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Canada  

Reduce opioid prescriptions

Updated opioid-prescribing guidelines released Monday encourage doctors to avoid giving the powerful narcotics as a first-line treatment to patients with chronic, non-cancer pain and instead try other medications or non-pharmaceutical therapies to prevent a host of potential harms associated with the widely used drugs.

Those harms include physical dependence or addiction, as well as the increasingly common risk of fatal overdoses. An estimated 2,000 Canadians died of opioid overdoses in 2015 alone, and initial 2016 data still being tallied suggest the number of fatalities linked to the drugs — both prescription and illicit — could far exceed that figure.

"It really comes down to the paradox of trying to provide important relief for patients dealing with unrelenting chronic pain while at the same time balancing the risks associated with the medications," said Dr. Jason Busse, a researcher at the National Pain Centre at McMaster University and lead author of the 10-recommendation document.

For patients whose chronic pain is not controlled with non-opioid therapy, the panel of experts that developed the guidelines says dosages of opioids like oxycodone, hydromorphone and the fentanyl patch should be restricted to less than the equivalent of 90 milligrams of morphine per day, and ideally to less than 50 mg.

Physicians treating patients already taking the equivalent of 90 mg of morphine or more should consider incrementally tapering their daily intake to the lowest effective dose, and possibly even discontinuing the potent medications, the panel recommends.

"Estimates are somewhere between half a million and a million Canadian adults are currently on long-term opioid therapy for chronic pain, often at very high doses," Busse said from Hamilton.

"And when you go on long-term opioid therapy, you will inevitably develop physical dependence. And opioids also become less effective the longer that you take them," leading many patients to seek higher and higher doses to achieve relief so they can function in their daily lives, he said.

The new guideline document, published Monday in the Canadian Medical Association Journal, provides much stronger and more detailed advice than a previous version released in 2010, which suggested doctors could use a "watchful dose" of the equivalent of 200 mg of morphine daily.

"After 2010, there was not the kind of impact on opioid prescribing that I think people were hoping for," Busse said.

"There was a little bit of a downtick, but maximum doses of opioid prescribing went up, admissions for hospital-related opioid toxicity went up, and death rates have continued to climb as well."



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