Recommendation 7
For patients with chronic non-cancer pain who are begin-
ning opioid therapy, it is suggested that the prescribed
dose be restricted to less than 50 mg morphine equiva-
lents daily. (weak recommendation)
• Th
e weak recommendation to restrict the prescribed dose
to less than 50 mg morphine equivalents daily acknowl-
edges that there are likely to be some patients who would
be ready to accept the increased risks associated with a dose
higher than 50 mg in order to potentially achieve improved
pain control.
Recommendation 8
For patients with chronic non-cancer pain who are cur-
rently using opioids, and have persistent problematic
pain and/or problematic adverse effects, we suggest rota-
tion to other opioids rather than keeping the opioid the
same. (weak recommendation)
• R
otation in such patients may be done in parallel with,
and as a way of facilitating, dose reduction.
Recommendation 9
For patients with chronic non-cancer pain who are cur-
rently using 90 mg morphine equivalents of opioids per
day or more, we suggest tapering opioids to the lowest ef-
fective dose, potentially including discontinuation, rather
than making no change in opioid therapy.
(weak recommendation)
• S ome patients may have a substantial increase in pain or
decrease in function that persists for more than one month
after a small dose reduction; tapering may be paused or
potentially abandoned in such patients.
Recommendation 10
For patients with chronic non-cancer pain who are using
opioids and experiencing serious challenges in tapering,
a formal multidisciplinary program is recommended.
(strong recommendation)
• I n recognition of the cost of formal multidisciplinary
opioid reduction programs and their current limited
availability/capacity, an alternative is a coordinated
multidisciplinary collaboration that includes several
health professionals whom physicians can access ac-
cording to their availability (possibilities include, but
are not limited to, a primary care physician, a nurse,
a pharmacist, a physical therapist, a chiropractor, a
kinesiologist, an occupational therapist, an addiction
medicine specialist, a psychiatrist and a psychologist).
MD
Explaining weak vs. strong recommendations
Evidence was available to support only four “strong” recom-
mendations and six “weak” recommendations. Strong rec-
ommendations indicate that all or almost all fully informed
patients would choose the recommended course of action,
and indicate to clinicians that the recommendation is ap-
propriate for all or almost all individuals.
Weak recommendations indicate that the majority of
informed patients would choose the suggested course of
action, but an appreciable minority would not. With weak
recommendations, clinicians should recognize that different
choices will be appropriate for individual patients, and they
should help patients arrive at a decision consistent with their
values and preferences. Weak recommendations should not
be used as a basis for standards of practice.
Issue 2, 2017 Dialogue
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