Teryl K. Nuckols, MD, MSHS; Laura Anderson, MPH; Ioana Popescu, MD, MPH; Allison L. Diamant, MD, MSHS; Brian Doyle, MD; Paul Di Capua, MD; Roger Chou, MD
Financial Support: By the California Department of Industrial Relations and the California Commission on Health and Safety and Workers’ Compensation. Dr. Nuckols was supported by a Mentored Clinical Scientist Career Development Award (K08) from the Agency for Healthcare Research and Quality (grant HS17954).
Potential Conflicts of Interest: Dr. Nuckols: Other: California Commission on Health and Safety and Worker's Compensation, Collaborative Spine Research Foundation. Dr. Chou: Grant: California Commission on Health and Safety and Worker's Compensation, American Pain Society. All other authors have no disclosures. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1193.
Requests for Single Reprints: Teryl K. Nuckols, MD, MSHS, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, 911 Broxton Avenue, Los Angeles, CA 90095; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Nuckols, Popescu, Diamant, Doyle, and Di Capua: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, 911 Broxton Avenue, Los Angeles, CA 90095.
Ms. Anderson: UCLA Fielding School of Public Health, 650 Charles E. Young Drive South, 16-035 Center for Health Sciences, Los Angeles, CA 90095-1772.
Dr. Chou: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098.
Author Contributions: Conception and design: T.K. Nuckols, A.L. Diamant, R. Chou.
Analysis and interpretation of the data: T.K. Nuckols, L. Anderson, I. Popescu, A.L. Diamant, B. Doyle, P. Di Capua, R. Chou.
Drafting of the article: T.K. Nuckols, I. Popescu, A.L. Diamant, R. Chou.
Critical revision of the article for important intellectual content: T.K. Nuckols, I. Popescu, A.L. Diamant, B. Doyle, R. Chou.
Final approval of the article: T.K. Nuckols, I. Popescu, A.L. Diamant, P. Di Capua, R. Chou.
Provision of study materials or patients: T.K. Nuckols.
Statistical expertise: T.K. Nuckols.
Obtaining of funding: T.K. Nuckols.
Administrative, technical, or logistic support: T.K. Nuckols, L. Anderson.
Collection and assembly of data: T.K. Nuckols, L. Anderson, I. Popescu, A.L. Diamant, B. Doyle, P. Di Capua.
Deaths due to prescription opioid overdoses have increased dramatically. High-quality guidelines could help clinicians mitigate risks associated with opioid therapy.
To evaluate the quality and content of guidelines on the use of opioids for chronic pain.
MEDLINE, National Guideline Clearinghouse, specialty society Web sites, and international guideline clearinghouses (searched in July 2013).
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.
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.
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.
Exclusion of non–English-language guidelines and reliance on published information.
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.
California Department of Industrial Relations and California Commission on Health and Safety and Workers’ Compensation.
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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. Ann Intern Med. 2014;160:38–47. doi: 10.7326/0003-4819-160-1-201401070-00732
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Published: Ann Intern Med. 2014;160(1):38-47.
Emergency Medicine, Prevention/Screening, Tobacco, Alcohol, and Other Substance Abuse.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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