“One Size Fits All” Doesn’t Fit When It Comes to Long-Term Opioid Use for People with Chronic Pain

Figures & data

Table 1. Present authors’ proposed modifications to the 2017 draft recommendations for use of opioids in chronic non-cancer pain.⁴

Number and Recommendation	Proposed Modification to Draft Recommendation
1 – Strong recommendation	No modification
2 – Weak recommendation	No modification
3- Strong recommendation (Against)	For patients with co-morbid serious chronic pain and substance use disorder, an opioid may still be considered but all efforts should be made to consult an addictions specialist and put in place appropriate structure (eg. supervised daily dispensing) to assure patient safety.
4 – Weak recommendation	For patients with co-morbid serious psychiatric disorder and chronic non-cancer pain, where it is not possible to stabilize the psychiatric disorder first, an opioid trial may be considered as long as the psychiatric condition is also being addressed.
5 – Weak recommendation	For patients with co-morbid serious chronic pain and a distant past history of a substance use disorder, an opioid may still be considered. The physician must assess the patient’s current level of safety with opioids and put into place appropriate structure to assure there will be no risk of relapse. The need for involvement with an addictions specialist should be discussed.
6 – Weak recommendation	The lowest effective dose should be used.
7 – Strong recommendation	For patients who have obtained a partial benefit and where there are no limiting side effects, a trial of higher dose therapy may be considered. In this case patients should be monitored more closely (e.g., weekly). For patients requiring more than 90 mg oral morphine equivalent per day referral to a pain specialist should be considered.
8 – Weak recommendation	No modification
9 – Weak recommendation	If opioid rotation is not helpful in improving pain control or reducing problematic side effects and if a trial of higher dose opioid therapy leads to no further improvement in pain or a worsening of side effects, the dose of opioid should be reduced to the dose that was associated with maximal benefit and minimal side effects. If there is no appreciable benefit this is a failed trial and the patient should taper and discontinue the opioid.
10 – Weak recommendation	If patients have experienced a reduction in pain without problematic side effects on a stable dose of opioid, and if a reduction in the dose leads to increased pain and a poorer quality of life then the dose of opioid should be increased back to the dose where pain was most effectively controlled.

Table 2. Definitions of substance use terms.

Term	Definition	Source
Addiction	A primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by one or more of impaired control, compulsive use, continued use despite harm and craving	Liaison Committee on Pain and Addiction^8
Opioid Use Disorder	A minimum of 2–3 criteria is required for a mild substance use disorder diagnosis, while 4–5 is moderate, and 6– is severe. Opioid Use Disorder is specified instead of Substance Use Disorder, if opioids are the drug of abuse. Note: A printable checklist version is linked below: Taking the opioid in larger amounts and for longer than intended Wanting to cut down or quit but not being able to do it Spending a lot of time obtaining the opioid Craving or a strong desire to use opioids Repeatedly unable to carry out major obligations at work, school, or home due to opioid use Continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use Stopping or reducing important social, occupational, or recreational activities due to opioid use Recurrent use of opioids in physically hazardous situations Consistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological difficulties from using opioids *Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision) *Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal (Does not apply when used appropriately under medical supervision) *This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.	DSM-5^9
Opioid misuse NSDUH	Use in any way not directed by a doctor, including … use in greater amounts, more often, or longer than told to take a drug	*NSDUH^18
Opioid use to get high CTADS	Use of an opioid in order to get high	**CTADS^19
Physical dependence	A state of adaptation manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist	Liaison Committee on Pain and Addiction^8
Tolerance	A state of adaptation in which exposure to the drug results in changes that result in diminution of one or more of the drugs effects over time	Liaison Committee on Pain and Addiction^8
Opioid use	Use of an opioid as opposed to a disorder (see definition above)

*NSDUH = US National Survey on Drug Use and Health.

**CTADS = Canadian tobacco, alcohol and drug use monitoring survey.

Hughes A, Williams MR, Lipari RN, Bose J, Copello EAP, Kroutil LA. Prescription drug use and misuse in the United States: Results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review 2016. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016 Sep 1 [accessed 2017 Apr 28] https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm.

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Government of Canada. Canadian Tobacco Alcohol and Drugs Survey (CTADS) 2013: Table 11. Illicit drug use (past year and lifetime) by province, 2013. Ottawa, ON: Government of Canada [accessed 2017 Feb 19] https://www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2013-supplementary-tables.html#t11.

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