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

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.

Background

First-line therapy for chronic pain should be an individualized combination of non-opioid pharmacotherapy and nonpharmacological therapies, rather than a trial of opioids. For many people, non-opioid pharmacotherapy is at least as effective as opioids for managing chronic pain and improving function and does not carry the opioid-associated risks of addiction or overdose.

Multimodal and multidisciplinary therapies can help reduce pain and improve function more effectively than single modalities. The best therapies for a particular person depend on many factors, including their diagnosis and management goals. Passive modalities, such as massage or spinal manipulation, provide short-term pain relief and potential medium-term benefit with a minimal risk of harm, but should be recommended and implemented only as a complement to an active physical therapy or exercise program. Non-opioid pharmacotherapy should be initiated with the goal of increasing function and restoring a person’s overall quality of life, not just providing pain relief.

The time and financial commitments required to access some non-opioid therapies can create barriers to access for some people with chronic pain, perpetuating health inequities. To increase access to these therapies where they exist, health care professionals should be aware of resources for low- or no-cost non-opioid therapies and self-management programs for chronic pain in their community.

What This Quality Statement Means

For Patients

A combination of physical therapies, psychological therapies, and non-opioid medications is the first choice for treating chronic pain. Your health care professional should offer you different combinations of these therapies before offering opioids.

For Clinicians

Offer people with chronic pain a multimodal combination of non-opioid pharmacotherapy and nonpharmacological therapies as first-line treatment. Tailor these therapies to the needs of the person based on their management goals and locally available resources.

For Health Services

Ensure that systems, resources, and training are available to allow health care professionals to deliver multidisciplinary, multimodal chronic pain management therapies to reduce the use of opioids, and ensure that people with chronic pain have equitable access to these therapies.

Quality Indicators

Process Indicator

Percentage of people with chronic pain prescribed an opioid who received non-opioid pharmacotherapy and/or nonpharmacological therapies as first-line treatment prior to starting opioid therapy

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

Definitions Used Within This Quality Statement

Multidisciplinary approach

A multidisciplinary approach involves a team of two or more different types of health care professional; for example, physicians, nurses, pharmacists, psychologists, physiotherapists, and other allied health care professionals.

Multimodal therapy

Multimodal therapy is the use of a combination of different types of non-opioid pharmacotherapies and nonpharmacological therapies to treat pain and improve function.

Non-opioid pharmacotherapy

Examples of non-opioid pharmacological therapies include the following:

Acetaminophen
Nonsteroidal anti-inflammatory drugs
Anticonvulsants, such as gabapentin and pregabalin
Antidepressants, such as amitriptyline, nortriptyline, and duloxetine
Medical cannabis (however, evidence on benefits and harms is limited)

Nonpharmacological therapies

There are a broad range of nonpharmacological therapies that may be used to manage chronic pain, typically grouped into the categories of physical interventions and psychological therapies. The efficacy of each therapy may vary by type or cause of pain.

Physical interventions include the following:

Active physical interventions, such as floor exercise, exercise on special equipment, and aquatic therapy
Passive physical interventions, such as spinal manipulation, passive physical therapy, and massage

Psychological therapies include the following:

Self-management programs (in-person or online)
Psychotherapy (e.g., cognitive behavioural therapy)
Mindfulness-based stress reduction

Interventional treatments, such as therapeutic injections, are percutaneous or minor surgical procedures targeting specific anatomical structures identified as possible sources of pain. Interventional treatments may be appropriate for people with chronic pain who have not received sufficient benefit from other non-opioid pharmacotherapy and nonpharmacological therapies.

Evidence to Improve Care