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7 The Path Forward
Pages 167-184

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From page 167...
... In addition, unused opioids may be available for misuse by family members or for diversion to others, further fueling opioid-related morbidity and mortality. Although opioids are effective for the management of acute pain, the continuing morbidity and mortality related to opioid analgesics in the United States underscores the need for evidence-based clinical practice guidelines (CPGs)
From page 168...
... Several CPGs addressing opioid prescribing for acute pain were identified (e.g., AAPD, 2018; Qaseem et al., 2017; VA/DoD, 2017) , but few of them provided specific evidence-based recommendations on the appropriate opioid dosage, the number of pills prescribed, and the duration of opioid use for a particular surgical or medical indication.
From page 169...
... . In addition to guidelines developed by professional societies or health care organizations, there are laws, regulations, and policies of various states, health insurers, and health care organizations, including state medical boards, that govern the actions of clinicians prescribing opioids for acute pain.
From page 170...
... For example, CDC; the American Pain Society; the National Health, Lung, and Blood Institute; the American College of Occupational and Environmental Medicine; and the American Academy of Orthopaedic Surgeons have all developed evidence-based CPGs that discuss pain management, although not all of them specifically address opioid prescribing for acute pain. The guidelines considered by the committee also varied in whether and how they addressed each of the key elements in the committee's analytic framework -- that is, identifying the specific patient populations to which the guideline is applicable, presenting an evidence-based opioid prescribing strategy, identifying potential intermediate outcomes, and specifying the expected health outcomes associated with the strategy.
From page 171...
... DEVELOPING CLINICAL PRACTICE GUIDELINES FOR OPIOIDS Appropriate Use of Opioids and Nonopioid Interventions Recommendation B: Developers of evidence-based clinical practice guidelines (CPGs) for an acute pain indication should address the appropriate use of opioids for the indication as well as the optimal opioid prescribing strategies.
From page 172...
... . For acute pain, individualized pain management is complicated by the many factors that may influence opioid requirements, including patient demographics, the underlying cause of the pain, prior pain history, substance use history, opioid use history, comorbid psychiatric and medical conditions including kidney and liver impairment, the duration of the symptoms, clinical settings, the use of nonopioid therapies, and other factors.
From page 173...
... For example, opioids may be prescribed for acute pain following surgical care performed as an inpatient or prescribed at discharge for outpatients following ambulatory surgery. Other acute pain indications, including many medical indications such as renal stones and fractures, may first present in emergency departments (EDs)
From page 174...
... Guideline Implementation Recommendation E: Organizations that develop evidence-based clinical practice guidelines (CPGs) on opioid prescribing for acute pain, including governmental entities (federal, state, and local)
From page 175...
... As additional research is carried out, organizations that produce CPGs on opioid prescribing for acute pain can modify their guidelines to take into account new evidence and strengthen the effectiveness of the CPG. Increased efforts to link government and private data resources can also provide new information on prescribing practices, patient outcomes, and community outcomes.
From page 176...
... Furthermore, they should work with policy makers to ensure appropriate implementation, and monitor the impacts of CPGs on clinical practice and health outcomes to ensure that they are applied in the manner for which they were intended. DEVELOPING THE EVIDENCE BASE Study Design Recommendation F: Researchers studying opioid prescribing for acute pain should address evidence gaps by linking opioid prescribing strategies to health outcomes using appropriate study designs.
From page 177...
... (Corrigan-Curay et al., 2018) , they use larger study populations and therefore may have greater statistical power to detect infrequent outcomes (such as chronic opioid use after acute pain in opioid-naïve patients)
From page 178...
... FDA requested that the committee identify and prioritize surgical and medical indications that are associated with acute pain and for which opioid analgesics are commonly prescribed and considered clinically necessary. In addition, the committee was asked to recommend where evidence-based CPGs would help inform prescribing practices.
From page 179...
... For example, one guideline might seek to aggregate laparoscopic surgery for appendicitis and cholecystitis. The aggregation and extrapolation of studies might bolster the applicability and implementation of CPGs for opioid prescribing for acute pain by expanding the available evidence on which they are based.
From page 180...
... Recommendation J: Researchers studying opioid prescribing for acute pain should address the evidence gaps in the following key priority areas: • outcomes of opioid prescribing strategies in key patient populations; • the impact of clinical setting on opioid prescribing strategies; and • the links between intermediate outcomes, such as the number of unused pills or long term opioid use, and health outcomes, such as pain, mortality, overdose, opioid use disorder, and function. Few of the opioid prescribing guidelines reviewed in this report discuss the different prescribing needs of subpopulations, and this lack of guidance can result in inappropriate prescribing for some patients.
From page 181...
... Research on whether the reduced opioid prescriptions recommended in CPGs will provide adequate pain relief to patients is also needed. Chapter 2 showed that while a majority of patients with an acute pain indication do not require more than a certain number of MMEs, some percentage of patients -- around 20%, depending on the indication and the opioid prescribing amount in the guideline -- do not have adequate pain control and need further assessment or an opioid refill.
From page 182...
... 2019. Opioid prescribing limits for acute pain: Potential problems with design and implementation.
From page 183...
... 2013. Expected benefits of clinical practice guidelines: Factors affecting their adherence and methods of implementation and dissemination.
From page 184...
... 2017. VA/DoD clinical practice guideline for opioid therapy for chronic pain.


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