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



Utah Department of Health: "Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain", Utah Department of Health, 2009.
APS/ACPM: "Opioid Treatment Guidelines – Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain," for The American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel, 2009.
IASP: Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214). Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk. IASP Press: Seattle, © 1994.


Aberrant drug-related behaviours Behaviours that may cause suspicion about addiction in opioid-treated pain patients.  (Passik 2006b)
Abuse, drug Any use of an illegal drug, or the intentional self-administration of a medication for a non-medical purpose such as altering one’s state of consciousness, e.g., "getting high." (APS/ACPM 2009)
Addiction A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. (Utah Department of Health 2009)
Dependence, Physical A state of adaptation manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (APS/ACPM 2009) (Utah Department of Health 2009)
Diversion The intentional transfer of a controlled substance from legitimate distribution and dispensing channels. (APS/ACPM 2009)
Dose, optimal

The optimal dose is reached with a BALANCE of three factors:

  • Effectiveness: improved function or at least 30% reduction in pain intensity
  • Plateauing: effectiveness plateaus—increasing the dose yields negligible benefit
  • Adverse effects/complications: adverse effects or complications are manageable
Dose, stable

A "pharmacologically stable dose" is one that produces a fairly steady plasma level; it is established when the total daily dose is fixed for at least two weeks and:

1) frequency is scheduled and spread throughout the day


2) at least 70% of the prescribed opioid is controlled release.

Dose, watchful Watchful dose = morphine or equivalent dose exceeding 200 mg/day.
Double-doctoring  … receiving a prescription for a narcotic, and then seeking and receiving another prescription or narcotic from a different practitioner without disclosing to that practitioner particulars of every prescription or narcotic obtained within the previous 30 days. (Minister of Justice)
Hyperalgesia An increased response to a stimulus which is normally painful. (APS/ACPM 2009)
Misuse, opioid Use of an opioid in ways other than those intended by the prescribing physician (sometimes also called problematic opioid use). (Ballantyne 2007).
Narcotic Narcotic: any drug included in the "Schedule" under the Controlled Drugs and Substances Act: Narcotic Control Regulations. (Minister of Justice)
Opioid, controlled release (CR) CR (Sustained Release) preparations consist of an opioid embedded in a wax matrix, micro-granules or other milieu that slowly releases the opioid into the GI tract or subcutaneous tissues. CR preparations of morphine, codeine, oxycodone and hydromorphone induce analagesia for up to 12 hours (e.g., MS-Contin®, Codeine-Contin®, OxyContin®, Hydromorph-Contin®). These CR preparations can be easily converted to immediate-release by biting or crushing the tablet. The duration of action of Kadian® (slow-release morphine) is 24 hours and for the transdermal fentanyl patch (e.g., Duragesic®), 72 hours. Tramadol is also available in a CR preparation (e.g., Zytram®, Tridural™, and Ralivia™).
Opioid, immediate release (IR) IR formulations release the full dose of the opioid into the GI tract as the tablet dissolves. IR tablets generally contain a much smaller opioid dose than CR preparations. Some of the IR formulations also contain acetaminophen and caffeine. Examples of IR formulations include Tylenol® No. 1, 2, 3 and 4 (acetaminophen plus codeine), Percocet® and Oxycocet® (acetaminophen and oxycodone), Dilaudid® (hydromorphone), Statex® (morphine), Supeudol® (oxycodone), Codeine (codeine), and Tramacet® (tramadol 37.5 mg and acetaminophen 325 mg).

A family of drugs that act by attaching to endogenous mu, kappa and delta receptors in the brain and share a common set of clinical effects, including analgesia, sedation, constipation, and respiratory depression.

Note: Reference throughout this document to specific pharmaceutical products as examples does not imply endorsement of any of these products.

Pain, breakthrough Transient or episodic exacerbation of pain that occurs in patients with pain that is otherwise considered stable but persistent. (APS/ACPM 2009)
Pain, chronic Pain that persists for more than six months. (College of Physicians and Surgeons of Ontario 2000)
Pain, chronic non-cancer (CNCP) Chronic pain that is not associated with cancer.
Pain, chronic non-malignant Not used in this document; see chronic non-cancer pain.
Pain, neuropathic

Pain initiated or caused by a primary lesion or dysfunction in the nervous system.

Peripheral neuropathic pain occurs when the lesion or dysfunction affects the peripheral nervous system. Central pain may be retained as the term when the lesion or dysfunction affects the central nervous system. (IASP)

Substance Any drug with pleasant psychoactive effects and addiction potential, including alcohol, illegal drugs, and prescription drugs.
Substance dependence See addiction.
Tapering A gradual decrease in a dose of a drug; could result in a lower daily dose or cessation of the drug.
Therapy, structured opioid Use of opioids to treat CNCP with specific controls in place, including: patient education, written treatment agreement, agreed-on dispensing intervals, and frequent monitoring.
Therapy, chronic opioid Not used in this document; see therapy, long-term opioid.
Therapy, long-term opioid (LTOT). Use of opioids to treat chronic non-cancer pain for prolonged duration.
Titration A technique of adjusting a dose until a stable/optimal dose is reached; usually means gradually increasing the dose to allow the body to develop tolerance and minimize adverse effects.
Tolerance A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more opioid effects over time. (APS/ACPM) (Utah Department of Health)
Withdrawal Characteristic syndrome produced by abrupt cessation of a drug.