Dr. Jason Busse and I are pleased to present a project led by one of our early career researchers at McMaster, Dr Andrea Darzi. Dr Busse and I have appreciated the opportunity to provide a series of articles for Open Access Government on the topic of safe and effective use of opioids for chronic pain
Our goal has been to discuss contributors, and possible solutions, to the opioid crisis in Canada with a focus on issues that affect the provision of best-practice care for chronic pain.
One of the missions of the Michael G. DeGroote Institute for Pain Research and Care [IPRC] is to identify, create, and disseminate best-practice information concerning pain management, especially chronic pain. This is conducted through the National Pain Centre [NPC], which has been the home of the Canadian Opioid Guideline since its initial publication in 2010. Provision of best-practice pain care information is part of the overall strategy for avoiding the tragic outcomes of the opioid crisis in Canada.
Guidelines play an important role in ensuring that medications such as opioids are used appropriately – both when prescribed, if demonstrably effective, and maintained to avoid creating artificial situations of abrupt discontinuation, as well as when not prescribed if they are deemed unnecessary or if the harms outweigh the benefits.
Pain management is not limited to a purely medical model that relies solely on pharmacological interventions; pain is a complex biopsychosocial phenomenon. Therefore, choosing not to prescribe certain medications also requires that patients remain invested in their care and receive support along with alternative treatments. These issues have been discussed in previous articles.
We have endeavoured to ensure that the Canadian Opioid Guideline and other guidelines, including Cannabis for Chronic Pain and Management of Chronic Pain Associated with Temporomandibular Disorders, are based on the best available evidence and patient values and preferences. We acknowledge that other guidelines may reach dramatically different conclusions or make recommendations that differ from those resulting from these processes. These conflicting recommendations, often from well-established sources, create confusion and may result in suboptimal patient care.
One of our faculty members, Dr Andrea Darzi, has recently undertaken a significant project designed to help clinicians, policymakers, and others in understanding and implementing best practice pain care when different guidelines present conflicting recommendations, even though they are ostensibly based on the same information. This project is called the eChronic Pain RecMap – short for Recommendation Mapping. We have invited Dr Darzi to provide a summary of this project for your information and in the hope of fostering ongoing discussion. We trust that this work will contribute to supporting the provision of evidence-based pain care and the creation of policies that will underpin that care. A more detailed account of the actual methodology will be published as the project progresses, but in the meantime, we are very pleased to present Dr Darzi’s summary of the background, rationale, and intent of Recommendation Mapping. We look forward to your feedback.
Addressing inconsistent recommendations for Chronic Pain Management through a Digital Recommendation Map
Chronic pain is a major public health concern that affects 1 in 5 adults and children globally and is associated with physical, emotional, and economic burden (1, 2). Moreover, management of chronic pain is highly variable, and patients often receive interventions that are ineffective or that provide greater harm than benefit (3-7).
Making sense of Chronic Pain Guidelines
Many national and international organizations have developed guidelines to promote evidence-based care for chronic pain, but they vary widely in terms of quality and often provide conflicting recommendations. For example, in 2022, the U.S. Department of Defense and Department of Veterans Affairs strongly recommended against using opioids for chronic pain (8). In contrast, the U.S. Centers for Disease Control and Prevention (CDC) issued a guideline suggesting that doctors consider prescribing opioids if the benefits outweigh the risks, but without clearly defining when this might apply (9).
Conflicting or inconsistent guideline recommendations may arise because of the types of evidence reviewed, the quality of the guidelines, conflicts of interest among guideline developers, and a lack of consideration for patients’ values and preferences (10). Doctors, patients, and health policymakers trying to navigate competing guideline recommendations can find it challenging to determine which ones are trustworthy. Conflicting guidelines can complicate patient decision-making and lead to mistrust in guidelines.
A solution: Recommendation Mapping
Our goal is to develop an open-access digital platform that identifies all guideline recommendations in three high-priority areas: [1] opioids for chronic pain, [2] medical cannabis for chronic pain, and [3] interventional procedures for spine-related chronic pain.
This platform is called a Recommendation Map (RecMap) (11, 12), which offers a practical solution by: [1] organizing and visually mapping guideline recommendations in one place; [2] helping users quickly access and compare recommendations by showing key details like the quality of the evidence, trustworthiness of recommendations, and how they were developed; [3] providing information used to develop recommendations such as evidence on benefits and harms, information on patient values and preferences, cost and feasibility concerns; [4] identifying gaps in current research, [5] providing plain language recommendations to facilitate shared decision- making between people living with chronic pain and their healthcare providers, and [6] providing a platform so other parties can contextualize (adopt or adapt) the available recommendations to their particular context and settings. Also, users can filter recommendations by specific factors such as populations (e.g., age group, medical condition) and interventions (e.g., opioids, cannabis).
Benefits for users
For healthcare professionals and policymakers, the RecMap supports decision-making by making it easier to identify trustworthy recommendations. It also helps guideline developers adapt recommendations for different settings by providing access to the original evidence and allowing them to adjust for jurisdiction-specific factors like cost, the impact on health equity, and feasibility.
For patients and their families, the RecMap makes recommendations more accessible by offering clear, easy-to-understand information that supports shared decision-making with healthcare providers. This tool supports users in making decisions about chronic pain care based on the best available evidence (11, 12).
Transforming chronic pain care
Our aim in developing this digital RecMap is to provide relevant information to different users, explore inconsistent recommendations among chronic pain guidelines, identify the most trustworthy recommendations, and improve the concordance between evidence and practice. This initiative represents a vital step toward empowering knowledge users and improving care for the millions of people living with chronic pain.
References
- Force CPT. An action plan for pain in Canada. 2021. 2022.
- Goldberg DS, McGee SJ. Pain as a global public health priority. BMC public health. 2011;11:1-5.
- Barnett ML, Gray J, Zink A, Jena AB. Coupling policymaking with evaluation—the case of the opioid crisis. New England Journal of Medicine. 2017;377(24):2306-9.
- Buchbinder R, Underwood M, Hartvigsen J, Maher CG. The Lancet Series call to action to reduce low value care for low back pain: an update. Pain. 2020;161:S57-S64.
- Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, et al. Expenditures and health status among adults with back and neck problems. Jama. 2008;299(6):656-64.
- Siemieniuk RA, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. Bmj. 2017;357.
- Vandvik PO, Lähdeoja T, Ardern C, Buchbinder R, Moro J, Brox JI, et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. Bmj. 2019;364.
- Sandbrink F, Murphy JL, Johansson M, Olson JL, Edens E, Clinton-Lont J, et al. The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline. Annals of Internal Medicine. 2023.
- Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1-95.
- Nasir ZH, Mertz D, Nieuwlaat R, Santesso N, Lotfi T, Motilall A, et al. An evaluation of the COVID-19 recommendation map identified diverging clinical and public health guidance. Journal of Clinical Epidemiology. 2022;147:83-94.
- Hajizadeh A, Lotfi T, Falzon D, Mertz D, Nieuwlaat R, Gebreselassie N, et al. Recommendation mapping of the World Health Organization’s guidelines on tuberculosis:
A new approach to digitizing and presenting recommendations. Journal of clinical epidemiology. 2021;134:138-49. - Lotfi T, Stevens A, Akl EA, Falavigna M, Kredo T, Mathew JL, et al. Getting trustworthy guidelines into the hands of decision-makers and supporting their consideration of contextual factors for implementation globally: recommendation mapping of COVID-19 guidelines. Journal of Clinical Epidemiology. 2021;135:182-6.
