With the growing use -- and misuse -- of prescription painkillers in Canada, several groups of Canadian experts have created new guidelines for prescribing these powerful drugs to patients.

The use of opioid painkillers has grown significantly in Canada in recent years. There was a 50 per cent increase in the use of the drugs between 2000 and 2004 and Canada is now thought to be the third-largest opioid consumer per capita in the world.

Opioid medications, which include morphine, codeine and oxycodone, can be highly effective in treating patients with chronic pain, defined as pain that persists for more than six months. But they are also extremely potent and can also be addictive.

Just last December, a study in the Canadian Medical Association Journal found that Ontario deaths related to drugs made with one opioid called oxycodone increased fivefold from 1999 to 2004. What's more, opioids are highly coveted by drug dealers, who often sell the pills for high prices on the street.

With growing use of opioids in Canada have come growing problems, leading Canada's provincial colleges of physicians and surgeons to create the National Opioid Use Guideline Group.

A review article of the guideline was published Monday in the Canadian Medical Association Journal, and contains recommendations designed to help doctors prescribe the medications safely to patients who need them while keeping them away from those who might abuse them.

The full guideline is available from the National Pain Centre at McMaster University, and can be found on their website

"We hope that one of the benefits of these guidelines, will be to reduce the diversion and abuse and addiction problems with these drugs, because these are really good medications," says lead researcher Dr. Andrea Furlan, of the Toronto Rehabilitation Institute.

While the guidelines are aimed at family doctors and surgeons, pharmacists, nurses, and dentists may also find it useful, the authors note.

The guidelines include 24 practice recommendations to help doctors decide when and how to prescribe narcotics to patients with chronic pain. They include:

  • Advice on which medications are effective for which kinds of pain
  • Recommendations of giving patients urine tests before treatment to see if they are already using painkillers.
  • Dosage recommendations that call for increasing painkiller doses gradually and then monitoring effectiveness.
  • Advice on how to monitor for adverse side effects
  • Signs of possible abuse, including how to spot and prevent prescription fraud
  • Guidelines for how to treat specific kinds of patients, such as adolescents, pregnant patients and those with psychiatric illnesses
  • Guidelines for weaning patients off of opioids

In a related commentary in the CMAJ, Dr. Roger Chou, the director of Guideline Development at The American Pain Society, says it's unfortunate that that most of the recommendations in the new Canadian guideline were based primarily on consensus opinion, rather than on strong evidence.

"In other words, the developers of the guidelines found that what we know about opioids is dwarfed by what we don't know," he writes.

He says what's needed are more long-term studies that look at high-risk patients to see how they fare taking opioids for long periods. As well, he writes, there needs to be more studies to determine the best way to choose which patients are best for which medications, how to choose dosages, and how to monitor and discontinue therapy.

The groups involved in researching and reviewing the new guideline included:

  • A research team of academics
  • A National Advisory Panel of 49 individuals, including pain specialists, addiction experts, nurses and others
  • The National Opioid Use Guideline Group, which consists of 18 representatives from Canadian Medical Regulatory Authorities and the Federal Medical Regulatory Authorities of Canada