chronic-pain-opioid-treatment-report-140929

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Conclusions. Evidence on long-term opioid therapy for chronic pain is very limited but suggestsan increased risk of serious harms that appears to be dose-dependent. More research is needed tounderstand long-term benefits, risk of abuse and related outcomes, and effectiveness of differentopioid prescribing methods and risk mitigation strategies.ix
ContentsExecutive Summary ................................................................................................................ ES-1Introduction ......................................................................................................................................1Background ................................................................................................................................. 1Scope of Review and Key Questions .......................................................................................... 2Key Question 1. Effectiveness and Comparative Effectiveness ........................................ 2Key Question 2. Harms and Adverse Events ........................................................................ 2Key Question 3. Dosing Strategies ..................................................................................... 3Key Question 4. Risk Assessment and Risk Mitigation Strategies .....................................3Methods .............................................................................................................................................5Topic Refinement and Review Protocol ..................................................................................... 5Literature Search Strategy ........................................................................................................... 5Study Selection ........................................................................................................................... 5Data Extraction ........................................................................................................................... 7Assessing Methodological Risk of Bias of Individual Studies ................................................... 7Assessing Research Applicability ............................................................................................... 8Evidence Synthesis and Rating the Body of Evidence ................................................................ 9Peer Review and Public Commentary......................................................................................... 9Results .......................................................................................................................................... 11Overview ................................................................................................................................... 12Key Question 1a. In patients with chronic pain, what is the effectiveness of long-term opioidtherapy versus placebo or no opioid therapy for long-term (≥1 year) outcomes related to pain,function, and quality of life? ..................................................................................................... 12Key Points ......................................................................................................................... 12Detailed Synthesis ............................................................................................................. 12Key Question 1b. How does effectiveness vary depending on: (1) the specific type or cause ofpain (e.g., neuropathic, musculoskeletal [including low back pain], fibromyalgia, sickle celldisease, inflammatory pain, and headache disorders); (2) patient demographics (e.g., age, race,ethnicity, gender); (3) patient comorbidities (including past or current alcohol or substance usedisorders, mental health disorders, medical comorbidities and high risk for addiction)? ........ 12Key Points ......................................................................................................................... 12Detailed Synthesis ............................................................................................................. 12Key Question 1c. In patients with chronic pain, what is the comparative effectiveness ofopioids versus nonopioid therapies (pharmacological or nonpharmacological) on outcomesrelated to pain, function, and quality of life? ............................................................................ 13Key Points ......................................................................................................................... 13Detailed Synthesis ............................................................................................................. 13Key Question 1d. In patients with chronic pain, what is the comparative effectiveness ofopioids plus nonopioid interventions (pharmacological or nonpharmacological) versus opioidsor nonopioid interventions alone on outcomes related to pain, function, quality of life, anddoses of opioids used? .............................................................................................................. 13Key Points ......................................................................................................................... 13Detailed Synthesis ............................................................................................................. 13Key Question 2a. In patients with chronic pain, what are the risks of opioids versus placebo orx
Page 1 and 2: Evidence Report/Technology Assessme
Page 4 and 5: PrefaceThe Agency for Healthcare Re
Page 6 and 7: Charles Inturrisi, Ph.D.Professor o
Page 8 and 9: Robert Jamison, Ph.D.Professor of A
Page 12 and 13: no opioid on: (1) opioid abuse, add
Page 14 and 15: References ........................
Page 16 and 17: The purpose of this report is to sy
Page 18 and 19: patient education, (3) urine drug s
Page 20 and 21: Each abstract was independently rev
Page 22 and 23: We rated the quality of each cohort
Page 24 and 25: ResultsOverviewThe search and selec
Page 26 and 27: Key Question 4. Risk Assessment and
Page 28 and 29: Table A. Summary of evidence (conti
Page 34 and 35: Evidence on the effectiveness of di
Page 36 and 37: ApplicabilityA number of issues cou
Page 38 and 39: the exception of buccal or intranas
Page 40: References1. International Associat
Page 43 and 44: outcome study of long-term opioid d
Page 45 and 46: patients? Pain Physician. 2006;9(1)
Page 47 and 48: American Academy of Pain Medicine,
Page 49 and 50: d. What is the comparative effectiv
Page 51 and 52: inclusion to English-language artic
Page 53 and 54: adequately reported and acceptable;
Page 55 and 56: eview comments will be made availab
Page 57 and 58: Key Question 1aIn patients with chr
Page 59 and 60: Key Question 2aIn patients with chr
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and F2). 49-58 All were rated fair-
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Table 1. Uncontrolled studies of lo
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Table 1. Uncontrolled studies of lo
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The annual overdose rate was 256 pe
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The SOE for the association between
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One fair-quality cross-sectional st
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5300 controls who did not visit the
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Key Question 3cIn patients with chr
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Table 2. Head-to-head trials and ob
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Table 2. Head-to-head trials and ob
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withdrawal due to opioid misuse, bu
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Table 3. Trials of different strate
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Table 3. Trials of different strate
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• Two studies evaluated the Scree
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Table 4. Studies of risk assessment
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Detailed SynthesisThe APS review id
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Evidence on the effectiveness of di
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Table 6. Summary of evidence (conti
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Page 99 and 100:
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The setting in which studies were c
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switching to other prescription opi
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States: Fact Sheet. Atlanta, GA: Ce
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overdose: a cohort study. Ann Inter
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placebo-controlled study. Clin Ther
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pain. Ann Intern Med. 2014;160(1):3
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Appendix A. Search StrategiesDataba
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19. 18 and (random$ or control$ or
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11. (urine adj7 (screen$ or test$ o
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3. (alfentanil or alphaprodine or b
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25. Risk Reduction Behavior/ or Ris
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KQ 4a-4c: Risk Prediction and Mitig
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"meperidine" OR "meptazinol" OR (MH
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PICOT Include ExcludeOutcomes • F
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Moore TM, Jones T, Browder JH, et a
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Banning A, Sjogren P, Kaiser F. Rea
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study. Pain. 2004;108(1-2):17-27. P
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Edlund MJ, Sullivan M, Steffick D,
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Gianutsos L, Safrenek S. Is there a
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China. Addiction. 2011;106(10):1801
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study. Compr Psychiatry. 1979;20(1)
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2009;10(4):531-43. PMID: 19243306.
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Mercadante S, Casuccio A, Tirelli W
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2003;107(3):486-92. PMID: 14506751.
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Quigley C. Hydromorphone for acute
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osteoarthritis-related pain: placeb
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2013;7(2):96-101. PMID: 23385449. E
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effect of maternal, postnatal, adol
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Vestergaard P, Rejnmark L, Mosekild
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Yulug B, Ozan E. Buprenorphine: a s
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Author, YearType of StudySettingDur
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Page 167 and 168:
Author,yearDunn,2010ScreenedEligibl
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Author,yearGomes,2011ScreenedEligib
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Author,yearLi, 2013Method For Asses
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Author,yearMethod For AssessingOutc
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Appendix Table E4. Observational St
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Author, YearKQLi, 2013 KQ2a Case-Co
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Appendix Table E5. Observational St
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0Appendix Table E6. Observational S
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Appendix Table E7. Trials of Differ
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Appendix Table E8a. Head-to-Head Tr
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AuthorYearStudydesignDurationWild 2
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Author,YearHartung,2007Type of Stud
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Author,YearKrebs,2011Type of Study,
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AuthorYearStudyDesignDurationRCT12
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Author yearAshburn, 2011Study Desig
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Author yearPortenoy, 2007Study Desi
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Author yearSimpson, 2007Study Desig
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Author yearStudy designDurationCowa
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Author YearRalphs, 1994StudyDesignD
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Author,Year Study DesignAkbik 2006
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Author,YearWebster2005Study DesignP
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Appendix F. Quality Assessment Tabl
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Author,YearGomes,2011Gomes,2013KQKQ
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Evaluatespopulationother than theon
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Key QuestionOutcomeStudy DesignNumb
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Key QuestionOutcomeStudy DesignNumb
Page 219:
Key Question Outcome4. Risk assessm
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