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

VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
In addition to developing recommendations during the face-to-face meeting, the Work Group also revised
the 2010 OT CPG algorithm to reflect the new and amended recommendations. They discussed the
available evidence as well as changes in clinical practice since 2010, as necessary, to update the algorithm.
D. Grading Recommendations
This CPG uses the GRADE methodology to assess the quality of the evidence base and assign a grade for
the strength for each recommendation. The GRADE system uses the following four domains to assess the
strength of each recommendation:[68]
• Balance of desirable and undesirable outcomes
• Confidence in the quality of the evidence
• Values and preferences
• Other implications, as appropriate, e.g.,:
• Resource Use
• Equity
• Acceptability
• Feasibility
• Subgroup considerations
The following sections further describe each domain.
Balance of desirable and undesirable outcomes refers to the size of anticipated benefits (e.g., increased
longevity, reduction in morbid event, resolution of symptoms, improved quality of life, decreased
resource use) and harms (e.g., decreased longevity, immediate serious complications, adverse event,
impaired quality of life, increased resource use, inconvenience/hassle) relative to each other. This
domain is based on the understanding that the majority of clinicians will offer patients therapeutic or
preventive measures as long as the advantages of the intervention exceed the risks and adverse effects.
The certainty or uncertainty of the clinician about the risk-benefit balance will greatly influence the
strength of the recommendation.
Some of the discussion questions that fall under this domain include:
• Given the best estimate of typical values and preferences, are you confident that the benefits
outweigh the harms and burden or vice versa?
• Are the desirable anticipated effects large?
• Are the undesirable anticipated effects small?
• Are the desirable effects large relative to undesirable effects?
Confidence in the quality of the evidence reflects the quality of the evidence base and the certainty in
that evidence. This second domain reflects the methodological quality of the studies for each outcome
variable. In general, the strength of recommendation follows the level of evidence, but not always, as
other domains may increase or decrease the strength. The evidence review used for the development of
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