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22nd of June 2018

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The Canadian National Opioid Guideline from 2017 - The Good Men Project

Professor Gordon Guyatt, MD, MSc, FRCP, OC is a Distinguished University Professor in the Department of Health Research Methods, Evidence and Impact and Medicine at McMaster University. He is a Fellow of the Canadian Academy of Health Sciences.

Here we talk about the start of national opioid guidelines for Canada from late 2017.

Professor Guyatt helped with the national opioid guidelines. He talked about the over-prescription of non-cancer pain alongside an increase in excessive doses of opioids for it. This led to narcotic dependency among the population of these users.

“Everybody knows this is a problem. An earlier Canadian guideline in the days before people were really waking up to this, basically, did not say when to use opioids. It said, ‘If you decide to use opioids, what are the best ways? What are the guides for giving out the opioids?’”

Within the context of the medical community and the patients receiving care, the reasonableness of these prescriptions was within it. People needed care. People were in pain. Opioids reduced the pain.

Problem solved. However, the problem came with unpredicted side effects. It contributed to the opioid overprescribing, which was a problem.

“So, a couple of years ago, and a few months ago produced, a national guideline for opioid use,” Guyatt stated, “It starts out saying, ‘Before you use opioids, try non-steroidal, try drugs like Acetaminophen, try a number of other drugs such as those in the anticonvulsant class that have analgesic properties. Some antidepressants have analgesic properties. Bottom line: do not use opioids as your first, second, or third option. Try other things before you move to opioids.’”

The next finding for the Canadian medical community was the opioids were really great for the short-term but powerful pain, or acute pain. These provided substantially positive effects for the acute pain of patients.

However, there is a point at which the patients become used to the opioids. That means the opioid effects wear off. “When you give opioids chronically, the effect is actually quite limited,” Guyatt said.

If there was a visual analogue of the pain as a scale with 0 as no pain and 10 as the worst pain, chronic opioids only lower pain by about one unit on the scale using whole numbers. A 6 becomes a 5 and a 4 becomes a 3, and so on.

“Very modest effect, it has lots of side effects,” Guyatt explained, “So, the guidelines say, ‘Do not give large doses of opioids. No extra benefits, extra risks, if you are going to give opioids, first try everything else, then when you try this make the dose modest.’”

The guidelines also provided people who are stuck on opioids how to reduce their opioid use and even eliminate opioids as part of their medication set.

Guyatt concluded, “A whole set of recommendations for dealing with the over-prescription of opioids. That will hopefully lead to much better prescribing.”

The British Medical Journal or BMJ had a list of 117 nominees in 2010 for the Lifetime Achievement Award. Guyatt was short-listed and came in second-place in the end. He earned the title of an Officer of the Order of Canada based on contributions from evidence-based medicine and its teaching.

He was elected a Fellow of the Royal Society of Canada in 2012 and a Member of the Canadian Medical Hall of Fame in 2015. He lectured on public vs. private healthcare funding in March of 2017, which seemed like a valuable conversation to publish in order to have this in the internet’s digital repository with one of Canada’s foremost academics.

For those with an interest in standardized metrics or academic rankings, he is the 14th most cited academic in the world in terms of H-Index at 222 and has a total citation count of more than 200,000. That is, he has the highest H-Index, likely, of any Canadian academic living or dead.

He talks here with Scott Douglas Jacobsen who founded In-Sight Publishing and In-Sight: Independent Interview-Based Journal. We conducted an extensive interview before: here, here, here, here, here, and here. We have other interviews in Canadian Atheist (here and here), Canadian Students for Sensible Drug Policy, Humanist Voices, and The Good Men Project (here, here, and here).

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Photo credit: Getty Images

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