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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Framing Opioid
Prescribing
Guidelines for
Acute Pain

DEVELOPING THE EVIDENCE

Committee on Evidence-Based Clinical Practice Guidelines
for Prescribing Opioids for Acute Pain

Board on Health Care Services

Health and Medicine Division

A Consensus Study Report of

images

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by a contract between the National Academy of Sciences and the U.S. Food and Drug Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-49687-2
International Standard Book Number-10: 0-309-49687-X
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Framing opioid prescribing guidelines for acute pain: Developing the evidence. Washington, DC: The National Academies Press. https://doi.org/10.17226/25555.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
×

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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

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Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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COMMITTEE ON EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES FOR PRESCRIBING OPIOIDS FOR ACUTE PAIN

BERNARD LO (Chair), President and Chief Executive Officer, The Greenwall Foundation; Professor of Medicine, Emeritus, and Director, Program in Medical Ethics, Emeritus, University of California, San Francisco

MARK C. BICKET, Director of Pain Fellowship Program, Director of Quality and Safety, Assistant Professor, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine (resigned from committee August 2019)

NICHOLAS W. CARRIS, Assistant Professor, Department of Pharmacotherapeutics and Clinical Research, USF Health Taneja College of Pharmacy, Assistant Professor, Department of Family Medicine, USF Health Morsani College of Medicine, University of South Florida

ROGER CHOU, Professor, Medicine, Oregon Health & Science University School of Medicine; Director, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University

M. KIT DELGADO, Assistant Professor, Emergency Medicine and Epidemiology, University of Pennsylvania Perelman School of Medicine

CHRISTINE D. GRECO, Clinical Director, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital; Assistant Professor, Anesthesia, Harvard Medical School

HILLARY V. KUNINS, Executive Deputy Commissioner, New York City Department of Health and Mental Hygiene

MARJORIE C. MEYER, Associate Professor, Maternal Fetal Medicine, Division Director, Maternal Fetal Medicine, Medical Director, Birthing Center, University of Vermont Medical Center

RICHARD PAYNE, Esther Colliflower Professor of Medicine and Divinity Emeritus, Duke Divinity School and Duke University Medical Center; John B. Francis Chair in Bioethics, Center for Practical Bioethics (resigned from committee December 2018)

ROSEMARY C. POLOMANO, Associate Dean for Practice, Professor, Pain Practice, University of Pennsylvania School of Nursing; Professor, Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine; Adjunct Professor, Uniformed Services University of the Health Sciences Graduate School of Nursing

CARDINALE B. SMITH, Associate Professor of Medicine, Division of Hematology/Medical Oncology and Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai; Director, Quality for Cancer Services, Mount Sinai Health System

ERIC C. SUN, Assistant Professor, Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University (resigned from committee September 2019)

JENNIFER F. WALJEE, Associate Professor of Surgery, Department of Surgery, University of Michigan School of Medicine; Co-Director, Michigan Opioid Prescribing Engagement Network

STEVEN J. WEISMAN, Medical Director, Pain Management, Children’s Wisconsin; Professor, Anesthesiology and Pediatrics, Medical College of Wisconsin

CHARLES G. WIDMER, Head, Division of Facial Pain, Department of Orthodontics, Associate Professor, Department of Orthodontics, University of Florida College of Dentistry

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Study Staff

ROBERTA WEDGE, Study Director

CYNDI TRANG, Research Associate

RUTH COOPER, Senior Program Assistant

MICAH WINOGRAD, Senior Finance Business Partner

SHARYL J. NASS, Director, Board on Health Care Services

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
×

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

RITA AGARWAL, Stanford University

HUDA AKIL, University of Michigan

SORAYA AZARI, University of California, San Francisco

BRIAN T. BATEMAN, Brigham and Women’s Hospital

ALFRED O. BERG, University of Washington School of Medicine

JAMES C. EISENACH, Wake Forest School of Medicine

DANIEL M. FOX, Milbank Memorial Fund

HAYTHAM KAAFARANI, Massachusetts General Hospital

NANCY E. LANE, University of California, Davis

ZACHARY F. MEISEL, University of Pennsylvania

ROBERT WALLACE, The University of Iowa

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by KENNETH W. KIZER, Atlas Research, and LINDA C. DEGUTIS, Henry M. Jackson Foundation. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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In Memoriam

This Consensus Study Report is dedicated to Dr. Richard Payne, an international expert in palliative care and pain management, a valued member of the committee, and an irreplaceable friend and colleague.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Preface

If readers look in their medicine cabinets, it is likely many will find prescription opioids left over from a previous acute pain episode. The treating clinician likely wanted to err on the side of providing adequate pain relief. But from an individual and a public health perspective, these leftover opioid pills may lead to long-term use, opioid use disorder, and unintentional overdoses among patients and others if taken by people for whom the pills were not prescribed. The committee believes that the need both to alleviate severe acute pain and to reduce public health harms make this report important for a broad audience, including clinicians and other health care providers, patients, and the public.

How might this report be useful? Evidence on opioid use, patient outcomes, and adverse effects for patients and the public health is being published continuously. This report offers a framework for evaluating that evidence to support a clinical practice guideline, recommends acute pain indications where better practice guidelines might affect public health, and points out evidence gaps that need to be filled with future research. Both acute pain and opioid use disorder and overdose can cause distress to patients and their communities; emotions on these topics run high. This report points the way to how rigorous evidence and guidelines based on that evidence can reduce inappropriate opioid prescribing for acute pain and thereby help prevent further distress.

On behalf of the committee, I would like to express our sincere gratitude to the many individuals and groups who provided valuable information and insights to assist the committee with its deliberations. In particular, we would like to thank the representatives of the U.S. Food and Drug Administration: Scott Gottlieb, Judy Staffa, and Douglas Throckmorton. The following individuals also participated in the committee’s workshops: Richard Barth, Jr., Dartmouth-Hitchcock Medical Center; Brian Bateman, Brigham and Women’s Hospital; Leslie Bisson, University at Buffalo; Kevin Bozic, The University of Texas at Austin Dell Medical School; Steven Brown, University of Arizona College of Medicine; Benjamin Friedman, Albert Einstein College of Medicine; David Goldfarb, New York University School of Medicine; Elizabeth Habermann, Mayo Clinic; Elliot Hersh, University of Pennsylvania School of Dental Medicine; Debra Houry, Centers for Disease Control and Prevention (CDC); Ula Hwang, Icahn School of Medicine at Mount Sinai; David Jevsevar, Geisel School of Medicine at Dartmouth; Clifford Ko, University of California, Los Angeles (UCLA), School of Medicine; Elliot Krane, Stanford University;

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Lisa Leffert, Massachusetts General Hospital; Christina Mikosz, CDC; Paul Moore, University of Pittsburgh School of Dental Medicine; Douglas Owens, U.S. Preventive Services Task Force and Stanford University; Darshak Sanghavi, OptumLabs; Holger Schünemann, GRADE and McMaster University; Paul Shekelle, UCLA School of Medicine; Wally Smith, Virginia Commonwealth University; and Joanna Starrels, Albert Einstein College of Medicine.

We would also like to thank the following individuals for conducting data analyses for the committee: Jill Ashman, Carol DeFrances, Pinyao Rui, Susan Schappert, and Brian Ward from CDC, and Brian Bateman from Brigham and Women’s Hospital. We also appreciate the materials sent by other interested parties, including several medical specialty societies.

As chair, I also want to thank my colleagues on the committee for their hard work, willingness to reconsider their views in the light of evidence and other perspectives, and their collegiality. I also want to acknowledge the contributions of Mark Bicket, M.D., and Eric Sun, M.D., Ph.D., who stepped off the committee when they started full-time positions with the federal government. I also want to remember Richard Payne, M.D., who died shortly after resigning from the committee, for his career-long dedication to relieving the suffering of patients living with pain and his commitment to reducing health disparities.

Finally, the committee’s report would not have been possible without the expertise, dedication, and hard work of the National Academies’ staff: Roberta Wedge, Cyndi Trang, Ruth Cooper, Daniel Bearss, and Rebecca Morgan. The committee gratefully thanks them.

Bernard Lo, Chair

Committee on Evidence-Based Clinical Practice Guidelines for Prescribing Opioids for Acute Pain

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
×

Acronyms and Abbreviations

AAAPT ACTTION−APS−AAPM Pain Taxonomy
AAN American Academy of Neurology
AAOMS American Association of Oral and Maxillofacial Surgeons
AAOS American Academy of Orthopaedic Surgeons
AAPD American Academy of Pediatric Dentistry
AAPM American Academy of Pain Medicine
ACOEM American College of Occupational and Environmental Medicine
ACOG American College of Obstetricians and Gynecologists
ACP American College of Physicians
ACTTION Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks
ADA American Dental Association
AGREE Appraisal of Guidelines, Research and Evaluation
AHIP America’s Health Insurance Plans
AHRQ Agency for Healthcare Research and Quality
AHS American Headache Society
APS American Pain Society
ASIPP American Society of Interventional Pain Physicians
AUA American Urological Association
CDC Centers for Disease Control and Prevention
CI confidence interval
CMSS Council of Medical Specialty Societies
CORE Center for Opioid Research and Education
CPG clinical practice guideline
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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DoD U.S. Department of Defense
DSM-5 Diagnostic and Statistical Manual for Mental Disorders, 5th Edition
EAU European Association of Urology
ED emergency department
EHC Effective Health Care program
EHR electronic health record
FDA U.S. Food and Drug Administration
GRADE Grading of Recommendations Assessment, Development and Evaluation
IOM Institute of Medicine
IQR interquartile range
MHA Massachusetts Health & Hospital Association
MME morphine milligram equivalent
NAMCS National Ambulatory Medical Care Survey
NHAMCS National Hospital Ambulatory Medical Care Survey
NHLBI National Heart, Lung, and Blood Institute
NSAID nonsteroidal anti-inflammatory drug
OME oral morphine equivalent
OPEN Opioid Prescribing Engagement Network
OR odds ratio
PDMP prescription drug monitoring program
PICOTS patient, problem, or population; intervention; comparison, control, or comparator; outcome; time; and setting
QI quality improvement
RCT randomized controlled trial
SCD sickle cell disease
THA total hip arthroplasty
TKA total knee arthroplasty
USPSTF U.S. Preventive Services Task Force
VA U.S. Department of Veterans Affairs
VOC vaso-occlusive crisis
WHO World Health Organization
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/25555.
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The opioid overdose epidemic combined with the need to reduce the burden of acute pain poses a public health challenge. To address how evidence-based clinical practice guidelines for prescribing opioids for acute pain might help meet this challenge, Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence develops a framework to evaluate existing clinical practice guidelines for prescribing opioids for acute pain indications, recommends indications for which new evidence-based guidelines should be developed, and recommends a future research agenda to inform and enable specialty organizations to develop and disseminate evidence-based clinical practice guidelines for prescribing opioids to treat acute pain indications.

The recommendations of this study will assist professional societies, health care organizations, and local, state, and national agencies to develop clinical practice guidelines for opioid prescribing for acute pain. Such a framework could inform the development of opioid prescribing guidelines and ensure systematic and standardized methods for evaluating evidence, translating knowledge, and formulating recommendations for practice.

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