In 2000, the College of Physicians and Surgeons of Ontario (CPSO) released "Evidence-based Recommendations for Medical Management of Chronic Non-Malignant Pain," which was accepted by the Ontario Guidelines Advisory Committee as its recommended guideline for chronic pain management. This document was completed by a CPSO-appointed task force of physicians with expertise in pain management. The topics included chronic headache, migraines, neuropathic pain, opioid management for chronic non-malignant pain, and chronic musculoskeletal pain. In 2007, the task force co-chairs recommended updating the 2000 guideline. It was agreed that completing a methodologically rigorous update of all the sub-topics in the 2000 guideline was beyond the resources and the scope of the College’s mandate. However, CPSO agreed that one section, the use of opioids for chronic non-malignant pain, presented a pressing problem in practice and should be revised and further developed.
At the same time, other Canadian medical regulatory authorities (MRAs) were meeting to discuss issues of common interest and it became evident that Colleges across Canada shared the need to provide physicians with guidance on prescribing opioids for CNCP. In response, Canadian MRAs created the National Opioid Use Guideline Group (NOUGG) to oversee the development and implementation of a guideline for safe and effective opioid use for CNCP. NOUGG is a unique collaboration of MRAs with the active support and/or representation from all provincial Colleges, Yukon Medical Council, Government of Nunavut, and the Federation of Medical Regulatory Authorities of Canada (FMRAC). See Appendix A-1 for NOUGG members.
NOUGG’s primary aim was to assist physicians in managing patients with CNCP by prescribing opioids in a safe and effective manner. Three key goals were to:
- Facilitate development of a national evidence-based guideline.
- Implement the guideline to clinical practice.
- Find a permanent home for the guideline to ensure the evidence remains current and useful.
From the outset, NOUGG grappled with the notion that creating clinical practice guidelines (CPG) is a task traditionally, and probably best, left to researchers, academics, and clinicians. MRAs do, however, have a central mandate to regulate the practice of medicine in the pubic interest that includes a responsibility to provide guidance and contribute to ensuring the quality of practice.
At its annual June 2008 meeting, FMRAC discussed the regulators’ role in creating CPGs, citing NOUGG’s work as a case in point. It was reasoned that, ideally, CPGs are created by clinical/research groups, but the topic of opioid prescribing met the requisites of a "special case," in that:
- No academic body can be clearly identified to take responsibility.
- The topic extends beyond clinical care into other areas, e.g., criminality, professional conduct.
- Societal impacts are significant.
- MRAs have a unique role to play in implementation.
- Membership or other stakeholders are requesting MRAs participation.
With the FMRAC meeting confirmation, NOUGG’s work began. Two NOUGG co-chairs convened monthly meetings to facilitate and oversee the development and implementation.