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

Summary of Recommendations

Cluster 2: Conducting an Opioid Trial

No. Recommendation Keyword
R07 During dosage titration in a trial of opioid therapy, advise the patient to avoid driving a motor vehicle until a stable dosage is established and it is certain the opioid does not cause sedation (Grade C) ; and when taking opioids with alcohol, benzodiazepines, or other sedating drugs (Grade B). Titration and driving
R08 During an opioid trial, select the most appropriate opioid for trial therapy using a stepped approach, and consider safety (Grade C). Stepped opioid selection
R09 When conducting an opioid trial, start with a low dose, increase gradually, and monitor analgesic effectiveness until the optimal dose is attained (Grade C). Optimal dose
R10 Chronic non-cancer pain can be managed effectively in most patients with dosages at or below 200 mg/day of morphine or equivalent (Grade A). Consideration of a higher dosage requires careful reassessment of the pain and of risk for misuse, and frequent monitoring with evidence of improved patient outcomes (Grade C). Watchful dose

When initiating a trial of opioid therapy for patients at higher risk for misuse:

  • Prescribe only for well-defined somatic or neuropathic pain conditions (Grade A)
  • Start with lower doses and titrate in small-dose increments (Grade B)
  • Monitor closely for signs of aberrant drug-related behaviors (Grade C)
Risk: opioid misuse