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The Canadian Guideline’s key recommendations are deeply flawed. Based on three small studies on highly select patients (2), the Guideline recommends that tapering for all patients on doses above 90 mg MED, regardless of their clinical response to the opioid. The Guideline neglects to warn physicians that tapering can put patients at high risk for overdose, because patients will lose tolerance, experience distressing withdrawal symptoms, and turn to other sources for their opioid.
The Guideline does not address treatment of opioid use disorder, even though it is the most serious complication of prescription opioid use and is the major cause of overdose. Buprenorphine/naloxone and methadone treatments have been shown to reduce overdose deaths (3). By not discussing these treatments, the Guideline encourages physicians to manage opioid addiction through tapering, which is usually ineffective and sometimes dangerous.
The Guideline is contributing to a climate of fear around opioid prescribing. We are aware of several instances of death following rapid tapering or abrupt discontinuation. The Guideline needs extensive revision to ensure patient safety; until this is done, the medical community and medical regulators must not use the Guideline as the standard for opioid prescribing.
1. Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. Cmaj. 2017;189(18):E659-e66.
2. Krumova EK, Bennemann P, Kindler D, Schwarzer A, Zenz M, Maier C. Low Pain Intensity After Opioid Withdrawal as a First Step of a Comprehensive Pain Rehabilitation Program Predicts Long-term Nonuse of Opioids in Chronic Noncancer Pain. The Clinical journal of pain. 2013;29(9):760-9.
3. Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ (Clinical research ed. 2017;357:j1550.