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

Recommendations

Info

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. February 2017 Page 118 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Table E-6. Evidence to Recommendation Framework Decision Domain Balance of desirable and undesirable outcomes • 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 • Is there high- or moderate-quality evidence that answers this question? • What is the overall certainty of this evidence? Judgment Benefits outweigh harms/burden Benefits slightly outweigh harms/burden Benefits and harms/burden are balanced Harms/burden slightly outweigh benefits Harms/burden outweigh benefits High Moderate Low Very low Values and preferences • Are you confident about the typical values and preferences and are they similar across the target population? Similar values • What are the patient’s values and preferences? Some variation • Are the assumed or identified relative values similar across the target Large variation population? Other implications (e.g., resource use, equity, acceptability, feasibility, subgroup considerations) • Are the resources worth the expected net benefit from the recommendation? • What are the costs per resource unit? • Is this intervention generally available? Various considerations • Is this intervention and its effects worth withdrawing or not allocating resources from other interventions? • Is there lots of variability in resource requirements across settings? The strength of a recommendation is defined as the extent to which one can be confident that the desirable effects of an intervention outweigh its undesirable effects and is based on the framework above, which combines the four domains.[68] GRADE methodology does not allow for recommendations to be made based on expert opinion alone. While strong recommendations are usually based on high or moderate confidence in the estimates of effect (quality of the evidence) there may be instances where strong recommendations are warranted even when the quality of evidence is low.[256] In these types of instances where the balance of desirable and undesirable outcomes and values and preferences played large roles in determining the strength of a recommendation, this is explained in the discussion section for the recommendation. The GRADE of a recommendation is based on the following elements: • Four decision domains used to determine the strength and direction (described above) • Relative strength (Strong or Weak) • Direction (For or Against) February 2017 Page 119 of 192
Page 1 and 2:
VA/DoD CLINICAL PRACTICE GUIDELINE
Page 3 and 4:
VA/DoD Clinical Practice Guideline
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68: VA/DoD Clinical Practice Guideline
Page 81 and 82: Appendix D: Drug Tables A. Short-ac
Page 83 and 84: Short-Acting Opioid Initial Oral Do
Page 85 and 86: Short-Acting Opioid Initial Oral Do
Page 87 and 88: Short-Acting Opioid Tramadol (alone
Page 89 and 90: Long-Acting/ER Opioids 1 Buprenorph
Page 91 and 92: Long-Acting/ER Opioids 1 Hydrocodon
Page 93 and 94: Long-Acting/ER Opioids 1 Initial Do
Page 99 and 100: 3 CYP-3A4 inhibiting agents include
Page 117: VA/DoD Clinical Practice Guideline
Page 163 and 164: DRAFT 3 - DO NOT DISTRIBUTE VA/DoD
Page 169 and 170:
DRAFT 3 - DO NOT DISTRIBUTE VA/DoD
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?