Cited by 707Opioid Use Disorder TreatmentPain Management and Opioid UseAnesthesia and Pain Management

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Guideline for opioid therapy and chronic noncancer pain

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Busse, Jason W., Craigie, Samantha, Juurlink, David N., Buckley, D. Norman, Wang, Li, Couban, Rachel J., Agoritsas, Thomas, Akl, Elie A., Carrasco-Labra, Alonso, Cooper, Lynn, Cull, Chris, da Costa, Bruno R., Frank, Joseph W., Grant, Gus, Iorio, Alfonso, Persaud, Navindra, Stern, Sol, Tugwell, Peter, Vandvik, Per Olav, Guyatt, Gordon H.·2017·Canadian Medical Association Journal

DOI 10.1503/cmaj.170363PMC PMC5422149

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Abstract

Chronic noncancer pain includes any painful condition that persists for at least three months and is not associated with malignant disease.[1][1] According to seven national surveys conducted between 1994 and 2008, 15%–19% of Canadian adults live with chronic noncancer pain.[2][2] Chronic

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GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., & Schünemann, H. J. (2008) · BMJ · doi:10.1136/bmj.39489.470347.ad · Cited by 23,305
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Going from evidence to recommendations
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GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations
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Opioid Prescriptions for Chronic Pain and Overdose
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A synthesis of oral morphine equivalents (OME) for opioid utilisation studies
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Opioid Wisely
Herx, L. (2019) · Canadian Medical Association Journal · doi:10.1503/cmaj.71591
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Singovski, S., Pautex, S., & Escher, M. (2022) · JMIG · doi:10.53738/revmed.2022.18.787.1238
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Mukhida, K., Sedighi, S., & Hart, C. (2022) · Canadian Journal of Pain · doi:10.1080/24740527.2022.2123308
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Jackson, T. D., Maeda, A., Beath, T., Ahmad, N., Arsenault, P. P., Jia, H., Lam, J. M. C., & Schramm, D. (2022) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzac077
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Deng, G. (2023) · Springer eBooks · doi:10.1007/978-3-031-12998-8_10
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Harrison, L. D., Kitchen, S. A., Whitehead, M., Mahar, A. L., Busse, J. W., & Gomes, T. (2023) · Journal of Military Veteran and Family Health · doi:10.3138/jmvfh-2022-0027
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Kendzerska, T., Malhotra, A., Gershon, A. S., Povitz, M., McIsaac, D. I., Aaron, S. D., Bryson, G. L., Talarico, R., Godbout, M., Tanuseputro, P., et al. (2023) · Frontiers in Sleep · doi:10.3389/frsle.2023.1161857
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Directive clinique no 443a : Opioïdes aux différentes étapes de la vie des femmes : Fertilité, contraception, douleur chronique et ménopause
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“[7,8] Due to the risks of addiction and overdoses, systematic assessments like the USFDA’s Risk Evaluation and Mitigation Strategies are crucial, which include patient education about risks and prescriber guidelines on safe use.”
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“…levels of opioid prescribing have updated clinical guidelines to avoid or limit the use of opioids in many painful conditions, especially in CNCP. 13,21,46,51 41, 43 The United Kingdom National Health The Prescribed Opioids Difficulties Scale (PODS) is a survey tool developed to assess recent…”
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King, A. C., Zahrai, A., Bisson, E. J., Shergill, Y., Rice, D. B., Wai, E. K., Nedden, N. Z., Cooper, L., James, D. J., Rash, J. A., et al. (2025) · Digital Health · doi:10.1177/20552076251326229
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“The recommended dose of opioid to administer is 10% of this calculation [5].”
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“The absolute risk of non-fatal opioid overdose is 0.2%, and the risk of death is 0.1% following prescription for chronic pain; also, a prior focus group study of pain patients found that they placed little importance on the small likelihood of accidental overdose or death [33,34].”
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“30,31 This context likely contributes to the volume of eConsults sent to addiction medicine inquiring about chronic pain management, even for patients where opioid use disorder has not been diagnosed.”
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Holton, A. E., Wang, T., Hamzat, B., Bragg, S., deGonzague, B., Mecredy, G. C., Campbell, T. J., Antoniou, T., McGregor, L., Bertram, J., et al. (2025) · Canadian Journal of Public Health · doi:10.17269/s41997-025-01097-3
“…the risks of iatrogenic opioid-related harm, prescribing guidelines recommend reserving these drugs for cases where other options have been ineffective, using the lowest effective dose and avoiding concurrent use of other respiratory depressants, such as benzodiazepines (Busse et al., 2017).”
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Patel, M., Parnian, P., Madden, K., Sprague, S., Acai, A., Kleinlugtenbelt, Y. V., Saka, N., Landman, E. B. M., Shanthanna, H., Khanna, V., et al. (2025) · PLoS ONE · doi:10.1371/journal.pone.0331335
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Jani, M., Girard, N., Bates, D. W., Buckeridge, D. L., Dixon, W. G., & Tamblyn, R. M. (2025) · Pain · doi:10.1097/j.pain.0000000000003792
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Kataria, S., Roberts, C. J., Dupaquier, M. M., Arya, P., Sharpe, M., Shekoohi, S., & Kaye, A. D. (2025) · Springer eBooks · doi:10.1007/978-3-032-07407-2_7
Prevalence of prescribed opioid claims among persons with non-traumatic spinal cord dysfunction in Ontario, Canada: a population-based retrospective cohort study
Guan, Q., Hogan, M., Calzavara, A. J., McCormack, D., Lofters, A., Patel, T., Hitzig, S. L., Packer, T. L., & Guilcher, S. J. T. (2025) · Spinal Cord · doi:10.1038/s41393-025-01140-7
Opioid Initiation in Older Patients with Chronic Pain Who Received Authorized Cannabis Prescription
Fontaine, E., El-Mourad, J., Dubois, C., Eurich, D. T., Dyck, J. R. B., Hanlon, J. G., & Zongo, A. (2025) · Substance Use & Misuse · doi:10.1080/10826084.2025.2586250
“Among the pharmacological options for the treatment of chronic pain, opioids are prescribed when pain is not adequately controlled with non-opioid medications (Busse et al., 2017; Dowell & Haegerich, 2016).”
Impact of chiropractic care on opioid use for noncancer spine pain: systematic review and meta-analysis
Emary, P. C., Corcoran, K. L., Coleman, B. C., Brown, A. L., Ciraco, C., DiDonato, J., Wang, L., Couban, R., Sud, A., & Busse, J. W. (2025) · PAIN Reports · doi:10.1097/pr9.0000000000001374
“16,30,33 However, because the current evidence informing the impact of chiropractic care on new or continued prescription opioid use for noncancer spine pain is only of very low certainty, rigorously designed RCTs are needed to confirm these findings.”
InfluentialSelf-citation
Additional file 1 of Prescription opioids among older adults: ten years of data across five countries
Hamina, A., Muller, A. E., Clausen, T., Skurtveit, S., Hesse, M., Tjagvad, C., Thylstrup, B., Odsbu, I., Zoega, H., Jónsdóttir, H. L., et al. (2022) · Figshare · doi:10.6084/m9.figshare.19778154
Additional file 5 of Eye acupuncture for pain conditions: a scoping review of clinical studies
Chi, Y., Barth, J., Wang, M., Robinson, N., Li, Z.-H., & Liu, J.-P. (2021) · Figshare · doi:10.6084/m9.figshare.14274116
Additional file 4 of Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training
Smylie, J. K., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C. L., Klopfer, K., Lofters, A., O’Neill, B., Graham, M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26659339
Additional file 6 of Eye acupuncture for pain conditions: a scoping review of clinical studies
Chi, Y., Barth, J., Wang, M., Robinson, N., Li, Z.-H., & Liu, J.-P. (2021) · Figshare · doi:10.6084/m9.figshare.14274119
Additional file 3 of Exceeding the guideline-recommended maximum daily dose of opioids for long-term treatment of non-cancer pain in Germany – a large retrospective observational study
Schrader, N. F., Niemann, A., Weitzel, M., Speckemeier, C., Abels, C., Blase, N., Giebel, G. D., Riederer, C., Nadstawek, J., Straßmeir, W., et al. (2024) · Figshare · doi:10.6084/m9.figshare.27123668
Additional file 3 of Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training
Smylie, J. K., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C. L., Klopfer, K., Lofters, A., O’Neill, B., Graham, M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26659336
Additional file 2 of Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training
Smylie, J. K., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C. L., Klopfer, K., Lofters, A., O’Neill, B., Graham, M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26659333
Additional file 1 of Exceeding the guideline-recommended maximum daily dose of opioids for long-term treatment of non-cancer pain in Germany – a large retrospective observational study
Schrader, N. F., Niemann, A., Weitzel, M., Speckemeier, C., Abels, C., Blase, N., Giebel, G. D., Riederer, C., Nadstawek, J., Straßmeir, W., et al. (2024) · Figshare · doi:10.6084/m9.figshare.27123662
Additional file 5 of Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training
Smylie, J. K., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C. L., Klopfer, K., Lofters, A., O’Neill, B., Graham, M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26659342
Additional file 1 of A retrospective quantitative implementation evaluation of Safer Opioid Prescribing, a Canadian continuing education program
Sud, A., Doukas, K., Hodgson, K., Hsu, J., Miatello, A., Moineddin, R., & Paton, M. (2021) · Figshare · doi:10.6084/m9.figshare.13978855
Additional file 4 of Eye acupuncture for pain conditions: a scoping review of clinical studies
Chi, Y., Barth, J., Wang, M., Robinson, N., Li, Z.-H., & Liu, J.-P. (2021) · Figshare · doi:10.6084/m9.figshare.14274113
Additional file 7 of Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training
Smylie, J. K., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C. L., Klopfer, K., Lofters, A., O’Neill, B., Graham, M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26659348
Additional file 1 of Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training
Smylie, J. K., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C. L., Klopfer, K., Lofters, A., O’Neill, B., Graham, M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26659330
Additional file 2 of Exceeding the guideline-recommended maximum daily dose of opioids for long-term treatment of non-cancer pain in Germany – a large retrospective observational study
Schrader, N. F., Niemann, A., Weitzel, M., Speckemeier, C., Abels, C., Blase, N., Giebel, G. D., Riederer, C., Nadstawek, J., Straßmeir, W., et al. (2024) · Figshare · doi:10.6084/m9.figshare.27123665
Additional file 6 of Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training
Smylie, J. K., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C. L., Klopfer, K., Lofters, A., O’Neill, B., Graham, M., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26659345
Additional file 2 of Eye acupuncture for pain conditions: a scoping review of clinical studies
Chi, Y., Barth, J., Wang, M., Robinson, N., Li, Z.-H., & Liu, J.-P. (2021) · Figshare · doi:10.6084/m9.figshare.14274107
Additional file 2 of Efficacy of interventions targeted at physician prescribers of opioids for chronic non-cancer pain: an overview of systematic reviews
Peri, K., Honeycutt, L., Wennberg, E., Windle, S. B., Filion, K. B., Gore, G., Kudrina, I., Paraskevopoulos, E., Moiz, A., Martel, M. O., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26683201
Additional file 1 of Efficacy of interventions targeted at physician prescribers of opioids for chronic non-cancer pain: an overview of systematic reviews
Peri, K., Honeycutt, L., Wennberg, E., Windle, S. B., Filion, K. B., Gore, G., Kudrina, I., Paraskevopoulos, E., Moiz, A., Martel, M. O., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26683198
Additional file 3 of Eye acupuncture for pain conditions: a scoping review of clinical studies
Chi, Y., Barth, J., Wang, M., Robinson, N., Li, Z.-H., & Liu, J.-P. (2021) · Figshare · doi:10.6084/m9.figshare.14274110
Additional file 1 of Evolving through multiple, co-existing pressures to change: a case study of self-organization in primary care during the COVID-19 pandemic in Canada
Thille, P., Tobin, A., Evans, J. M., Katz, A., & Russell, G. M. (2024) · Figshare · doi:10.6084/m9.figshare.26500350
Additional file 3 of A retrospective quantitative implementation evaluation of Safer Opioid Prescribing, a Canadian continuing education program
Sud, A., Doukas, K., Hodgson, K., Hsu, J., Miatello, A., Moineddin, R., & Paton, M. (2021) · Figshare · doi:10.6084/m9.figshare.13978861
Additional file 1 of Eye acupuncture for pain conditions: a scoping review of clinical studies
Chi, Y., Barth, J., Wang, M., Robinson, N., Li, Z.-H., & Liu, J.-P. (2021) · Figshare · doi:10.6084/m9.figshare.14274104
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Albert, C. A., & Sarver, C. (2025) · Springer eBooks · doi:10.1007/978-3-032-10403-8_5
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Caramma, S., Condorelli, R., Buccheri, E., Maria, M., Rosta, G., Longo, L., Gotti, F. L., Brundo, S., & Chiaramonte, R. (2026) · Frontiers in Rehabilitation Sciences · doi:10.3389/fresc.2026.1683677
Continuity of Primary Care and Delayed Opioid Initiation in Non‐Cancer Pain: A Cohort Study
Jo, A. J., Choo, E., Kim, S., Je, N. K., & Lee, I. (2026) · European Journal of Pain · doi:10.1002/ejp.70226
“Although opioids remain an essential option for severe and cancer-related pain, their long-term use in non-cancer pain (NCP) is associated with limited effectiveness and a substantial risk of dependence, misuse and overdose (Busse et al. 2017; Els et al. 2023).”
Pain neuroscience education intervention for patients who experience chronic musculoskeletal pain with concurrent opioid dependence: A pilot study
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“7,17,35,46 Our findings extend previous research by highlighting the risks of unintended mental health outcomes associated with large opioid dose reductions or discontinuing opioids.”
Temporal trends in emergency department opioid prescribing and related harms in Alberta, Canada: A population-based cohort study
Hayward, J., Li, H., Holodinsky, J. K., Dong, K. A., & Innes, G. D. (2026) · Canadian Journal of Public Health · doi:10.17269/s41997-026-01182-1
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Halpape, K., Jorgenson, D. J., & Rogers, M. (2026) · Canadian Journal of Pain · doi:10.1080/24740527.2026.2627924
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Piotrowski, A., Schmidt, A., Kufeld, N., Kersting, C., Bencheva, V., Wiese, B., Bahrs, O., Hunger‐Schoppe, C., Maas, M., Preuss, J., et al. (2026) · Journal of Pain Research · doi:10.2147/jpr.s564795
“104,106 The fact that established pain guidelines do not yet address gender-sensitive care 8,61,66–71 suggests a potential gap in current clinical practice which the GESCO intervention aims to address.”
Sex, gender, and sociodemographic factors associated with repeated prescription refills in chronic pain: insights from a prescription claims cohort study
Godbout-Parent, M., Julien, N., Nguefack, H. L. N., Pagé, M. G., Guénette, L., Blais, L., Ménard, N., Beaudoın, S., & Lacasse, A. (2026) · Frontiers in Pain Research · doi:10.3389/fpain.2026.1810867 · Cited by 1
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“25 Predictors and ML methods Similar to our previous work, all candidate predictors were obtained from the PIN dataset and were either derived from the literature 26 27 or directly incorporated from the data, unmodified (online supplemental etable 2).”
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Xu, Z., Si, C., Dong, Y., Zhang, H., Zhang, J., Ge, W., & Wu, X. (2026) · BMC Anesthesiology · doi:10.1186/s12871-026-03941-6
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Authors: Busse, J. W., Craigie, S., Juurlink, D. N., Buckley, D. N., Wang, L., Couban, R. J., Agoritsas, T., Akl, E. A., Carrasco-Labra, A., Cooper, L., Cull, C., da Costa, B. R., Frank, J. W., Grant, G., Iorio, A., Persaud, N., Stern, S., Tugwell, P., Vandvik, P. O., & Guyatt, G. H.
Affiliations: University of Bern (CH)
ORCID: Busse, Jason W.
Juurlink, David N.
Buckley, D. Norman
Wang, Li
Couban, Rachel J.
Agoritsas, Thomas
Akl, Elie A.
Cooper, Lynn
Cull, Chris
Frank, Joseph W.
Iorio, Alfonso
Persaud, Navindra
Tugwell, Peter
Vandvik, Per Olav
Guyatt, Gordon H.
Venue: Canadian Medical Association Journal
Publisher: CMA Impact Inc.
Published: 2017-05-07
Volume: 189
Issue: 18
Pages: E659-E666
ISSN: 0820-3946 (ISSN-L)
1488-2329
DOI: 10.1503/cmaj.170363
PMC: PMC5422149
OpenAlex: W2612284626
Cited by: 707
References: 50
Citations by year: 2026: 37 · 2025: 58 · 2024: 71 · 2023: 59 · 2022: 82 · 2021: 107 · 2020: 105 · 2019: 86 · 2018: 67 · 2017: 29
FWCI: 73.70
Type: journal article
Language: en
Open access: gold
doi.org
Locations: Canadian Medical Association Journal (publishedVersion)
Europe PMC (PubMed Central) (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Archive ouverte UNIGE (University of Geneva) (publishedVersion, other-oa)
BORIS (University Library Bern) (submittedVersion)
Funders: U.S. Department of Veterans Affairs (IK2 HX001914)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Pain Management
Keywords: opioid therapy, chronic non-cancer pain, pain management, opioid prescribing
MeSH terms: Analgesics, Opioid, Dose-Response Relationship, Drug, Humans, Opioid-Related Disorders, Pain Measurement, Primary Health Care, Treatment Outcome, Drug Monitoring, Chronic Pain

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