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.