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Attitudes toward the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain: A qualitative study

Yaping Chang, MSc, Kan Lun Zhu, Ivan D. Florez, MD, MSc, Sung Min Cho, BHSc, Nasim Zamir, HBSc, Augustin Toma, BESc, Reza Donald Mirza, MD, Gordon H. Guyatt, MD, MSc, Norman Buckley, MD, Jason W. Busse, DC, PhD

Abstract


Background: Chronic noncancer pain (CNCP) refers to all pain disorders, not due to cancer, that persist for 3 months. The point prevalence of CNCP in the general population of Western countries is between 19 and 33 percent. Opioids are commonly prescribed for CNCP and are associated with both benefits and harms. The Canadian Guideline for Safe and Effective Use of Opioids for CNCP was published in 2010 to provide guidance for optimal opioid prescribing in patients with CNCP.

Objectives: To investigate the attitudes toward, and use of, the Canadian Opioids Guideline among pain physicians.

Design: A qualitative study using one-on-one, semistructured interviews with 12 pain physicians in Ontario, Canada, and thematic analysis of verbatim transcripts.

Results: Major themes that emerged from interviews included: (1) generally positive attitudes toward the 2010 Canadian Opioids Guideline, but limited use—half (six of 12) reported they did not use the guideline in practice; (2) strongly contrasting views regarding the 200 mg/d morphine equivalent watchful dose; (3) recognition of gaps in the guideline, especially recommendations for urine drug screening and pain severity-specific therapy; (4) the guideline is excessively long and the format suboptimal; and (5) improved dissemination and education are needed to enhance guideline uptake.

Conclusions: Despite its merits, the Canadian Opioids Guideline suffers from information gaps and from limited uptake, at least in part due to suboptimal format and suboptimal dissemination.


Keywords


clinical guideline, opioids, chronic pain, Canadian attitudes, usage barrier

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References


International Association for the Study of Pain, Subcommittee on Taxonomy: Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain. 1986; 3(suppl): S1-S225.

Noble M, Treadwell JR, Tregear SJ, et al.: Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010; CD006605.

Committee on Advancing Pain Research, Care, and Education, Institute of Medicine: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press, 2011.

Schopflocher D, Taenzer P, Jovey R: The prevalence of chronic pain in Canada. Pain Res Manag. 2011; 16(6): 445-450.

Reid KJ, Harker J, Bala MM, et al.: Epidemiology of chronic non-cancer pain in Europe: Narrative review of prevalence, pain treatments and pain impact. Curr Med Res Opin. 2011; 27(2): 449-462.

Franklin GM, American Academy of Neurology: Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology. 2014; 83: 1277-1284.

National Opioid Use Guideline Group (NOUGG): Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Canada: National Opioid Use Guideline Group (NOUGG), 2010. Available at: http://nationalpaincentre.mcmaster.ca/opioid/. Accessed March 7, 2016.

Hogan ME, Taddio A, Katz J, et al.: Incremental health care costs for chronic pain in Ontario, Canada: A population-based matched cohort study of adolescents and adults using administrative data. Pain. 2016; 157(8): 1626-1633.

Nadeau SE: Opioids for chronic noncancer pain to prescribe or not to prescribe—What is the question? Neurology. 2015; 85(7): 646-651.

Kalso E, Edwards JE, Moore RA, et al.: Opioids in chronic non-cancer pain: Systematic review of efficacy and safety. Pain. 2004; 112(3): 372-380.

Alam A, Juurlink DN: The prescription opioid epidemic: An overview for anesthesiologists. Can J Anaesth. 2016; 63(1): 61-68.

Dyer O: Canada's prescription opioid epidemic grows despite tamperproof pills. BMJ. 2015; 351: h4725.

Murphy Y, Goldner EM, Fischer B: Prescription opioid use, harms and interventions in Canada: A review update of new developments and findings since 2010. Pain Physician. 2015; 18(4): E605-E614.

International Narcotics Control Board (INCB): Narcotic Drugs Estimated World Requirements for 2014—Statistics for 2012. New York: United Nations Publications, 2014.

Gomes T, Mamdani MM, Paterson JM, et al.: Trends in high-dose opioid prescribing in Canada. Can Family Physician. 2014; 60(9): 826-832.

Ballantyne JC, Shin NS: Efficacy of opioids for chronic pain. Clin J Pain. 2008; 24: 469-478.

Busse JW, Mahmood H, Maqbool B, et al.: Characteristics of patients receiving long-term opioid therapy for chronic noncancer pain: A cross-sectional survey of patients attending the Pain Management Centre at Hamilton General Hospital, Hamilton, Ontario. CMAJ Open. 2015; 3(3): E324-E330.

Madadi P, Hildebrandt D, Lauwers AE, et al.: Characteristics of opioid-users whose death was related to opioid-toxicity: A population-based study in Ontario, Canada. PLoS One. 2013; 8(4): e60600.

Chou R, Ballantyne JC, Fanciullo GJ, et al.: Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009; 10: 147-159.

Jamison RN, Edwards RR, Liu X, et al.: Relationship of negative affect and outcome of an opioid therapy trial among low back pain patients. Pain Pract. 2012; 13: 173-181.

Allen MJ, Asbridge MM, Macdougall PC, et al.: Self-reported practices in opioid management of chronic noncancer pain: A survey of Canadian family physicians. Pain Res Manag. 2013; 18: 177-184.

Khalid L, Liebschutz JM, Xuan Z, et al.: Adherence to prescription opioid monitoring guidelines among residents and attending physicians in the primary care setting. Pain Med. 2015; 16(3): 480-487.

Martinez V, Attal N, Vanzo B, et al.: Adherence of French GPs to chronic neuropathic pain clinical guidelines: Results of a cross-sectional, randomized,“e” case-vignette survey. PloS One. 2014; 9(4): e93855.

Krebs EE, Bergman AA, Coffing JM, et al.: Barriers to guideline-concordant opioid management in primary care—A qualitative study. J Pain. 2014; 15(11): 1148-1155.

Cabana MD, Rand CS, Powe NR, et al.: Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999; 282(15): 1458-1465.

Sandelowski M: Focus on research methods-whatever happened to qualitative description? Res Nurs Health. 2000; 23(4): 334-340.

Sandelowski M: What's in a name? Qualitative description revisited. Res Nurs Health. 2010; 33(1): 77-84.

Braun V, Clarke V: Using thematic analysis in psychology. Qual Res Psych. 2006; 3: 77-101.

Vaismoradi M, Turunen H, Bondas T: Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013; 15: 398-405.

Kastner M, Bhattacharyya O, Hayden L, et al.: Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: A realist review. J Clin Epidemiol. 2015; 68(5): 498-509.

Miles MB, Huberman AM: Qualitative Data Analysis: A Sourcebook of New Methods. 2nd ed. Thousand Oaks, CA: Sage, 1994.

Corson K, Doak MN, Denneson L, et al.: Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: Results from the study of the effectiveness of a collaborative approach to pain. Pain Med. 2011; 12(10): 1490-1501.

Forsner T, Hansson J, Brommels M, et al.: Implementing clinical guidelines in psychiatry: A qualitative study of perceived facilitators and barriers. BMC Psychiatry. 2010; 10: 8.

Williams CM, Maher CG, Hancock MJ, et al.: Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med. 2010; 170(3): 271-277.

Ista E, van Dijk M, van Achterberg T: Do implementation strategies increase adherence to pain assessment in hospitals? A systematic review. Int J Nurs Stud. 2013; 50(4): 552-568.

Rasu RS, Sohraby R, Cunningham L, et al.: Assessing chronic pain treatment practices and evaluating adherence to chronic pain clinical guidelines in outpatient practices in the United States. J Pain. 2013; 14(6): 568-578.

Schers H, Wensing M, Huijsmans Z, et al.: Implementation barriers for general practice guidelines on low back pain: a qualitative study. Spine. 2001; 26(15): E348-E353.

Kahan M, Mailis-Gagnon A, Tunks E: Canadian guideline for safe and effective use of opioids for chronic non-cancer pain: Implications for pain physicians. Pain Res Manag. 2011; 16(3): 157-158.

Weimer MB, Hartung DM, Ahmed S, et al.: A chronic opioid therapy dose reduction policy in primary care. Subst Abus. 2016; 37(1): 141-147.

Weeks C: College of Family Physicians rejects call for mandatory course on safe opioid prescribing. The Globe and Mail. March 10, 2016. http://www.theglobeandmail.com/life/health-and-fitness/health/college-of-family-physicians-rejectscall-for-mandatory-course-on-safe-opioid-prescribing/article29141141/. Accessed August 24, 2016.

Dunn KM, Saunders KW, Rutter CM, et al.: Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010; 152: 85-92.

Gomes T, Mamdani MM, Dhalla IA, et al.: Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011; 171(7): 686-691.

Bohnert AS, Valenstein M, Bair MJ, et al.: Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011; 305(13): 1315-1321.

Zedler B, Xie L, Wang L, et al.: Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Med. 2014; 15(11): 1911-1929.

Abdel Shaheed C, Maher CG, Williams KA, et al.: Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: A systematic review and meta-analysis. JAMA Intern Med. 2016; 176(7): 958-968.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016; 315(15): 1624-1645.

Naliboff BD, Wu SM, Schieffer B, et al.: A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain. J Pain. 2011; 12(2): 288-296.

Busse JW, Schandelmaier S, Kamaleldin M, et al.: Opioids for chronic non-cancer pain: A protocol for a systematic review of randomized controlled trials. Syst Rev. 2013; 2(1): 66.

Busse JW, Juurlink D, Guyatt GH: Addressing the limitations of the CDC Guideline for Prescribing Opioids for Chronic [noncancer] Pain. CMAJ. 2016 (in press).




DOI: https://doi.org/10.5055/jom.2016.0357

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