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Chou R, Hartung D, Turner J, et al. Opioid Treatments for Chronic Pain [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Apr. (Comparative Effectiveness Review, No. 229.)
Table B-1PICOTS
| Key Question | Population | Intervention | Comparator | Outcome |
|---|---|---|---|---|
| 1a, 1b | Adults (age ≥18 years) with various types of chronic pain including pregnant/breast-feeding women and patients treated with opioids for opioid use disorder 1b subgroups: (1) the specific type or cause of pain (e.g., neuropathic, musculoskeletal [including low back pain], fibromyalgia, sickle cell disease, inflammatory pain, and headache disorders); (2) patient demographics (e.g., age, race, ethnicity, gender); (3) patient comorbidities (including past or current alcohol or substance use disorders, mental health disorders, medical comorbidities and high risk for opioid use disorder) | Long- or short-acting opioids (including partial agonists and dual mechanism agents) Exclude: Intravenous or intramuscular administration of opioids | Placebo or no opioid therapy | Pain, function, and quality of life |
| 1c | Adults (age ≥18 years) with various types of chronic pain | Long- or short-acting opioids (including partial agonists and dual action medications) Exclude: Intravenous or intramuscular administration of opioids | Nonopioid therapies (pharmacologic [antiepileptic drugs, benzodiazepines, nonsteroidal antiinflammatory drugs, skeletal muscle relaxants, serotonin norepinephrine reuptake inhibitors, topical lidocaine, topical capsaicin, topical diclofenac, tricyclica antidepressants, acetaminophen, memantine, and cannabis] or nonpharmacologic [noninvasive]) | Pain, function, and quality of life; doses of opioids used |
| 1d | Adults (age ≥18 years) with various types of chronic pain | Opioids plus nonopioid interventions (pharmacologic or nonpharmacologic) Exclude: Intravenous or intramuscular administration of opioids | Opioids or nonopioid interventions alone, including cannabis | Pain, function, and quality of life, doses of opioids used |
| 2a, 2b | Adults (age ≥18 years) with various types of chronic pain 2b subgroups: (1) the specific type or cause of pain (e.g., neuropathic, musculoskeletal [including back pain], fibromyalgia, sickle cell disease, inflammatory pain, headache disorders); (2) patient demographics; (3) patient comorbidities (including past or current substance use disorder or at high risk for opioid use disorder); (4) the dose of opioids used; (5) the mechanisms of actions of the opioids; and (6) use of sedative hypnotics | Long- or short-acting opioids (including tapentadol, buprenorphine, and tramadol) opioids Exclude: Intravenous or intramuscular administration of opioids | Placebo or no opioid | Substance misuse, substance use disorder and related outcomes, overdose, and other harms |
| 2c | Adults (age ≥18 years) with various types of chronic pain | Long- or short-acting opioids (including partial agonists and dual action medications) Exclude: Intravenous or intramuscular administration of opioids | Nonopioid therapies (pharmacologic [antiepileptic drugs, benzodiazepines, nonsteroidal antiinflammatory drugs, skeletal muscle relaxants, serotonin norepinephrine reuptake inhibitors, topical lidocaine, topical capsaicin, topical diclofenac, tricyclica antidepressants, acetaminophen, memantine, and cannabis] or nonpharmacologic [noninvasive]) | Substance misuse, substance use disorder and related outcomes, overdose, and other harms |
| 2d | Adults (age ≥18 years) with various types of chronic pain | Opioids plus nonopioid interventions (pharmacologic or nonpharmacologic) Exclude: Intravenous or intramuscular administration of opioids | Opioids or nonopioid interventions alone, including cannabis | Substance misuse, substance use disorder and related outcomes, overdose, and other harms |
| 3a | Adults (age ≥18 years) with various types of chronic pain | Long- or short-acting opioids (including tapentadol, buprenorphine, and tramadol) | Other opioids with different dose initiation and titration strategies | Pain, function, and quality of life; doses of opioids used |
| 3b | Adults (age ≥18 years) with various types of chronic pain | Short-acting opioid | Long-acting opioid | Pain, function, and quality of life; risk of misuse, opioid use disorder, overdose and other harms; doses of opioids used |
| 3c | Adults (age ≥18 years) with various types of chronic pain | Long-acting opioid | Other long-acting opioid | Pain, function, and quality of life; risk of misuse, opioid use disorder, and overdose and other harms; doses of opioids used |
| 3d | Adults (age ≥18 years) with various types of chronic pain | Short- and long-acting opioid | Long-acting opioid | Pain, function, and quality of life; risk of misuse, opioid use disorder, overdose and other harms; doses of opioids used |
| 3e | Adults (age ≥18 years) with various types of chronic pain | Scheduled, continuous dosing | As-needed dosing | Pain, function, and quality of life; risk of misuse, opioid use disorder, overdose, and other harms; doses of opioids used |
| 3f | Adults (age ≥18 years) with various types of chronic pain | Opioid dose escalation | Dose maintenance or use of dose thresholds | Pain, function, and quality of life |
| 3g | Adults (age ≥18 years) with various types of chronic pain | Opioid rotation | Maintenance of current opioid therapy | Pain, function, and quality of life; doses of opioids used |
| 3h | Adults (age ≥18 years) with various types of chronic pain and an acute exacerbation | Treatments for acute exacerbations of chronic pain | Other treatments for acute exacerbations of chronic pain | Pain, function, and quality of life |
| 3i | Adults (age ≥18 years) with various types of chronic pain | Decreasing opioid doses or of tapering off opioids | Continuation of opioids | Pain, function, and quality of life; opiate withdrawal and other harms (including overdose, use of illicit opioids, suicidality, and anger/violence) |
| 3j | Adults (age ≥18 years) with various types of chronic pain | Tapering protocols and strategies | Other tapering protocols or strategies | Pain, function, quality of life, likelihood of opioid cessation, opiate withdrawal symptoms and other harms (including overdose, use of illicit opioids, suicidality, and anger/violence) |
| 3k | Adults (age ≥18 years) with various types of chronic pain | Dosage of opioid | Other dose of same opioid | Pain, function, and quality of life; risk of misuse, opioid use disorder, overdose and other harms |
| 4a | Adults (age ≥18 years) with various types of chronic pain | Instruments, genetic/metabolic tests for predicting risk of misuse, opioid use disorder, and overdose | Reference standard for misuse, opioid use disorder, or overdose; or other benchmarks | Measures of diagnostic accuracy |
| 4b | Adults (age ≥18 years) with various types of chronic pain | Use of risk prediction instruments, genetic/metabolic tests | Usual care or other control | Misuse, opioid use disorder, overdose and other harms |
| 4c | Adults (age ≥18 years) with various types of chronic pain | Risk mitigation strategies, including (1) opioid management plans, (2) patient education, (3) urine drug screening, (4) use of prescription drug monitoring program data, (5) use of monitoring instruments, (6) more frequent monitoring intervals, (7) pill counts, (8) use of abuse-deterrent formulations, (9) consultation with mental health providers when mental health conditions are present, (10) avoidance of benzodiazepine co-prescribing and (11) co-prescribing of naloxone | Usual care | Pain, function, quality of life, misuse, opioid use disorder, overdose and other harms (including use of illicit opioids, suicidality, and anger/violence) |
| 4d | Adults (age ≥18 years) with various types of chronic pain and opioid use disorder | Treatment strategies | Other treatment strategies | Pain, function, quality of life, misuse, opioid use disorder, overdose, other harms, pain, function, and quality of life |
- Table B-1, PICOTS - Opioid Treatments for Chronic PainTable B-1, PICOTS - Opioid Treatments for Chronic Pain
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