What is the evidence on opioids and pain management?

Delivering on CADTH’s commitment to the opioid crisis

By Jonathan Mitchell

Canada is the world’s second largest per capita consumer of prescription opioids. The growing rates of addiction, overdoses, and death continue to be seen across the country. In British Columbia alone, illicit drug overdoses claimed the lives of 914 people in 2016 making it the deadliest overdose year on record, an increase of nearly 80 per cent compared to the previous year. Opioid overdoses resulted in 343 deaths in Alberta in 2016, up from 257 in 2015.

On November 18, 2016, the Federal Minister of Health Dr. Jane Philpott and the Ontario Minister of Health and Long Term Care Dr. Eric Hoskins convened a national conference to address Canada`s growing opioid crisis. Commitments were made by federal and provincial/territorial organizations focusing on the prevention, treatment and reduction of harm associated with problematic opioid use.

For guidance on breakthroughs in health technologies, governments, healthcare organizations, clinicians, and patients turn to CADTH – an independent, not-for-profit agency that delivers balanced evidence on drugs and medical devices. At the November national summit to address Canada’s growing opioid crisis, CADTH made a commitment to identify best practices and provide evidence-based recommendations, advice and tools focused on both pain management interventions (drug and non-drug), and the treatment of opioid addiction.

New resources

Opioids and pain management are two topics where significant work is underway at CADTH. This leads to a wealth of assessments, advice, recommendations, and tools, which are all available for use by health care professionals, patients, and governments. We have gathered all these resources together in topic-specific evidence bundles.

For the latest evidence on opioids, go to www.cadth.ca/opioids. Categories include Pain Treatment; Misuse, Overdose, and Harms; Addiction Treatment; and Alternatives to Opioids. Here you will find our 2017 report Buprenorphine for Chronic Pain: A Review of the Clinical Effectiveness which indicated that there is no evidence that other opioids are superior to buprenorphine for treating chronic non-cancer pain. Another example is the fall 2016 report Buprenorphine/Naloxone Versus Methadone for the Treatment of Opioid Dependence which can be found under Addiction Treatment. This report suggested that buprenorphine/naloxone is a safe, effective, and cost-effective choice for treating opioid use disorder compared with methadone. The effective treatment of opioid use disorder is one of many strategies that will help to address the opioid crisis in Canada.

Many other examples of alternatives to opioids are profiled at www.cadth.ca/opioids. One of the most common medications for treatment of acute pain – from muscles, ligaments, tendons, joints or bones – are non-steroidal anti-inflammatory drugs (NSAIDs). Topical NSAIDs were shown to be effective in reducing pain from acute musculoskeletal conditions, such as sprains, strains or sport injuries. Adverse events were rare and usually related to skin reactions.

Emerging technologies are also profiled. An implant placed underneath the skin may offer a new treatment option for certain people coping with opioid addiction. The Probuphine implant, the first of its kind, uses four rods placed underneath the skin on the upper-arm to deliver a constant, non-fluctuating dose of the drug buprenorphine, for up to six months at a time. It is intended for patients who are ‘clinically stable’ on low-to-moderate doses of the same medication, taken in the form of a pill or a film dissolved in the mouth.

The latest evidence on pain management

At www.cadth.ca/pain, we have compiled evidence on the management of pain – both acute and chronic. This includes pharmacological treatments (such as gabapentin), physical therapies (such as shockwave therapy), psychological therapies, and multidisciplinary treatments.  Physical Therapy Treatments for Chronic Non-Cancer Pain (including a discussion of acupuncture, massage, and yoga) and Behavioural and Psychological Interventions for Chronic Non-Cancer Pain (including a discussion of Cognitive Behaviour Therapy) are but two of the reports found here that were published in the last six months.

Evidence is available at www.cadth.ca/pain on treatments for chronic pain that do not involve medication and that patients can use in their own homes. One such technology is transcutaneous electrical nerve stimulation or TENS where electrodes are placed on the skin around the area of pain. The area is then stimulated with low-voltage electricity usually for 30 minutes up to an hour, twice each day. The available evidence (see the CADTH report published in December 2016) does not prove that it works, but it also does not prove that TENS in the home does not work. In order words, it is unclear how effective TENS in the home may be for chronic pain and we need more evidence.

Additional resources are being developed

Both the opioid and pain resources will be updated regularly with more evidence, including rapid evidence reviews (Rapid Response Reports), Environmental Scans, and our larger Optimal Use projects with expert recommendations, as they are completed. To learn more about CADTH and the evidence we offer to help guide health care decisions in Canada, visit www.cadth.ca, follow us on Twitter @CADTH_ACMTS, or speak to a CADTH liaison officer in your region.

Jonathan Mitchell, M.Sc., CHE, FISQua is a consultant for CADTH’s Knowledge Mobilization and Liaison Program.