Few high-quality guidelines exist for prescribing opioids

Few high-quality guidelines exist for prescribing opioids to treat chronic pain, a review found, noting that there was at least consensus among guidelines on ways to mitigate opioid-related risks.

Researchers looked at MEDLINE, the National Guideline Clearinghouse, specialty society websites, and international guideline clearinghouses in July 2013 for guidelines published since January 2007 that addressed using opioids for chronic pain in adults. Guidelines on specific settings, populations and conditions were excluded. The review was published online first Nov. 12 by Annals of Internal Medicine.

Researchers used 2 methods for evaluating the literature: the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and A Measurement Tool to Assess Systematic Reviews (AMSTAR).

With AGREE II, appraisers rated 23 items across 6 domains, scored from 1 for strongly disagree to 7 for strongly agree. Scaled domain scores (0% to 100%) were based on the sum of ratings across all appraisers and the difference between the maximum and minimum possible scores. Using AGREE II, overall guideline assessment scores ranged from 3.00 to 6.20. Rigor-of-development scores were 20% to 84%, clarity-of-presentation scores ranged from 37% to 93%, applicability scores were 13% to 56%, and editorial independence scores ranged from 0% to 88%.

Ratings were highest for a guideline by the American Pain Society and the American Academy of Pain Medicine and for a guideline by the Canadian National Opioid Use Guideline Group. These were the only guidelines that more than half of the appraisers voted to use without modification. A majority of appraisers recommended against using 4 other guidelines because of limited confidence in development methods, lack of evidence summaries or concerns about readability.

In the original version of AMSTAR, appraisers answer 6 domain questions, which typically addressed multiple concepts. Using this system, systematic reviews within 10 guidelines were of poor or fair quality. The authors noted that the American Pain Society and the American Academy of Pain Medicine review was of excellent to outstanding quality, the review by the Canadian National Opioid Use Guideline Group was of good to excellent quality, and a review by the Department of Veterans Affairs and Department of Defense was of good quality.

Reasons for lower scores on other guidelines included limited information about whether inclusion criteria were selected beforehand, whether at least 2 reviewers participated in study selection and data extraction, whether more than 1 database was searched, search terms used, inclusion criteria, lists of included studies, whether the scientific quality of the studies was assessed, how information from different studies was combined, and whether publication bias was considered.

On mitigating opioid-related risks, a majority of the guidelines recommended that clinicians avoid doses greater than 90 to 200 mg of morphine equivalents per day, have additional knowledge to prescribe methadone, recognize risks of fentanyl patches, titrate cautiously, and reduce doses by at least 25% to 50% when switching opioids. Guidelines also agreed that opioid risk assessment tools, written treatment agreements, and urine drug testing can mitigate risks. Most recommendations were supported by observational data or expert consensus.

But, the review authors cautioned, few studies directly addressed questions of whether changing practices decreases risks of opioid use. “Given the pressing need to address opioid-related adverse outcomes, which some have described as an epidemic, developers seem to agree on forging recommendations based on relatively weak or indirect evidence now rather than waiting for more rigorous studies,” they wrote.

“SAFE Opioid Prescribing,” a free online training program to educate clinicians about safety and efficacy when prescribing opioids, was recently launched by ACP and its curriculum partner Pri-Med. The program is available on the Pri-Med website and is a REMS-compliant training program eligible for up to 6 hours of category 1 CME.