Chronic Opioid Therapy Guideline Appraisal

Guideline Title

Use of Chronic Opioid Therapy in Chronic Noncancer Pain.

Scope and Purpose

The overall objectives of the guideline are specifically described

The purpose of the guideline is “to provide evidence-based recommendations for the use of COT for CNCP in both primary care and specialty settings” (Chou et al., 2009, pp. 114-115). The guidelines aim to benefit the patients with the identified disorder and minimize possible public health risks.

The health questions covered by the guideline are specifically described

The addressed questions are not specifically defined, but Chou et al. (2009) clearly state the target audience and focus mainly on the risk-benefit ratio of COP throughout the recommendations.

The population to whom the guideline is meant to apply is specifically described

The target audience comprises “all clinicians who provide care for adults with CNCP, including cancer survivors with chronic pain due to their cancer or its treatment” (Chou et al., 2009, p. 115).

Stakeholder Involvement

The guideline development group includes individuals from all relevant professional groups

The panel consists of multidisciplinary professionals: medical informatics, neurology, palliative care, epidemiology, et cetera.

The views and preferences of the target population have been sought

It is observed that COP is highly effective in pain management and is beneficial for patients with multiple noncancer disorders. However, public views are controversial due to multiple risks, including addiction and drug abuse. The guidelines aim to find a balance between the two sides.

The target users of the guideline are clearly defined

The users are clinicians working with CNCP patients.

Rigor of Development

Systematic methods were used to search for evidence

A full description of the search and evidence review strategy is provided.

The criteria for selecting the evidence are not clearly described

The panel selected “a total of 14 systematic reviews and 57 primary studies” yet did not explain the criteria (Chou et al., 2009, p. 115). Nevertheless, the background information suggests that the chosen studies were specifically focused on the use of COP for CNCP.

The strengths and limitations of the body of evidence are clearly described

The paper has a separate section and Appendix 2 explaining grading of the evidence-based on the type, sample, overall quality, et cetera.

The methods for formulating the recommendations are clearly described

The methods and timelines are explained in Guideline Development Process.

The health benefits, side effects, and risks have been considered in formulating the recommendations

Chou et al. (2009) note that “a strong recommendation is based on the panel’s assessment that potential benefits of following the recommendation clearly outweigh potential harms and burdens” (p. 115).

There is an explicit link between the recommendations and the supporting evidence

The recommendations are followed by an explicit explanation of the synthesized evidence.

The guideline has been externally reviewed by experts before its publication

The panel involved over twenty external reviewers who provided additional comments on the members’ drafts.

A procedure for updating the guideline is provided

Chou et al. (2009) note that the panel intends to update the guideline regularly (first time: by 2012).

Clarity of Presentation

The recommendations are specific and unambiguous

All the recommendations state-specific actions such as periodic urine screens for confirming COP adherence, use of opioid rotation in case of adverse effects, et cetera.

The different options for management of the condition or health issue are clearly presented

Chou et al. (2009) sufficiently discuss various dosing strategies and implementation of psychotherapeutic co-interventions.

Key recommendations are easily identifiable

The recommendations are well-structured and divided into fourteen relevant themes/sections.

Applicability

The guideline describes facilitators and barriers to its application

Facilitators and barriers are outlined for all recommendations: for instance, “barriers to obtaining interdisciplinary therapy include high costs, limited availability in the United States, and frequent lack of insurance coverage” (Chou et al., 2009, p. 122). They are based on the retrieved research evidence.

The guideline provides advice and/or tools on how the recommendations can be put into practice

Implementation tools (Opioid Risk Tool, Current Opioid Misuse Measure, et cetera) are provided in the appendices.

The potential resource implications of applying the recommendations have not been considered.

The guideline does not present monitoring and/or auditing criteria.

Editorial Independence

The views of the funding body have not influenced the content of the guideline

Chou et al. (2009) state that “the content of the guideline is the sole responsibility of the authors and panel members” (p. 115).

Competing interests of guideline development group members have been recorded and addressed

It is noted that the panel members were asked to disclose any conflicts of interest. A complete list is provided in Appendix 1.

Overall Guideline Assessment

Rate the overall quality of the guideline

Although the panel members identified numerous research gaps during the guideline development process, the given recommendations meet the current state of knowledge in the area of COP use for CNCP and are up-to-date.

I would recommend this guideline for use. It is well-written and informative.

Reference

Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P.,… & Miaskowski, C. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113-130.