Last month, the CDC released its final Guideline for Prescribing Opioids for Chronic Pain -- United States, 2016,(www.cdc.gov) intended to be used by primary care physicians who are treating patients with chronic pain.
The guideline offers 12 recommendations about initiating or continuing opioid therapy for chronic pain, including drug selection, dosage, duration of treatment and follow-up, as well as risk assessment, addressing possible harms of opioid use and alternative therapies for pain.
After the draft guideline was released, the Academy conducted a peer review of the document, examining its methodology and evidence base and assessing the recommendations. And at that time, the AAFP agreed with some of those recommendations but expressed concerns about others based on the methodology used and a lack of supporting evidence.
The AAFP's Commission on the Health of the Public and Science (CHPS) has now had the chance to review the final version of the guideline and has given the resource its designation of "affirmation of value."
Jennifer Frost, M.D., medical director of the AAFP Health of the Public and Science Division, told AAFP News that the Academy follows a strict methodology based on standards outlined by the National Academy of Medicine (NAM) -- formerly the Institute of Medicine -- when producing clinical practice guidelines to offer members guidance based on the best available evidence.
"When we endorse a guideline from an external organization, we expect similar standards," she said. "We do recognize, however, that there are guidelines that may offer valuable guidance to our members despite concerns about the methodology used. So 'affirmation of value' is an attempt to recognize the value of a guideline, even though we may not have full confidence in the process used."
The Academy applauded the CDC for improving its methodology compared to previous guidelines and revising this guideline based on comments from numerous organizations.
The commission's designation of affirmation of value for the guideline was based on factors including -- its greatest concern -- that all but one of the guideline's recommendations were strong (category A) while all of the recommendations were based on low-quality or insufficient evidence. Due to the poor evidence base, the recommendations are generally consensus and therefore are "good practice points" rather than category A recommendations.
The AAFP CHPS also pointed out that inconsistent inclusion and exclusion criteria were used to assess the benefits of opioids and non-opioid treatments.
"The CDC has been working to adopt the (NAM) standards and has made great progress," Frost said. "Its guideline on opioids for chronic pain was a courageous attempt to tackle a challenging issue. Unfortunately, there is limited evidence available to guide physicians. We need better quality studies on the potential benefits of opioids, the appropriate length of use, the appropriate dosing for different conditions and how to better predict patients at risk for abuse or addiction."
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