Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines

Guideline Quality Assessment

We used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument^13-15 to evaluate the quality of each guideline selected for inclusion. The AGREE II instrument includes 23 statements, spanning 6 domains. Each guideline was rated by 3 appraisers (S.J.H., S.L.C., M.V.R., N.V., L.S., A.L., and M.K.) who indicated the degree to which they agreed with each of the 23 statements using a scale from 1 (strongly disagree) to 7 (strongly agree). They additionally rated the overall quality of the guideline, also on a scale of 1 to 7, and indicated whether they would recommend the guideline for use. Scaled domain scores are reported as a percentage and calculated as described in Table 1.

Guideline Synthesis and Analysis

We extracted recommendations from each guideline related to the following topics: 1) deciding when to use opioids, nonopioid medications, and nonmedication-based pain management modalities, 2) best practices in screening/monitoring/education prior to prescribing an opioid and/or during treatment, 3) opioid selection considerations, including selection of dose, duration, and route of administration, 4) strategies to minimize the risk of opioid-related adverse events, and 5) safe practices on discharge.

Role of the Funding Source

The Society of Hospital Medicine provided administrative and material support for the project, but had no role in the design or execution of the scientific evaluation.

RESULTS

We identified 923 unique records for screening, from which we identified 4 guidelines meeting the selection criteria (see Figure). Guidelines by the American College of Occupational and Environmental Medicine (ACOEM) and the Washington State Agency Medical Directors’ Group (WSAMDG) include recommendations related to management of acute, subacute, postoperative, and chronic pain.^16,17 The guideline by the American College of Emergency Physicians (ACEP) focuses on management of acute pain in the ED setting,¹⁸ and the guideline by the National Institute for Health and Care Excellence (NICE) focuses on safe opioid management for any indication/setting.¹⁹ Almost all of the studies upon which the recommendations were based occurred in the outpatient setting. Only the guidelines by NICE¹⁹ and WSAMDG¹⁷ made recommendations related to prescribing in the hospital setting specifically (these recommendations are noted in Table 2 footnotes), often in the context of opioid prescribing in the postoperative setting, which, although not a focus of our systematic review, included relevant safe prescribing practices during hospitalization and at the time of hospital discharge.

Guideline Quality Assessment

See Table 1 for the AGREE II scaled domain scores, and Appendix Table 1 for the ratings on each individual item within a domain. The range of scaled scores for each of the AGREE II domains were as follows: Scope and purpose 52%-89%, stakeholder involvement 30%-81%, rigor of development 46%-81%, clarity of presentation 59%-72%, applicability 10%-57%, and editorial independence 42%-78%. Overall guideline assessment scores ranged from 4 to 5.33 on a scale from 1 to 7. Three of the guidelines (NICE, ACOEM, and WSAMDG)^16,17,19 were recommended for use without modification by 2 out of 3 guideline appraisers, and one of the guidelines (ACEP)¹⁸ was recommended for use with modification by all 3 appraisers. The guideline by NICE¹⁹ was rated the highest both overall (5.33), and on 4 of the 6 AGREE II domains.

Although the guidelines each included a systematic review of the literature, the NICE¹⁹ and WSAMDG¹⁷ guidelines did not include the strength of recommendations or provide clear links between each recommendation and the underlying evidence base. When citations were present, we reviewed them to determine the type of data upon which the recommendations were based and included this information in Table 2. The majority of the recommendations in Table 2 are based on expert opinion alone, or other guidelines.

Guideline Synthesis and Analysis

Table 2 contains a synthesis of the recommendations related to each of our 5 prespecified content areas. Despite the generally low quality of the evidence supporting the recommendations, there were many areas of concordance across guidelines.

Deciding When to Use Opioids, Nonopioid Medications, and Nonmedication-Based Pain Management Modalities

Three out of 4 guidelines recommended restricting opioid use to severe pain or pain that has not responded to nonopioid therapy,^16-18 2 guidelines recommended treating mild to moderate pain with nonopioid medications, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs),^16,17 and 2 guidelines recommended co-prescribing opioids with nonopioid analgesic medications to reduce total opioid requirements and improve pain control.^16,17 Each of these recommendations was supported by at least one randomized controlled trial.

Best Practices in Screening/Monitoring/Education to Occur Prior to Prescribing an Opioid and/or During Treatment

Three guidelines recommended checking prescription drug monitoring programs (PDMPs), all based on expert consensus.^16-18 Only the WSAMDG guideline offered guidance as to the optimal timing to check the PDMP in this setting, specifically recommending to check before prescribing opioids.¹⁷ Two guidelines also recommended helping patients set reasonable expectations about their recovery and educating patients about the risks/side effects of opioid therapy, all based on expert consensus or other guidelines.^17,19