Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain

Teryl K. Nuckols, Laura Anderson, Ioana Popescu, Allison L. Diamant, Brian Doyle, Paul Di Capua, Roger Chou

Research output: Contribution to journalArticle

173 Citations (Scopus)

Abstract

Background: Deaths due to prescription opioid overdoses have increased dramatically. High-quality guidelines could help clinicians mitigate risks associated with opioid therapy. Purpose: To evaluate the quality and content of guidelines on the use of opioids for chronic pain. Data Sources: MEDLINE, National Guideline Clearinghouse, specialty society Web sites, and international guideline clearinghouses (searched in July 2013). Study Selection: Guidelines published between January 2007 and July 2013 addressing the use of opioids for chronic pain in adults were selected. Guidelines on specific settings, populations, and conditions were excluded. Data Extraction: Guidelines and associated systematic reviews were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument and A Measurement Tool to Assess Systematic Reviews (AMSTAR), respectively, and recommendations for mitigating opioid-related risks were compared. Data Synthesis: Thirteen guidelines met selection criteria. Overall AGREE II scores were 3.00 to 6.20 (on a scale of 1 to 7). The AMSTAR ratings were poor to fair for 10 guidelines. Two received high AGREE II and AMSTAR scores. Most guidelines recommend 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 agree that opioid risk assessment tools, written treatment agreements, and urine drug testing can mitigate risks. Most recommendations are supported by observational data or expert consensus. Limitation: Exclusion of non-English-language guidelines and reliance on published information. Conclusion: Despite limited evidence and variable development methods, recent guidelines on chronic pain agree on several opioid risk mitigation strategies, including upper dosing thresholds; cautions with certain medications; attention to drug-drug and drug- disease interactions; and use of risk assessment tools, treatment agreements, and urine drug testing. Future research should directly examine the effectiveness of opioid risk mitigation strategies.

Original languageEnglish (US)
Pages (from-to)38-47
Number of pages10
JournalAnnals of Internal Medicine
Volume160
Issue number1
StatePublished - Jan 7 2014

Fingerprint

Chronic Pain
Opioid Analgesics
Guidelines
Pharmaceutical Preparations
Urine
Information Storage and Retrieval
Methadone
Fentanyl
Drug Interactions
MEDLINE
Morphine
Patient Selection
Prescriptions
Consensus
Language
Therapeutics

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Nuckols, T. K., Anderson, L., Popescu, I., Diamant, A. L., Doyle, B., Di Capua, P., & Chou, R. (2014). Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain. Annals of Internal Medicine, 160(1), 38-47.

Opioid prescribing : A systematic review and critical appraisal of guidelines for chronic pain. / Nuckols, Teryl K.; Anderson, Laura; Popescu, Ioana; Diamant, Allison L.; Doyle, Brian; Di Capua, Paul; Chou, Roger.

In: Annals of Internal Medicine, Vol. 160, No. 1, 07.01.2014, p. 38-47.

Research output: Contribution to journalArticle

Nuckols, TK, Anderson, L, Popescu, I, Diamant, AL, Doyle, B, Di Capua, P & Chou, R 2014, 'Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain', Annals of Internal Medicine, vol. 160, no. 1, pp. 38-47.
Nuckols TK, Anderson L, Popescu I, Diamant AL, Doyle B, Di Capua P et al. Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain. Annals of Internal Medicine. 2014 Jan 7;160(1):38-47.
Nuckols, Teryl K. ; Anderson, Laura ; Popescu, Ioana ; Diamant, Allison L. ; Doyle, Brian ; Di Capua, Paul ; Chou, Roger. / Opioid prescribing : A systematic review and critical appraisal of guidelines for chronic pain. In: Annals of Internal Medicine. 2014 ; Vol. 160, No. 1. pp. 38-47.
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