Canadian Opioid Guidelines: Development and Implications for Pain
Dr. Andrea Furlan
Staff Physician and Senior Scientist at Toronto Rehabilitation Institute
Scientist at Institute for Work and Health
Associate Member of Institute of Medical Science, Faculty of Medicine, UofT
Associate Professor in Division of Physical Medicine and Rehabilitation, Faculty of Medicine, UofT
By: Parnian Pardis
Photo By: Krystal Jacques
Over-prescription of opioids is common, especially among North Americans. As a nation, we consume over 80% of the opioids produced in the world. Opioids may be essential to treat chronic pain, a debilitating symptom of many diseases. However, opioids are misused among 21% to 29% of patients who receive a prescription and addiction occurs in 8% to 12% of users.1
Dr. Andrea Furlan is a Staff Physician and Senior Scientist at the Toronto Rehabilitation Institute (TRI), and Scientist at the Institute for Work and Health. Within the Faculty of Medicine at the University of Toronto, she is also an Associate Member of the Institute of Medical Sciences and Associate Professor in the Division of Physical Medicine and Rehabilitation. As a pain specialist, she suggests four reasons why our nation has become so liberal when prescribing opioids.
“It starts with a desire to help. Why should you suffer when I have the power to give you something that’s not expensive?” says Dr. Furlan. Physicians may assume that addiction is a myth, or at least very rare, given the multitude of advertisements suggesting the benefits of opioid use. To complicate matters further, opioids are covered by every formulary, from private insurance to OHIP. In comparison, the same coverage may not be offered for services such as physiotherapy, acupuncture, or massage. In fast-paced healthcare environments (emergency care, walk-in clinics), it may also be easier to prescribe a pain medication than it is to examine the patient and teach them appropriate exercises. Dr. Furlan suggests this is a common problem when healthcare professionals are paid by the volume of patients seen, rather than the quality of care provided.
Ultimately, we perpetuate a system that leads to opioid overdose, which can cause death or irreversible brain damage. Dr. Furlan suggests that approximately one third to a half of individuals who overdose were prescribed opioids for a health condition at some point in their lives. They may inadvertently consume a dose to which they are intolerant, take a higher dose because they perceive no initial effect, or mix the drug with alcohol or sleeping pills–all of which have detrimental consequences. Patients who become addicted, but are then refused further opioids prescriptions, may resort to illicit or street sources, such as fentanyl.
While Dr. Furlan is a “believer that opioids are essential for us to treat pain,” she recognizes that only a minority of people with chronic pain actually benefit from them. During her doctoral studies in Clinical Epidemiology at the University of Toronto, Dr. Furlan published a meta-analysis in collaboration with the Cochrane Database on the use of opioids for chronic pain. This 2005 publication piqued the interest of the College of Physicians and Surgeons of Canada, and they invited her to lead the development of the Canadian Opioid Guideline. Additionally, the College established the National Opioid Use Guideline Group (NOUGG), co-chaired by Rhoda Reardon and Clarence Weppler and comprised of 49 experts nominated from across the Canadian provinces.
In 2008, with the support of NOUGG, Dr. Furlan conducted a systematic review of the available literature on opioid use at the Institute of Work and Health. She then compiled evidence and drafted recommendations together with a small team of local experts. Following three rounds of appraisals by the NOUGG, Dr. Furlan and her team finalized a list of 24 recommendations and published the guidelines in 2010. The guideline covered topics such as selecting the appropriate patients with chronic pain to take opioids, appropriate dose and course of treatment, identification of risk factors for developing opioid use disorder and overdose, how to monitor patients on opioids, and best practices for tapering and stopping opioids.
Initially, these guidelines were in the form of a 200-page document. Even Dr. Furlan had a difficult time remembering all of its contents, so she created a quick and easy cheat sheet to rely on. When others expressed interest in this cheat sheet, she applied for and received funding from the Toronto Rehabilitation Institute for the creation of Opioid ManagerTM, a point-of-care tool for use by healthcare providers. Opioid ManagerTM started as a two-page brochure. It has since been adapted to be compatible with common Electronic Medical Records and turned into both an iOS App and a Youtube video. Finally, My Opioid Manager was created; a book and mobile app written in lay language by Dr. Furlan and Amy Robidas (RN) to explain opioid use to patients with chronic pain. These avenues of knowledge translation were imperative to Dr. Furlan, as they facilitate evidence-based practice and informed decision-making in the clinical setting.
Prior to the development of the Canadian Opioid Guideline, Dr. Furlan recalls learning in medical school that “the sky was the limit for opioids: you increase the dose, you increase the effect.” When Dr. Furlan coined the term “watchful dose” in the guideline, however, she initiated a fundamental shift in thinking. For the first time, many physicians in Canada were introduced to the idea that there was a ceiling recommended opioid dose. If physicians prescribe over this dose, they are now responsible for justifying their decision and are warned to exercise added caution.
Dr. Furlan notes that the impact of this guideline has yet to be determined. However, while presenting a series of lectures across Canada, one of her colleagues found that one in two physicians attending the lectures were aware this guideline exists. As a reflection of physicians becoming more careful, it is more common now for Dr. Furlan to receive referrals of patients on 100’s rather than 1000’s of milligrams of morphine equivalents.
Dr. Furlan’s current focus at TRI with her team of a nurse, pharmacist, and nurse practitioner, includes helping patients taper their opioid use. Of course, this is no small task given the physiological changes that occur with opioid use and the resulting dependence the body develops. Patients experience severe withdrawal symptoms, and Dr. Furlan “suffers with those patients because when they describe how they feel, it’s really, really horrible.” Consequently, she finds her work especially rewarding when patients report feeling much better after they are weaned off the drug.
In addition to her clinical responsibilities, Dr. Furlan co-chairs the Extension of Community Healthcare Outcomes (ECHO) Ontario Chronic Pain/Opioid Stewardship. Launched in 2014 as the first ECHO in Canada, its success during a two-year pilot project led to permanent funding by the Ministry of Health and Long Term Care. This telemedicine network connects primary care providers from all over Ontario with Dr. Furlan and her team. During two-hour sessions every week, a short didactic lecture is followed by one to two anonymized cases presented by healthcare professionals from their community.
“We tell them how we would treat that patient, using the opioid guidelines, but also guidelines for lower back pain, fibromyalgia, and so on. We apply all the evidence to each case,” says Dr. Furlan. Evaluations of Project ECHO determined that its participants are indeed modifying patient treatment. The prescribing habits of participants have improved, and post-questionnaires indicated greater knowledge and self-efficacy related to chronic pain. “The primary care providers are teachable and want to do the very best for their patients,” says Dr. Furlan.
There are still many unanswered questions, both with regards to the development of newer and better opioids and to the understanding of the pain system. With the dual perspective of a clinician and a scientist, Dr. Furlan brings clinical questions to the research field to find answers. Dr. Furlan’s contributions to the field ensure that “we’re using [opioids] with the right people… otherwise, we are going to penalize those who need it.”
- Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-76.