Opioid misuse sparks guidelines for doctors

Growing misuse of opioids like OxyContin has resulted in overdose deaths but newCanadian guidelines for prescribing the drugs aim to curtail the problem.

A committee of medical specialists struck by colleges of physicians and surgeons issuedguidelines Monday for family doctors prescribing opioids in an effort to preventoverdoses and address under-treatment of some types of pain.

Canada is the world's third-largest per capita consumer of opioid painkillers, researchers noted in asummary on the guidelines, published in Monday's issue of the Canadian Medical Association Journal.

Theguidelines, which have been indevelopment since 2007,aim to provide physicians with information to prescribe opioids such as Percoceteffectively to patients with chronic, non-cancer pain pain that lasts more than sixmonths and comes from a non-cancer source such as osteoarthritis or chronic low back pain.

"Certainly we've been hearing from physicians that they're seeking advice and guidance in this particular area. It is, or can be a difficult area of treatment," said Clarence Weppler ofthe Alberta College of Physicians and Surgeons in Edmonton.

Weppler isco-chair of the National Opioid Use Guideline Group, which wrote the guidelines.

"Chronic pain may be seen to be over-treated for some people, but in fact as our article in the CMAJ indicates under-treatment of pain is also a problem. So we're trying to balance the information available to cover both ends of that spectrum."

Comparison gaps

The guidelines are meant to help primary-care physicians and medical and surgical specialists whose patients sufferchronic, non-cancer pain by offering a step-by-step approach, including:

• Doing a thorough assessment.
• Determine whether opioids are the best choice for aparticular patient.
• How to detect and respond to opioid misuse, including addiction, and minimize side-effects.
• How to monitor whether the dose is effectiveover time.
• Reducing or stopping treatment.

The guidelinesare not designed as a training manual, said Weppler.

Pharmacists, nurses and dentists may also find the guidelines useful, the group said.

The guidelines are useful, but more research is needed toguide treatment decisions, said Dr. Roger Chouof the departments of medicine and medical informaticsand clinical epidemiology atOregon Health and Science University inPortland.

Chou said in a journal commentarythere are gaps in understanding the comparative benefits of different opioids, particularly with regards to rates of addiction or abuse, methods of prescribing short-acting versus long-acting forms of opioids, and what are the appropriate methods of monitoring patients, such asurine screening for drugs.

"While waiting for the research that is still needed, clinicians can use the new Canadian guideline as a clinically sensible framework for decisions that need to be made now," Chou concluded.

Risks of high doses

As opioids have become more widely used and abused, the number of people who've died as a result of taking opioids has doubled since 1991 toabout 300 people a yearin Ontario alone, according to a study published in December 2009.

The lead author of that study, pharmaceutical policy researcher Irfan Dhalla of St. Michael's Hospital in Toronto, also called the new guidelines a good start. But Dhallawould have preferred thatthe guidelines had recommended lower maximum doses, as some U.S. guidelines have done.

"We do know that these drugs are much more likely to cause harm when prescribed in very high doses," Dhalla said, since the risk-benefit trade-off becomes less favourable at higher doses.

Drug ads for OxyContin still promotehigh doses, andfamily doctors may not realize the risk, Dhalla said. But producing the new guidelines has raised awareness and could save lives, he added.