Opioid Guidelines Are Generally Consistent

A review of guidelines for use of opioid painkillers to treat chronic pain finds that they are in general agreement but are frequently based on limited or low-quality evidence.

Although the quality of guidelines on the use of opioid painkillers to treat chronic pain varies, guidelines offered by different organizations make many similar recommendations to prevent their abuse, a recent review finds.

As the use and abuse of opioids has steadily increased in recent years, several clinical guidelines have been produced to help inform prescribers about best practices for long-term use. The review, which was published online on November 12, 2013, in the Annals of Internal Medicine, identified guidelines for the use of the painkillers in patients with chronic pain, assessed their quality, and compared their recommendations for risk mitigation strategies.

The researchers searched MEDLINE, the National Guideline Clearinghouse, specialty society websites, and international guideline clearinghouses for guidelines and supporting systematic reviews that addressed the use of opioids to treat adults with chronic pain lasting longer than 3 months. The included guidelines and reviews were published between January 2007 and July 2013 and did not focus on a specific condition, population, or setting. The quality of the guidelines were then evaluated using the Appraisal of Guidelines for Research and Evaluation II. Recommendations on risk mitigation strategies were collected from each guideline and review and compared.

Among the 13 guidelines included in the study, joint guidelines from the American Pain Society and the American Academy of Pain Medicine and guidelines developed by the Canadian National Opioid Use Guideline Group were the only ones to receive high quality ratings. Intermediate ratings were given to 7 guidelines, and the researchers recommended against using the remaining 4. Even the high-quality guidelines, the researchers found, based many of their recommendations on small numbers of lower-quality observational studies.

Despite the limited evidence used to develop the guidelines, many of their recommendations were consistent. Of the 13 guidelines, 8 agree that caution should be exercised when giving patients doses greater than 90 mg to 200 mg of morphine equivalents per day, and 10 suggest that only knowledgeable clinicians should prescribe methadone. Eight of guidelines also recommend using caution with fentanyl patches, 10 make suggestions about carefully initiating and titrating the painkillers, and 7 agree that doses should be reduced by at least 25% to 50% when switching from one opioid to another. To prevent abuse with long-term use, 9 guidelines recommend using opioid risk-assessment tools and treatment agreements, and 9 determine that urine drug testing is beneficial.

Although the available guidelines make similar recommendations regarding long-term opioid use and can be helpful to prescribers, the authors of the study note that more research is needed to provide stronger evidence and potentially better recommendations.

“[F]uture research should directly examine the effectiveness of opioid risk mitigation strategies, including effects on pain control and overdose rates,” they write.