VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Table E-3. Key Question Specific Comparators Question Comparators 1 Patients without a co-occurring medical or mental health condition on LOT 2 Comparison groups that vary by LOT dosage and length of opioid use, other factors 3 4 5 No OT (including placebo) or other pain management strategies Other modalities: • Non-opioid medications (e.g., non-steroidal including compounded topical preparations) • Physical interventions (e.g., physical therapy, active/passive exercise, ultrasound stimulation, chiropractic, osteopathic manipulation therapy) • Behavioral/mental health interventions EXAMPLES: • CBT • Dialectical behavior therapy (DBT) • Mindfulness • Acceptance and commitment therapy (ACT) • Complementary and alternative interventions EXAMPLES: • Acupuncture • Chiropractic interventions No OT (including placebo) or other pain management strategies Other modalities: • Non-opioid medications (e.g., non-steroidal including compounded topical preparations) • Physical interventions (e.g., physical therapy, active/passive exercise, ultrasound stimulation, chiropractic, osteopathic manipulation therapy) • Behavioral/ mental health interventions (e.g., CBT, ACT, mindfulness, DBT) • Complementary and alternative interventions Long-acting opioid drugs or combination short and long-acting drugs (See list) Other route of administration/delivery alternatives Non abuse-deterrent formulations Other opioids No use of buprenorphine No use of methadone 6 Opioid therapy alone 7 No mitigation strategy or other mitigation strategy 8 No treatment for OUD or other treatment for OUD 9 Different tapering strategy or schedule d. Outcomes For the treatment and management questions (KQ 3–9), the following outcomes were of interest in the systematic review: • Pain relief • Quality of life • Cognitive/functional status • Mortality • Opioid abuse/misuse February 2017 Page 110 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain • Adverse events • SUD • Aberrant use • Overdose • Non-pain use of opiates • Abuse • Addictions • Cardiovascular events • Respiratory depression • Gastrointestinal complications (including constipation) • Endocrinological complications (including impotence) • Weight gain • Cognitive performance • Psychiatric decompensation • Psychological symptoms (e.g., depression, loss of libido, nightmares) • Headaches • Suicide • Accidents (including falls) • Infections • Increased risk of HIV and Hepatitis A, B, and C • Loss to follow-up/medical care e. Timing The timing considered in the systematic review was 12 weeks for studies looking at the efficacy of OT, and any follow-up for studies reporting on the safety of OT. f. Setting The setting considered in the systematic review was primary care. B. Conducting the Systematic Review Extensive literature searches using the search terms and strategy included in Appendix J identified 15,554 citations potentially addressing the KQs of interest to this evidence review. Of those, 11,633 were excluded upon title review for clearly not meeting inclusion criteria (e.g., not pertinent to the topic, not published in English, published prior to study inclusion publication date, not a full-length article). Overall, 3,921 abstracts were reviewed with 2,995 of those being excluded for the following reasons: not a systematic review or clinical study, did not address a KQ of interest to this review, did not enroll a population of February 2017 Page 111 of 192
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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