Opioid Guidelines from Around the World

(for Long-Term Pain Therapy) (not end-of-life)

Paul A. Sloan, M.D.

Professor and Vice Chair for Research
Associate Program Director, Pain Medicine Fellowship
Department of Anesthesiology
University of Kentucky

Editor-in-Chief, Journal of Opioid Management

Paul.Sloan@UKY.edu

International Conference on Opioids. June, 2018

Industry Support

• None

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 Outline
• Guideline origins
• Guideline limitations
• Guidelines for long-term opioid therapy from
around the world

I. Guideline Origins
Australia

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 First USA Guidelines

1986
1982

Eichhorn JH. JAMA 1986; 256:1017

II. Guideline Limitations

• We are only human, and limited by our interpretation of the data

American Civil War,

versus
War of Northern Aggression

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 Therapeutic Interventions in Chronic Pain

James Rathmell, MGH, Harvard

Epidural Steroids:
A Comprehensive, Evidence-Based Review
• Cohen S. Reg Anesth Pain Med 2013;38:175
• Modest effect size lasting more than 3 months
in well-selected patients
• For selected patients, ESI may prevent surgery
• “We are of the firm belief that ESIs should
continue to be part of a multimodal treatment
strategy”

• Armon C. Neurology 2007; 68:723

• “In general, epidural steroids for radicular
lumbosacral pain is not recommended”

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 Effect of Author Specialty
on Results/Conclusions

Cohen SP. Reg Anesth Pain Med 2013; 38;175

III. Opioid Guidelines from Around the World:

A Comparison with 2016 USA CDC Opioid Guidelines
Methods:
• Search the world for opioid guidelines for CNMP
• National groups (associations) only reviewed
• No local, hospital or state guidelines
• Compare directly with USA CDC guideline
• Part A: introduction remarks, special populations
and medical conditions addressed
• Part B: compare with 12 CDC definitive
recommendations
• Interesting comments from world guidelines

International Conference on Opioids. June, 2018

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CDC Guidelines for Prescribing Opioids
for Chronic Pain
(Sloan paraphrase)

• Intro: “Patients within the scope of this guideline

include cancer survivors with chronic pain who
have completed cancer treatment, are in clinical
remission, and are under surveillance only”
• Patients with active cancer, palliative care
or end-of-life care are excluded.
• 12 recommendations

CDC Morbidity and Mortality Weekly Report March 18, 2016; 65:1-49

CDC Guidelines for Prescribing Opioids: Introduction

• Adults only
• Patients with active cancer, palliative care
or end-of-life care are excluded.
• Cancer survivors included
• Elderly included
• Pregnant women included
• History of SUD included
• Active SUD addressed
• Sleep-disordered breathing addressed
• Patients with renal or hepatic insufficiency addressed
• Patients with mental health conditions addressed
• History of prior overdose attempt addressed

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 CDC Long-Term Opioid Guidelines
1. Non opioid therapies for chronic pain are preferred
2. Establish treatment goals before starting COT
A. Continue opioid therapy only if there is clinically meaningful
improvement in pain and function
3. Educate patients/families on risks and benefits, etc
4. Start with IR opioids only
5. Keep the daily dose low if possible. Avoid doses >90/d OME
6. When treating AP, use lowest opioid dose and for shortest
period of time
7. After initiation of COT, evaluate patient within 1-4 weeks for
benefits/harms. Evaluate at a minimum of q3months.
A. -document analgesia, activity, adverse side effects
CDC Morbidity and Mortality Weekly Report March 18, 2016; 65:1-49

CDC Long-Term Opioid Guidelines

8. Prior to initiation, evaluate patient for risk factors
-addiction history, family hx, psychological issues,
legal issues, social issues, for all patients
9. Review the Prescription Drug Monitoring data
10. Utilize UDS prior to initiation and a minimum of yearly
11. Avoid prescribing benzodiazepines with opioids
12. Offer or arrange treatment for patients that demonstrate
opioid use disorder
-do not dismiss from practice
-do not abandon patient
-continue with nonopioid analgesic treatment
-assist patient in finding qualified addiction treatment

CDC Morbidity and Mortality Weekly Report March 18, 2016; 65:1-49

Guidelines of Long-Term Opioid Therapy

for patients with chronic nonmalignant pain

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18 national guidelines; 16 enough detail for comparison; 12 from USA

III. Opioid Guidelines from Around the World:

A Comparison with 2016 USA CDC Opioid Guidelines

Results Part A Introduction:

• 16 useable national guidelines
• Majority (75%) in the USA;
all in countries of high opioid consumption
• No guideline addressed children
• CDC was only guideline to specifically include
cancer survivors
• Most guidelines designated for CNMP
• Only 4/16 guidelines addressed multiple issues
compared with the CDC guideline

Results Part A Introduction:

• Only 3/16 specifically addressed the elderly

• Only 4/16 specifically addressed pregnant women
• 6/16 addressed sleep-disordered breathing issues
• 6/16 addressed patients with active SUD
• Only 4/16 addressed patients with mental health
conditions

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USA CDC Guideline
March, 2016

Recommendations with majority agreement:

USA CDC Guideline

March, 2016

Recommendations with least agreement:

• Start with IR opioid only: split 50:50

• Avoid benzodiazepines: 10/16 in agreement
• For noncompliant patient-continue to treat with
nonopioids and arrange addiction specialist: 10/16

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 Guidelines almost exactly with CDC:

• American College of Cardiology

• USA VA Guideline
• ASIPP
• USA Federation of State Medical Boards
• ACOEM

• Royal College of Australia GPs

Unique Differences versus CDC Guideline:

• American College of Rheumatology 2012

– For osteoarthritis pain only
– “conditionally recommend tramadol”; but,
have no recommendations of “opioids”

• European Pain Federation 2016

– ER opioids preferred
– Opioid rotation addressed
– Do NOT address any maximum high opioid
dose

• American Academy of Pain Medicine 2016

– Opioids must remain an important option as
part of a multidisciplinary treatment
– We have concerns that the CDC guideline makes
disproportionately strong recommendations
based upon a narrowly selected portion of the
available clinical evidence

Unique Differences versus CDC Guideline:

• Canadian Guideline 2017

– ER opioids acceptable
– Evidence to avoid benzodiazepines is weak
– For history of SUD, or active SUD, do NOT use
opioids

• Royal College of Anesthetists 2018

– Excellent web site
– No mention of urine drug monitoring

• Pain Association of Singapore 2013

– ER opioids preferred over IR
– High opioid dose defined as
200 mg OME/day

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 Unique Differences versus CDC Guideline:

• USA VA Guideline 2017

– Strongly avoid benzodiazepines
– There is no absolute safe opioid dose
– Not supportive of ER opioids, but recognize
that the evidence is weak
– Patient with active SUD- do not use opioids

• American Society of Interventional

Pain Physicians 2017
– ER opioids only in “specific
circumstances”

Unique Differences versus CDC Guideline:

• German Pain Society 2015

– No recommendation or preference for a
particular opioid or route of administration
– ER opioids very acceptable
– After 6 months of long-term opioids; consider
a drug holiday
– No mention of benzodiazepines
– No mention of IR opioids to initiate an opioid
trial
– Very good section on special patient groups

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R Portenoy Guidelines (1996)

Portenoy R. J Law, Med & Ethics 1996; 24:296

Summary
 Most USA CDC recommendations are agreed upon by
national guidelines of developed western nations
 Guidelines have disagreement regarding a preference
for IR versus ER opioids
 37% of national opioid guidelines reviewed did not
discuss concomitant use of benzodiazepines
 Know at least one opioid guideline well
 Know your state opioid law/guideline very well
 Keep most patients within guidelines
 Keep all patients within your state law

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