-term opioid therapy has been initiated, health care professionals should not abruptly taper or discontinue opioids.

Evidence to Improve Care