Impetus for the Canadian Guideline
Canadian medical regulatory authorities undertook guideline development in response to:
- Physicians and other stakeholders seeking guidance regarding safe and effective use of opioids
- A growing concern about opioid misuse creating patient and public safety issues, and
- The lack of systematically developed national guidelines on opioid use for CNCP.
In November 2007, the National Opioid Use Guideline Group (NOUGG) formed under the umbrella of the Federation of Medical Regulatory Authorities of Canada (FMRAC) with support and/or representation from all provincial and territorial medical regulatory authorities (MRA). NOUGG’s aim was to oversee the development and implementation of a guideline to assist physicians in managing patients with CNCP by prescribing opioids in a safe and effective manner.
To achieve its aim, NOUGG established objectives:
- Develop a national guideline for safe and effective opioid use for CNCP that relies on the best available evidence and expert opinion consensus
- Develop and implement a knowledge-transfer strategy that ensures transition of the national guideline to practice as a useful decision-making tool for physicians who treat CNCP patients
- Evaluate the transfer of knowledge impact on practice
- Find a permanent home for the national guidelineto ensure currency and ongoing transfer of evidence to practice
- Report on the project as a model for MRAs national collaboration.
NOUGG’s work in developing the "Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-cancer Pain" (Canadian Guideline) was shaped by the following principles and values:
Treatment of pain
Patients deserve to have their chronic pain treated. Opioids can be a useful and appropriate treatment option. Harms associated with opioid use can be reduced when:
- Drugs are prescribed and monitored with knowledge of the patient’s history and risks,
- Patients understand potential benefits and harms and participate in reducing harms, and
- Clinicians assess outcomes for both effectiveness and harms.
Effective national guideline development requires rigorous methods to 1) search, appraise, and synthesize the best available evidence, and 2) create a national consensus of expert opinion to provide guidance where evidence is not available or insufficient.
Collaboration among Canadian physician organizations and other key stakeholders is central to the development and implementation.
The Canadian Guideline will be free from commercial bias from the pharmaceutical industry and any other commercial entities.
Clinician and Patient Input
Practicing physicians from multiple disciplines, other healthcare providers, and patients all have defined roles in the formulation and ongoing evaluation.
The Canadian Guideline is intended to educate/inform clinicians and to assist and guide practice decisions. Although MRAs oversaw the development, it is not intended for use as a standard of practice.
An implementation strategy will incorporate evidence-based principles of knowledge transfer and continuing professional development.
User-friendly resources, freely accessible to all, will enhance implementation to practice.
NOUGG assembled key resources to meet its objectives.
A Research Group comprising a physician/epidemiologist, four physician-researchers, and a research librarian was responsible for the literature review, quality appraisal, evidence summary, and the first draft of recommendations. A National Advisory Panel (NAP) comprising 49 individuals was structured to reach consensus and advise on recommendations. Recruitment criteria included representation from across Canada, the target audience, other healthcare providers, patients with CNCP, clinical expertise, and academia. NAP used a Modified Delphi technique to reach consensus on recommendations for practice, and also provided open-ended narrative comment used in iterative revision.
The National Faculty
comprising approximately 35 people (representing 9 provinces, 1 territory, and 8 national associations) held their inaugural meeting in June 2009 with a goal to guide and assist NOUGG with implementing the Canadian Guideline
In total, 6,580 studies were identified from the literature; from this search, 184 met inclusion criteria and were used to create 49 draft recommendations. The National Advisory Panel critically examined these 49 recommendations. With their direction, consensus was built to finalize 24 practice recommendations that were organized into five clusters:
- Deciding to Initiate Opioid Therapy
- Conducting an Opioid Trial
- Monitoring Long-Term Opioid Therapy (LTOT)
- Treating Specific Populations with LTOT
- Managing Opioid Misuse and Addiction in CNCP Patients
The Canadian Guideline includes tools intended to assist busy clinicians in decision making.
Throughout development, NOUGG engaged with various academics to find a permanent home for the Canadian Guideline. McMaster University’s Michael G. DeGroote National Pain Centre assumed responsibility for keeping the Canadian Guideline current, working collaboratively with national partners and alerting clinicians to new evidence.
NOUGG’s Message to Users
The number of patients with CNCP is significant and growing. Responsibility for care of these patients should rest with primary-care providers who use consultation/referral for specialized input selectively. With this in mind, the intent of the Canadian Guideline is to improve comfort and confidence in using opioids for CNCP among clinicians, particularly primary-care providers, while preserving patient and public safety. To achieve these ends, recommendations and practice tools are both supported by the best available evidence or expert opinion consensus, and also feasible in day-to-day practice.
All funding to support the development of the Canadian Guideline was provided by Canadian medical regulatory authorities and the Federation of Medical Regulatory Authorities of Canada. The Canadian Institute of Health Research (CIHR) provided a one-time grant to support two meetings of the National Faculty who are focused on implementation. The project received no funding from commercial organizations.