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

Recommendations

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VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain The relative strength of the recommendation is based on a binary scale, “Strong” or “Weak.” A strong recommendation indicates that the Work Group is highly confident that desirable outcomes outweigh undesirable outcomes. If the Work Group is less confident of the balance between desirable and undesirable outcomes, they present a weak recommendation. Similarly, a recommendation for a therapy or preventive measure indicates that the desirable consequences outweigh the undesirable consequences. A recommendation against a therapy or preventive measure indicates that the undesirable consequences outweigh the desirable consequences. Using these elements, the grade of each recommendation is presented as part of a continuum: • Strong For (or “We recommend offering this option …”) • Weak For (or “We suggest offering this option …”) • Weak Against (or “We suggest not offering this option …”) • Strong Against (or “We recommend against offering this option …”) Note that weak (For or Against) recommendations may also be termed “Conditional,” “Discretionary,” or “Qualified.” Recommendations may be conditional based upon patient values and preferences, the resources available, or the setting in which the intervention will be implemented. Recommendations may be at the discretion of the patient and clinician, or they may be qualified with an explanation about the issues that would lead decisions to vary. E. Recommendation Categorization a. Categorizing Recommendations with an Updated Review of the Evidence Recommendations were first categorized by whether or not they were based on an updated review of the evidence. If evidence had been reviewed, recommendations were categorized as “New-added,” “Newreplaced,” “Not changed,” “Amended,” or “Deleted.” “Reviewed, New-added” recommendations were original, new recommendations that were not in the 2010 OT CPG. “Reviewed, New-replaced” recommendations were in the previous version of the guideline, but were modified to align with the updated review of the evidence. These recommendations could have also included clinically significant changes to the previous version. Recommendations categorized as “Reviewed, Not changed” were carried forward from the previous version of the CPG unchanged. To maintain consistency between 2010 recommendations, which were developed using the USPSTF methodology, and 2017 recommendations, which were developed using the GRADE methodology, it was necessary to modify the 2010 recommendations to include verbiage to signify the strength of the recommendation (e.g., “We recommend,” “We suggest”). Because the 2010 recommendations inherently needed to be modified at least slightly to include this language, the “Not changed” category was not used. For recommendations carried forward to the updated CPG with review of the evidence and slightly modified wording, the “Reviewed, Amended” recommendation category was used. This allowed for the wording of the recommendation to reflect GRADE methodology as well as for any other non-substantive (i.e., not clinically meaningful) language changes deemed necessary. The evidence used to support these February 2017 Page 120 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain recommendations was carried forward from the previous version of the CPG and/or was identified in the evidence review for the update. Recommendations could have also been designated “Reviewed, Deleted.” These were recommendations from the previous version of the CPG that were not brought forward to the updated guideline after review of the evidence. This occurred if the evidence supporting the recommendations was out of date, to the extent that there was no longer any basis to recommend a particular course of care and/or new evidence suggests a shift in care, rendering recommendations in the previous version of the guideline obsolete. b. Categorizing Recommendations without an Updated Review of the Evidence There were also cases in which it was necessary to carry forward recommendations from the previous version of the CPG without a systematic review of the evidence. Due to time and budget constraints, the update of the OT CPG could not review all available evidence on management of LOT, but instead focused its KQs on areas of new or updated scientific research or areas that were not previously covered in the CPG. For areas of research that have not changed, and for which recommendations made in the previous version of the guideline were still relevant, recommendations could have been carried forward to the updated guideline without an updated systematic review of the evidence. The support for these recommendations in the updated CPG was thus also carried forward from the previous version of the CPG. These recommendations were categorized as “Not reviewed.” If evidence had not been reviewed, recommendations could have been categorized as “Not changed,” Amended,” or “Deleted.” “Not reviewed, Not changed” recommendations refer to recommendations from the previous version of the OT CPG that were carried forward unchanged to the updated version. The category of “Not reviewed, Amended” was used to designate recommendations that were modified from the 2010 CPG with the updated GRADE language, as explained above. Recommendations could also have been categorized as “Not reviewed, Deleted” if they were determined to be out of scope. A recommendation was out of scope if it pertained to a topic (e.g., population, care setting, treatment, condition) outside of the scope for the updated CPG as defined by the Work Group. The categories for the recommendations included in the 2017 version of the guideline are noted in the Recommendations. The categories for the recommendations from the 2010 OT CPG are noted in Appendix H. c. Recommendation Categories and Definitions For use in the 2017 OT CPG, a set of recommendation categories was adapted from those used by the United Kingdom National Institute for Health and Clinical Excellence (NICE).[72,73] These categories, along with their corresponding definitions, were used to account for the various ways in which recommendations could have been updated from the 2010 OT CPG. The categories and definitions can be found in Table E-7. February 2017 Page 121 of 192
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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