McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Cluster 3: Monitoring Long-Term Opioid Therapy (LTOT)

R15. Recommendation Statement

No. Recommendation Keyword
R15 For patients receiving opioids for a prolonged period who may not have had an appropriate trial of therapy, take steps to ensure that long-term therapy is warranted and dose is optimal (Grade C). Revisiting opioid trial steps
  • R15. Discussion

R15. Discussion

Not all patients on opioid therapy have progressed through the recommended steps of an opioid trial to determine an optimal dose. (See Recommendation 9 for optimal dose.) This situation can arise from various circumstances, e.g., when a patient on LTOT transfers from one doctor to another, or when a patient has inadvertently transitioned from receiving opioids for an acute condition to prolonged use. For these patients, the prescribing physician should review steps for an appropriate opioid trial and schedule follow-up visits to ensure all of the following have been addressed and documented:

  • Pain condition diagnosis
  • Risk screening
  • Goal setting
  • Informed consent
  • Appropriateness of opioid selected and dose
  • Opioid effectiveness

1. Diagnosis

  • Confirm the patient has a pain condition for which opioids have been shown to be effective. (See Recommendation 4.)

2. Screening

3. Goal Setting

  • Ensure the patient’s expectations are realistic.
  • Discuss specific goals related to pain reduction and function improvement.
  • Document agreed-on goals in the patient’s record. (They are critical in determining that opioids are effective.)

4. Informed Consent

  • Review goals of LTOT, i.e., potential benefits, potential adverse effects, medical complications, and risks. (See Recommendation 5.)
  • Consider using a treatment agreement. (See Recommendation 5.)

5. Opioid Selection and Dose

  • Confirm the most appropriate opioid has been selected. (See Recommendation 8.)
  • Review dose — if above daily 200 mg of morphine equivalent, confirm that the patient’s pain condition warrants the dose. (See Recommendation 10.)
  • Taper or switch opioid as required.

6. Opioid Effectiveness

  • Confirm that LTOT is providing significant benefit, i.e., the patient is experiencing an improvement in function or a reduction of pain intensity by at least 30%. (See Recommendation 9.)
  • Taper or switch opioid as required.