Objectives To describe how the development of a clinical practice guideline on the management of chronic pain (including back pain, osteoarthritis, and neuropathic pain) can potentially lead to better pain control with fewer medications.
Methods Based on the needs of family physicians, the guideline emphasized use of best available evidence and shared decision making. A guideline panel (10 health professionals and a patient representative) with no financial conflicts of interest identified key clinical questions and later created practice recommendations based on evidence review. Systematic reviews of randomized, controlled trials (RCTs) were performed by an experienced evidence team. RCTs were included if they reported a responder analysis (ie. how many patients had a meaningful reduction in pain). Additional rapid reviews were completed to answer supplemental questions. GRADE methodology was used in evidence review and recommendation creation, and the guideline was reviewed by clinicians and patients.
Results Three published comprehensive reviews including 35 systematic reviews (285 randomized, controlled trials) of individual treatments for osteoarthritis, chronic low back and neuropathic pain were completed. Based on evidence review, treatments were divided into those with clear evidence of benefit, those with unclear benefit, those with no evidence of benefit, and those where the potential harms likely outweigh the benefits. Absolute benefits and risks were presented in knowledge translation tools and decision aids to encourage shared decision making with patients. Due to the nature of chronic pain, treatments were not aligned in a stepwise hierarchy to prevent eventual treatment with opioids or other potentially harmful treatments; rather, they are presented in a way that allows dialogue between patients and providers regarding various options. Physical activity is recommended as the foundation for treating osteoarthritis and low back pain. Cognitive-behavioural therapy or mindfulness-based stress reduction are also potential non-drug options. Opioids and cannabinoids are examples of treatments where the potential harms likely outweigh the benefits for most conditions studied. Patient resources for understanding chronic pain and increasing physical activity were also identified and shared.
Conclusions This guideline, utilizing the best available evidence, highlights the role of effective non-drug options for managing chronic pain in primary care, and minimizes the role of treatments where the potential harms likely exceed the benefits. The provision of absolute benefits and risks of various treatments allows the principles of shared decision making to be used throughout the treatment process. More research is needed on the management of patients with complex chronic pain.
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