20-05-2025
Mixed Results for BC's Opioid Standard for Noncancer Pain
An opioid prescribing practice standard for chronic noncancer pain (CNCP) was associated with accelerated declines in opioid doses and high-dose prescribing in British Columbia (BC) but also with more aggressive and inappropriate dose tapering, a new analysis showed.
In addition, the standard resulted in restricted access to opioids for patients who may have benefited from them. For some individuals, this restriction continues today, despite a subsequent update, experts said.
Shifting Standards and Guidelines
The practice standard 'Safe Prescribing of Drugs with Potential for Misuse/Diversion' was released by the College of Physicians and Surgeons of British Columbia in 2016, then revised in 2018 to clarify that clinicians should not use aggressive tapering or reduce access to opioids for patients with cancer or those receiving palliative care, according to the new analysis, which was published on May 12 in CMAJ.
The 2016 standard, which was legally enforceable, was associated with the acceleration of preexisting declines in opioid prescriptions to patients with CNCP, as well as declines in high-dose prescribing. However, it also 'reflected the most worrisome recommendation by the US Centers for Disease Control and Prevention guideline,' which was published earlier [and has since been updated], Jason Busse, MD, professor of anesthesia at McMaster University in Hamilton, Ontario, told Medscape Medical News.
Jason Busse, MD
The 2016 standard recommended against increasing the dose of opioids to 90 morphine milligram equivalents or more per day for patients with CNCP but failed to clarify whether the recommendation pertained to new or legacy patients, said Busse. The result was that patients already on high doses risked being tapered aggressively to meet the new dose requirements.
In addition, the standard 'seems to have limited access for populations that have historically benefited from opioids, including patients with cancer or those receiving palliative care,' study author Dimitra Panagiotoglou, MD, associate professor in the Department of Epidemiology, Biostatistics and Occupational Health at McGill University in Montreal, told Medscape Medical News.
Dimitra Panagiotoglou, MD
The study's findings 'demonstrate the ability of practice standards to modify physician behavior but also highlight how misinterpretation can harm patients,' Panagiotoglou added.
In 2017, between the publication of the original practice standard and its subsequent update, the Canadian government released the 'Guideline for Opioids for Chronic Noncancer Pain.' The 2017 guideline was not legally enforceable and was more open to interpretation than the 2016 practice standard, however, and so the effects of the guideline on physician prescribing in BC 'appear to be small, if present at all,' the study authors noted.
The 2018 practice standard update is legally enforceable. But because appropriate access to opioid medications remains limited even now, clinicians on Panagiotoglou's team and patients they've spoken with have 'mixed feelings' about the updated standard and the 2017 prescribing guideline.
Furthermore, Busse said, 'There are now several recent guidelines for opioids and chronic pain that make different recommendations. Some recommend against use of opioids for CNCP under any circumstances, while others do not. Research is needed to understand why these discrepancies have arisen and to provide guidance on which recommendations are most trustworthy.'
One step in that direction is an update to the 2017 guideline, he noted. A quick reference summary of the update is available now, and full recommendations are expected to be published next winter.
'Unlearning' the Past
Why did BC health officials decide to address opioid prescribing in 2016? 'Today, there is an overall understanding that overprescribing can lead to opioid use disorder, but for a long time, that wasn't the case,' said Monty Ghosh, MD, an addiction physician and researcher and assistant professor at the University of Alberta, Edmonton, and the University of Calgary, Calgary.
Monty Ghosh, MD
'The previous philosophy was that pain was the fifth vital sign, that we should be prescribing opioids freely for all types of pain, and that they didn't have addictive potential,' he told Medscape Medical News . 'That is all being undone right now.'
In 2016, health officials saw higher than normal rates of drug poisonings and overdoses, spurring the declaration of an opioid 'crisis' in BC as well as in Alberta, Ghosh said. 'An alert went out to ensure that physicians were not fueling the crisis because at points in time, we were. That is when we started to see the gears change in terms of prescribing. Changes started trickling in before but really ramped up in 2017 to 2018.'
Nevertheless, he noted, 'It's much harder to unlearn than it is to learn, and the standards and the guideline increased awareness of the potential harms.' Prescribing changed due to other practice modifications as well, he said. For example, in Alberta, prescribers now receive quarterly memos showing the amount of opioids they've prescribed and where they fit in the spectrum of prescribers. The memos show, for example, whether the prescriber is in the top or bottom 5% of prescribers.
'Those memos link to information on how to properly prescribe for patients with CNCP that are pretty much in keeping with the guideline and standard,' said Ghosh.
Nonopioid Options
If the goal is to reduce inappropriate opioid prescribing, then it's important to take advantage of nonopioid options, Busse said. But although opioids are a 'treatment of last resort' for CNCP, several nonopioid options are inaccessible for many patients with chronic pain because services are unavailable where they reside, out-of-pocket costs are high, or waiting lists are long.
One potentially more accessible option is remote, therapist-guided cognitive-behavioral therapy, which seemed to be as effective as in-person therapy for chronic pain in a recent study by Busse's team. 'In addition, some emerging therapies for chronic pain, such as pain-reprocessing therapy, suggest large effects, and further high-quality trials are needed to confirm findings,' he said.
Evidence-based preventive strategies for CNCP also should be incorporated into clinical practice, he added. For example, a recent study showed that a program of education and progressive walking effectively reduces recurrence of low back pain.
Ghosh advised using as many adjunct interventions as possible when treating patients with CNCP. These interventions include physical therapy, proper sleep habits, and, if needed, treatment of concomitant depression and anxiety that can worsen pain perception. Potentially helpful medications could include acetaminophen, gabapentin, or selective serotonin reuptake inhibitors.
'We need to be maximizing those interventions before we start initiating, reducing, or tapering opioids,' he said.
In a related commentary, Kiran Grant, MD, and colleagues at the University of British Columbia, Vancouver, pointed out that evidence-based treatments for chronic pain are often inaccessible for many people with a concurrent diagnosis of opioid use disorder. They suggest integrating chronic pain management into the care for these patients to reduce overdose rates and improve outcomes.
'Prescribe Diligently'
When an opioid prescription is appropriate, Ghosh said, 'We should be prescribing it and making sure we do it diligently and that we really deal with the patient's pain. Importantly, people who have a substance use disorder should not be prevented from accessing pain medications if they're in acute pain. In fact, they should be worked with to make sure we're not underprescribing for the acute pain because we're worried about feeding their substance use.
'We need to prescribe higher amounts of pain medications to treat their acute pain: For example, if they've pulled a muscle or if they've been in a motor vehicle accident and sustained a fractured rib,' he said. 'That prescribing should trend down over time as their pain resolves, and we wean them from the extra opioids.'
'We know that the evidence for chronic pain management for all patients is limited and that opioid use can be detrimental,' he said. 'So, when we decide to prescribe, we need to be careful, and we need to do it appropriately.'
The study was supported by a Canadian Institutes of Health Research Project grant. Panagiotoglou, who holds a Tier 2 Canada Research Chair in the Economics of Harm Reduction, declared having no relevant financial relationships. Ghosh cofounded Canada's National Overdose Response Service, belongs to the Canadian Society of Addiction Medicine, and reported having no relevant financial relationships. Busse holds government grants to study opioids and chronic pain, including for the update of the opioid guideline, and he is on a funded grant with Panagiotoglou to study the spillover effects of opioid guidelines but reported having no relevant financial relationships.
