What is the Quality of Guidelines for Prescribing Opioids to Treat Chronic Pain?
High-quality guidelines may help clinicians prescribe opioids for chronic pain in a safe and effective manner. Researchers searched US and international guidelines and specialty society websites to assess English-language opioid prescribing guidelines published between January 2007 and July 2013. Guidelines were evaluated using the A Measurement Tool to Assess Systematic Reviews (AMSTAR) and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tools.
- Of the 1132 guidelines screened and 19 evaluated, 13 met selection criteria.*
- AGREE II quality ratings ranged from 3 to 6.2 (on a 1 to 7 scale) and were highest for the American Pain Society/American Academy of Pain Medicine (APS/AAPM) and the Canadian National Opioid Use Guideline Group (NOUGG) guidelines.
- AMSTAR ratings on quality of systematic review were poor-to-fair for 10 of the 13 guidelines. However, AMSTAR ratings were excellent-to-outstanding for the APS/AAPM guideline, good-to-excellent for the NOUGG guideline, and good for the VA/Department of Defense (VA/DOD) guideline.
- 10 of the 13 guidelines included relevant recommendations about mitigating risk. Recommendations included use of written treatment agreements, opioid risk assessment tools, urine drug testing, avoiding doses greater than 90 to 200 mg of morphine equivalents per day, acquiring extra training in order to prescribe methadone, attention to drug-drug (e.g., opioids and sedative-hypnotics) and drug-disease interactions (e.g., opioids and obstructive lung disease), and reducing doses by 25–50% when switching opioids.
*The 13 selected guidelines were from the APS/AAPM, the American College of Occupational and Environmental Medicine, the American Geriatrics Society, the American Society of Anesthesiologists, the American Society of Interventional Pain Physicians, the VA/DOD, the Colorado Division of Workers’ Compensation, the Institute for Clinical Systems Improvement, the NOUGG, the Utah Department of Health, the University of Michigan Health System, the Work Loss Data Institute, and Fine and colleagues (expert panel).
Comments:
Based on observational data and expert consensus for most recommendations, guidelines from the APS/AAPM and the NOUGG were judged to be acceptable in their current form by over 50% of the study appraisers. Unfortunately, the efficacy of implementing these guidelines in a practice setting is not known.
Kevin L. Kraemer, MD, MSc
Reference:
Nuckols TK, Anderson L, Popescu I, et al. Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2013 [Epub ahead of print]. doi: 10.7326/0003-4819-160-1-201401070-00732.