Department of Veterans Affairs
Veterans Health Administration
Office of Quality & Performance

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TITLE: MANAGEMENT OF OPIOID THERAPY FOR CHRONIC PAIN

 
Citation   Management of Opioid Therapy for Chronic Pain. Washington, DC: VA/DoD Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense (DoD), February 2003 Office of Quality and Performance publication 10Q-CPG/OT-03.

Completion Date:

 

February 2003

Release Date:

 

August 2003

Source(s):

  

The Opioid Therapy for Chronic Pain Guideline was developed by and written for clinicians by the Department of Veterans Affairs, and Department of Defense, An experienced moderator facilitated the multidisciplinary working group that included anesthesiologists, internists, nurses, psychiatrists, substance use and addictions specialists, pharmacists, and expert consultants in the field of guideline and algorithm development.

Adaptation:

  

The guideline draws heavily from the Guideline for Medical Management for Chronic Non-Malignant Pain  (Canadian Pain Society and the College of Physicians Ontario, Canada). The guideline integrates the recommendations developed by VHA's Medical Advisory Panel (MAP) and the Pharmacy Benefits Management Strategic Health Group.

Guideline Status:

  

This is the current release of the guideline. An update is targeted for 2006.

Developer(s):

  

Veterans Health Administration (VHA), Department of Veterans Affairs (VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [U.S.]

Funding Source:

  

United States Government

Committee:

  

The Management of Opioid Therapy for Chronic Pain Working Group
 

Group Composition:

  

The list of contributors to this guideline includes pain specialists, psychiatrist, substance use and addiction specialists, nurses, therapists, primary care physicians, and experts in the field of guideline and algorithm development.

Disease/Condition:

  

Chronic Pain

Category:

  

Assessment; Treatment; Early Recognition and Treatment of Co-morbid Conditions, Management; Evaluation

Intended Users:

  

While designed for use by primary care providers in an ambulatory care setting, the guideline can also be used to coordinate and standardize care within subspecialty teams and as teaching tools for students and house staff,

Target Population:

  

Any person who is eligible for care in the VA or DoD health care delivery system.

Contact Person(s):

  

VA:
Jack Rosenberg, MD
Clinical Assistant Professor, Anesthesia
Ann Arbor VAMC
2215 Fuller Road
Ann Arbor, MI 48105
Phone: 734-936-4280
Fax: 734-761-5398
E-mail: jackrose@umich.edu

Jane H. Tollett, PhD, RN
Natl. Coordinator, Pain Management Strategy
VHA Headquarters
810 Vermont Ave., NW
Washington, DC 20420
Phone: 202-273-8537
Fax: 202-273-9131
E-mail: jane.tollett@hq.med.va.gov
 

DoD:
LTC Christopher Black, MD
Chief of Family Practice
USA MEDDAC
1105 Mount Belvedere Blvd.
Fort Drum, NY 13602
Phone: 315-772-0859
Fax: 315-772-9762
E-mail: Christopher.p.black@us.army.mil
 

GOALS/OBJECTIVES

  • To promote evidence-based management of individuals with chronic pain
  • To identify the critical decision points in management of patients with chronic pain who are candidates for opioid therapy
  • To allow flexibility so that local policies or procedures, such as those regarding referrals to or consultation with substance use specialty, can be accommodated.
  • To decrease the development of complications
  • To improve patient outcome, i.e., reduce pain, decrease complications, increase functional status and enhance the quality of life.

INTERVENTIONS AND PRACTICES

The guideline consists of 1 modules addressing The Management of Opioid Therapy for Chronic Pain.

OUTCOMES CONSIDERED

The goal for management of patients with chronic pain is to reduce pain, decrease complications, increase functional status and enhance the quality of life.

MAJOR RECOMMENDATIONS

The guideline is presented in an algorithmic format that allows the practitioner to follow in the recognize and treat chronic pain with the use of opioids. Recommendations are made with regard to the intent to establish verifiable treatment objectives for patients with chronic pain that will lead to a reduction in pain, increase in function and quality of life

CLINICAL ALGORITHMS  ARE PROVIDED FOR:

Management of Opioid Therapy for Chronic Pain

TYPE OF EVIDENCE

The majority of the literature supporting the science for these guidelines is based upon key clinical randomized controlled trials and longitudinal studies published from 1995 through March 2002. Where existing literature is ambiguous or conflicting, and where scientific data are lacking on an issue, recommendations are based on the expert panel's opinion and clinical experience.

DESCRIPTION OF METHODS TO COLLECT EVIDENCE

See appendix A: Guideline Development Process

The majority of the literature supporting the science for these guidelines are referenced throughout the document and are based upon key clinical randomized controlled trials and longitudinal studies published from 1992 through March, 1999. The references listed have undergone a thorough review and rating based on the scientific rigor of the article, clinical relevance of the material presented and the ability to generalize using this data. Where existing literature is ambiguous or conflicting, or where scientific data are lacking on an issue, recommendations have been based on the clinical experience of the Expert Panel’s opinion. Annotations indicate whether each recommendation is based on scientific data or expert opinion. A letter, e.g., A or B within a box of the algorithm refers the reader to an annotation for that box. The annotation typically follows the specific page of the algorithm in the sections labeled Algorithms and Annotations in each module. Strength of recommendation and level of evidence grading is based on AHCPR guideline development efforts and a ACC/AHA publication (9, 10).

METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

The Grading Scheme Used for the Guideline

  TABLE 1: Quality of Evidence (QE)
I At least one properly done RCT
II-1 Well designed controlled trial without randomization
II-2 Well designed cohort or case-control analytic study
II-3 Multiple time series, dramatic results of uncontrolled experiment
III Opinion of respected authorities, case reports, and expert committees
  TABLE 2: Overall Quality
Good High grade evidence (I or II-1) directly linked to health outcome
Fair High grade evidence (I or II-1) linked to intermediate outcome; or
grade evidence (II-2 or II-3) directly linked to health outcome
Poor Level III evidence or no linkage of evidence to health outcome
  TABLE 3: Net Effect of the Intervention
Substantial More than a small relative impact on a frequent condition with a substantial burden of suffering; or
A large impact on an infrequent condition with a significant impact on the individual patient level.
Moderate A small relative impact on a frequent condition with a substantial burden of suffering; or
A moderate impact on an infrequent condition with a significant impact on the individual patient level.
Small A negligible relative impact on a frequent condition with a substantial burden of suffering; or
A small impact on an infrequent condition with a significant impact on the individual patient level.
Zero or Negative Negative impact on patients; or
No relative impact on either a frequent condition with a substantial burden of suffering; or an infrequent condition with a significant impact on the individual patient level.
  TABLE 4: Grade the Recommendation
A A strong recommendation that the intervention is always indicated and acceptable
B A recommendation that the intervention may be useful/effective
C A recommendation that the intervention may be considered
D A recommendation that a procedure may be considered not useful/effective, or may be harmful
I Insufficient evidence to recommend for or against - the clinician will use clinical judgment

REVIEW METHODS

Peer Review

ENDORSERS

VHA 's National Clinical Practice Guideline Council
DoD/VA Clinical Practice Guidelines Working Group

QUALIFYING STATEMENTS

Clinical practice guidelines, which are increasingly being used in health care, are seen by many as a potential solution to inefficiency and inappropriate variations in care. Guidelines should be evidenced-based as well as based upon explicit criteria to ensure consensus regarding their internal validity. However, it must be remembered that the use of guidelines must always be in the context of a health care provider's clinical judgment in the care of a particular patient. For that reason, the guidelines may be viewed as an educational tool analogous to textbooks and journals, but in a more user-friendly tone.

GUIDELINE AVAILABILITY

Electronic copies available from:
The Office of Quality and Performance web site.

Copy Statement: No copyright restrictions apply

8-30-03