Self-Reported Practices in Opioid Management of Chronic Noncancer Pain: An Updated Survey of Canadian Family Physicians

Abstract

Chronic pain affects one in five Canadians, and opioids continue to be prescribed to 12.3% of the Canadian population. A survey of family physicians was conducted in 2010 as a baseline prior to the release of the Canadian Opioid Guideline. We repeated the same survey with minor modifications to reflect the updated 2017 opioid prescribing guideline. The online survey was distributed in all provinces and territories in both English and French. There were 265 responses from May 2018 to October 2019, 55% of respondents were male, 16% had advanced training in pain management, 51% had more than 20 years in practice, 54% wrote five or fewer prescriptions of opioids per month, and 58% were confident in their skills in prescribing opioids. Of the 11 knowledge questions, only two were correctly selected by more than 80% of the respondents. Twenty-nine physicians (11%) do not prescribe opioids, and the main factor affecting their decisions were concerns about long-term adverse effects and lack of evidence for effectiveness of opioids in chronic noncancer pain. Of the 12 guideline-concordant practices, only two were performed regularly by 90% or more of the respondents: explain potential harms of long-term opioid therapy and beginning dose of less than 50 mg of morphine equivalent daily. This survey represents a small proportion of family physicians in Canada and its generalizability is limited. However, we identified a number of opioid-related and guideline-specific gaps, as well as barriers and enablers to prescribing opioids and adhering to the guideline.

Barriers and facilitators encountered by family physicians prescribing opioids for chronic non-cancer pain: a qualitative study

“…While uptake, since 2010, of some guideline-based practices by Canadian family physicians might be attributable to creation and dissemination of prescribing guidelines, 5 the systemic problems we identified in our study are not easily solved. Our findings suggest that while some family physicians have access to peers and experts to support their prescribing for challenging patient cases, others have to place their patients on long waitlists to obtain those supports because they do not have connections to knowledgeable peers or experts.…”

“…This survey, a follow-up to a similar 2010 survey, found that urine drug screening by respondents had increased from 22% in 2010 to 57% in 2018. 5 These findings cannot be fully generalized to Nova Scotia, however, because the 2018 survey included only one Nova Scotian respondent. 5 (Urine drug screening is described under a guidance statement rather than recommendation in the 2017 McMaster guideline, due to lack of evidence for its use.…”

“…5 These findings cannot be fully generalized to Nova Scotia, however, because the 2018 survey included only one Nova Scotian respondent. 5 (Urine drug screening is described under a guidance statement rather than recommendation in the 2017 McMaster guideline, due to lack of evidence for its use. 7 )…”

“…The most recent Canadian guidelines were released in 2017 by the McMaster University National Pain Centre to update their previous 2010 guideline; the 10 recommendations cover first-line therapies, POA therapy in substance use disorder, psychiatric disorders, history of substance use disorder, dosing, tapering and POA rotation. 7 In a 2020 survey of Canadian family physicians, Furlan et al 5 found that two of 12 guideline-concordant practices were performed regularly by the majority of respondents. This survey, a follow-up to a similar 2010 survey, found that urine drug screening by respondents had increased from 22% in 2010 to 57% in 2018.…”

“…4 A more recent survey, conducted from May 2018 to October 2019, found that 89% of family physicians prescribed opioid analgesics to treat CNCP. 5 A 2015 systematic review of 14 studies on physician adherence to prescribing guidelines for CNCP in Australia, Canada, France and the USA found that a significant proportion of physicians were not following guidelines largely because of a lack of awareness of their existence; because the guidelines were difficult to implement into practice; and because physicians were inadequately educated in pain management with POAs. 6 The most current widely-adopted Canadian guideline for https://doi.org/10.24095/hpcdp.41.…”