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

VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
recommendations for LOT, conducted by ECRI, assessed the confidence in the quality of the evidence base
and assigned a rate of “High,” “Moderate,” “Low,” or “Very Low.”
The elements that go into the confidence in the quality of the evidence include:
• Is there high or moderate-quality evidence that answers this question?
• What is the overall certainty of this evidence?
Values and preferences is an overarching term that includes patients’ perspectives, beliefs, expectations,
and goals for health and life. More precisely, it refers to the processes that individuals use in considering
the potential benefits, harms, costs, limitations, and inconvenience of the therapeutic or preventive
measures in relation to one another. For some, the term “values” has the closest connotation to these
processes. For others, the connotation of “preferences” best captures the notion of choice. In general,
values and preferences increase the strength of the recommendation when there is high concordance and
decrease it when there is great variability. In a situation in which the balance of benefits and risks are
uncertain, eliciting the values, concerns, and preferences of patients and empowering them or their
surrogates to make decisions consistent with patient goals of care becomes even more important. A
recommendation can be described as having “similar values,” “some variation,” or “large variation” in
typical values and preferences between patients and the larger populations of interest.
Some of the discussion questions that fall under the purview of values and preferences include:
• Are you confident about the typical values and preferences and are they similar across the
target population?
• What are the patient’s values and preferences?
• Are the assumed or identified relative values similar across the target population?
Other implications consider the practicality of the recommendation, including resources use, equity,
acceptability, feasibility and subgroup considerations. Resource use is related to the uncertainty around
the cost-effectiveness of a therapeutic or preventive measure. For example statin use in the frail elderly
and others with multiple co-occurring conditions may not be effective and depending on the societal
benchmark for willingness to pay, may not be a good use of resources. Equity, acceptability, feasibility, and
subgroup considerations require similar judgments around the practically of the recommendation.
The framework below (Table E-6) was used by the Work Group to guide discussions on each domain.
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