Table 2.
Recommendations from guidelines, their level of evidence and their strength
| Author (Sponsor), year, country | Population | Recommendations | Level of evidence |
|---|---|---|---|
| System-Based | |||
| Edwards (ASER, POQI), 2019, USA [117] | Patients on preoperative opioids | Patients should be assessed for risk factors for persistent opioid use prior to the initiation of opioid therapy and during therapy to develop and coordinate the pain treatment plan with the health care team. | Recommended (GRADE) |
| Kent (ASER, POQI, 2021, USA [115] | Surgery | Suggested | |
| Clarke, 2020, Canada [116] | Surgery | Expert consensus | |
| Trexler, 2020, USA [131] | TBI | ||
| Soffin, 2017, USA [118] | Orthopedic surgery | ||
| Washington State AMDG, 2015, USA [120] | All patients | ||
| The committeee on trauma of the ACS, 2020, USA [126] a | Trauma | No level of evidence | |
| Chou (APS, ASRA, ASA), 2016, USA [48] | Surgery | Clinicians should conduct a preoperative evaluation to guide the intraoperative pain management plan. It should include: assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimens and responses. | Strong recommendation, low-quality evidence |
| Soffin, 2017, USA [118] | Orthopedic surgery | Opioid tolerance should be diagnosed preoperatively. Referral to an addiction specialist should be made in the presence of opioid-tolerance. | Expert consensus |
| Mai, 2015, USA [119] | Musculoskeletal injuries | ||
| Hsu, 2019, USA [46] | Trauma | Doses of prescribed controlled substances should be verified via the relevant state Prescription Drug Monitoring Program (PDMP), or by contacting the original prescriber or dispensing pharmacist. | Strong recommendation, low-level of evidence |
| Soffin, 2017, USA [118] | Orthopedic surgery | Expert consensus | |
| Mai, 2015, USA [119] | Musculoskeletal injuries | ||
| Washington State AMDG, 2015, USA [120] | All patients | ||
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| Chou (APS, ASRA, ASA), 2016, USA [48] | Surgery | Facilities in which surgery is performed should provide clinicians with referral options to a pain specialist for patients with inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain (e.g. opioid-tolerant, history of substance abuse) | Strong recommendation, low-quality evidence |
| Clarke, 2020, Canada [116] | Surgery | Expert consensus | |
| Sodhi, 2020, USA [130] | TJA | ||
| Soffin, 2017, USA [118] | Orthopedic surgery | ||
| Mai, 2015, USA [119] | Musculoskeletal injuries | ||
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | If pain persists beyond 3 months, or if opioid misuse by patient is suspected, the patient should be referred to a transitional/chronic pain clinic or pain management specialist. | No level of evidence |
| The trauma center should provide a pain management service or resources to act as an expert consultant within the trauma service. | |||
| Edwards (ASER, POQI), 2019, USA [117] | Patients on preoperative opioids | The patient’s outpatient opioid prescriber should be identified and be contacted to anticipate discharge needs and to coordinate postoperative opioid tapering. | Recommended (GRADE) |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| Hsu, 2019, USA [46] | Trauma | For patients using illicit opioids, or patients misusing prescription opioids, follow-up should be coordinated with acute pain services (or addiction medicine or psychiatry depending on resources) for inpatients, and with the patient’s prescriber for outpatients, to ensure that there is only 1 prescriber for patients on medication-assisted therapy. | Strong recommendation, moderate-quality evidence |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| Hsu, 2019, USA [46] | Trauma | Prescribers, to the extent possible, should develop and/or support the implementation of a support system to inform clinical decisions regarding opioid prescription in the electronic medical record. | Strong recommendation, low-level of evidence |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| Kent (ASER, POQI), 2021, USA [115] | Surgery | Persistent postoperative opioid use occurs when a patient interacts with numerous health care providers and institutions. Addressing system-based characteristics may be more instrumental in tapering persistent opioid use than clinical decision making. Public health initiatives, policies, and legislation at the local, state, and federal levels aimed at safe opioid prescribing should be evaluated with subsequent recommendations for further improvements that target all health care system components. | Strongly recommended |
| Trexler, 2020, USA [131] | TBI | Expert consensus | |
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | Complex opioid and non-opioid management should be reimbursed with the time and resources required for patient education; safe evaluation; risk assessment; re-evaluation; and integration of alternative and non-opioid modalities. | Expert consensus |
| Pharmacological - Opioid Prescription Practices | |||
| Wainwright (ERAS Society), 2020, UK [132] | TJA | Add opioids only in the setting of suboptimal analgesia after first-line administration of nonopioid options or when the benefits outweigh the risks | Strongly recommend, High level of evidence |
| Edwards (ASER, POQI), 2019, USA [117] | Patients on preoperative opioids | Recommended (GRADE) | |
| Anger (PROSPECT), 2021, USA [127] | TJA | Expert consensus | |
| Trexler, 2020, USA [131] | TBI, | ||
| Franz (DMGP), 2019 Germany [129] | SCI | ||
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | ||
| No level of evidence | |||
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | ||
| Hsu, 2019, USA [46] | Trauma | The prescriber should use the lowest opioid effective dose for the shortest time period possible. | Strongly recommended, high-quality evidence |
| Edwards (ASER, POQI), 2019, USA [117] | Patients on preoperative opioids | Recommended (GRADE) | |
| Trexler, 2020, USA [131] | TBI | Expert consensus | |
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | ||
| Soffin, 2017, USA [118] | Orthopedic surgery | ||
| Washington State AMDG, 2015, USA [120] | All patients | ||
| Edwards (ASER, POQI), 2019, USA [117] | Patients on preoperative opioids | The prescriber should avoid opioid dose escalation. | Recommended (GRADE) |
| Washington State AMDG, 2015, USA [120] | All patients | Expert consensus | |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | Have a protocol for safe de-escalation of analgesics as quickly as possible. | No level of evidence |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | Promptly investigate the cause of increasing pain rather than responding by increasing the analgesic dose or adding new medications | No level of evidence |
| Hsu, 2019, USA [46] | Trauma | Prescribe precisely - Commonly written prescriptions with ranges of dose and duration can allow tripling of daily dose to levels consistent with adverse events. | Strongly recommended, low-level evidence |
| Hsu, 2019, USA [46] | Trauma | Avoid long-acting opioids in the acute phase. | Strongly recommended, moderate-quality evidence |
| Trexler, 2020, USA [131] | TBI | Expert consensus | |
| Hsu, 2019, USA [46] | Trauma | Benzodiazepines should not be prescribed in conjunction with opioids because of the significant risks posed by inconsistent sedation and the potential for misuse. | Strongly recommended, high-quality evidence |
| Trexler, 2020, USA [131] | TBI | Expert consensus | |
| Clarke, 2020, Canada [116] | Surgery | Patients should receive a prescription based on their opioid consumption in the hospital during the previous 24 hrs that should be written during the discharge process. | Expert consensus |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | Discharge prescriptions should separate opioids and nonopioid analgesics to make opioid tapering easier. | No level of evidence |
| Washington State AMDG, 2015, USA [120] | All patients | Strongly consider tapering the patient off opioids as the acute pain episode resolves. | Expert consensus |
| Clarke, 2020, Canada [116] | Surgery | The prescription for opioid-containing tablets should have an expiry date of 30 days from the date of discharge | |
| Washington State AMDG, 2015, USA [120] | All patients | A part-fill or prescription refill should be given to patients with an expected moderate or long-term recovery to reduce the number of opioid tablets distributed at one time. | Expert consensus |
| Hsu, 2019, USA [46] | Trauma | The prescription and continued use of opioids should be based on expected functional recovery, pain, opioid use and adverse events. Complete and regular evaluations are therefore necessary. | Strong recommendation, low-quality evidence |
| Chou (APS, ASRA, ASA), 2016, USA [48] | Surgery | ||
| Clarke, 2020, Canada [116] | Surgery | Expert consensus | |
| Trexler, 2020, USA [131] | TBI | ||
| Mai, 2015, USA [119] | Musculoskeletal injuries | ||
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | ||
| Washington State AMDG, 2015, USA [120] | |||
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| Soffin, 2017, USA [118] | Orthopedic surgery | The patient has to be physically present when the initial prescription for a controlled substance is made. No new prescriptions are made or refilled if the patient has not been seen and examined within the prior 30 days. | Expert consensus |
| Clarke, 2020, Canada [116] | Surgery | Patients should be discharged with a prescription for the following adjunct pain medications, unless contraindicated: Acetaminophen, NSAIDS | Expert consensus |
| Fillingham (AAHKS, ASRA, AAOS, Hip society, Knee society), 2020, USA [127] | TJA | ||
| Sodhi, 2020, USA [130] | |||
| Trexler, 2020, USA [131] | TBI | ||
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | ||
| Washington State AMDG, 2015, USA [120] | |||
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| Anger (PROSPECT), 2021, USA [127] | TJA | Postoperative NSAID are recommended for their analgesic and opioid-sparing effect. | High-quality evidence |
| Wainwright (ERAS Society), 2020, UK [132] | TJA | Strong recommadation, moderate – high level of evidence | |
| Fischer (PROSPECT), 2008, UK [124] | TKA | Low level of evidence | |
| Ftouh (NICE), 2011, UK [123] | Hip fracture | NSAID should not be used for pain management after a hip fracture because of their poor risk to benefit ratio | Expert consensus |
| Educational | |||
| Hsu, 2019, USA [47] | Trauma | Health service departments should support opioid education efforts for prescribers and patients. | Strongly recommended, moderate-quality evidence |
| Anger (PROSPECT), 2021, USA [127] | TJA | Patients should be provided education in the pre-operative period. | High-quality evidence |
| Wainwright (ERAS Society), 2020, UK [132] | TJA | Strong recommendation, low level of evidence (GRADE) | |
| Clarke, 2020, Canada [116] | Surgery | Patients should receive written and verbal information prior to discharge on the safe storage and disposal of unused opioids. | Expert consensus |
| Trexler, 2020, USA [131] | TBI | ||
| Hsu, 2019, USA [47] | Surgery |
Clinicians should provide education to all patients and / or family and/or primary caregivers: • On treatment options for pain management, the plan and goals for pain management and the pain treatment plan, including analgesic tapering after hospital discharge. • To fill the prescription only if their pain is not adequately managed with other therapies or if they are having difficulty completing activities of daily living secondary to pain. • On the risks and benefits of alternatives to chronic opioid therapy. |
Strong recommendation, low-quality evidence |
| Clarke, 2020, Canada [116] | Surgery | Expert consensus | |
| Trexler, 2020, USA [131] | TBI | ||
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | ||
| Washington State AMDG, 2015, USA [120] | |||
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | No level of evidence | |
| Chou (APS, ASRA, ASA), 2016, USA [48] | Surgery |
Patients chronically prescribed opioids before surgery should be instructed: • On how to taper opioids to their target maintenance dose • On who will prescribe controlled substances after surgery and discharge from hospital. |
Strong recommendation, low-quality evidence |
| Soffin, 2017, USA [118] | Orthopedic surgery | Expert consensus | |
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | Use apps for biopsychosocial treatments to inform physicians, providers, and patients on evidence-based and effective pain management treatments for various chronic pain syndromes more effectively. | Expert consensus |
| Multimodal | |||
| Chou (APS3, ASRA4, ASA5), 2016, USA [48] | Surgery | Nonopioid therapy should be the first-line of treatment and multimodal analgesia should be used as opposed to opioid monotherapy for pain control. Therapies can be pharmacological or nonpharmacological. | Strong recommendation, high-quality evidence |
| Wainwright (ERAS Society), 2020, UK [132] | TJA | ||
| Hsu, 2019, USA [47] | Trauma | Strong recommendation, moderate-quality evidence | |
| Edwards (ASER, POQI), 2019, USA [117] | Patients on preoperative opioids | Strongly recommended(GRADE) | |
| Galvagno (EAST, TAS), 2016, USA [122] | Blunt thoracic trauma | Conditionally recommended, very-low quality evidence | |
| Wu (ASER), 2019, USA [123] | Surgery | Expert consensus | |
| Wu (ASER), 2019, USA [123] | Surgery | Patients should be discharged home with a comprehensive multimodal analgesia care plan aiming to minimize or avoid post-discharge opioid use. | Expert consensus |
| Chou et al. (APS, ASRA, ASA), 2016, USA [48] | Surgery | Health professionals should consider gabapentin or pregabalin as components of multimodal analgesia. | Strong recommendation, moderate-quality evidence |
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | For neuropathic pain, as first-line therapy, consider anticonvulsants (gabapentin, pregabalin, carbamazepine, oxcarbazepine), SNRIs (duloxetine, venlafaxine), TCAs (nortriptyline, amitriptyline), and topical analgesics (lidocaine, capsaicin). | Expert consensus |
| Washington State AMDG, 2015, USA [120] | |||
| Chou (APS, ASRA, ASA), 2016, USA [48] | Surgery | Health professionals should consider ketamine as a component of multimodal analgesia in adults. | Weak recommendation, moderate-quality evidence |
| Fischer (PROSPECT), 2008, UK [124] | TKA | Cooling and compression techniques should be used for postoperative analgesia, based on limited procedure-specific evidence, for a reduction in pain scores and analgesic use. | Low level of evidence |
| Chou et al. (APS, ASRA, ASA), 2016, USA [48] | Surgery | Health professionals should consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other pain management strategies. | Weak recommendation, moderate-quality evidence |
| Washington State AMDG, 2015, USA [120] | All patients | In addition to medication, therapies should include physical activation and behavioral health interventions (such as cognitive behavioral therapy, mindfulness, coaching, patient education, and self-management). | Expert consensus |
| Hsu et al., 2019, USA [47] | Trauma | Strong recommendation, moderate-quality evidence | |
| U.S. Department of Health ad Human Services (Task Force), 2019, USA [121] | All patients | Consider complementary and integrative health approaches, including acupuncture, mindfulness meditation, movement therapy, art therapy, massage therapy, manipulative therapy, spirituality, yoga, and tai chi, in the treatment of acute and chronic pain, when indicated. | Expert consensus |
| The committee on trauma of the ACS, 2020, USA [126] | Trauma | Nonpharmacologic pain management strategies are recommended as adjuncts for pain and anxiety management in trauma to minimize opioid use and chronic pain development | No level of evidence |
Abbreviations: ACS American College of Surgeons, AMDG Agency Medical Directors’ Group, APS American Pain Society, ASA American Society of Anesthesiologists, ASER American Society for Enhanced Recovery, ASRA American Society of Regional Anesthesia and Pain Medicine, EAST Eastern Association for the Surgery of Trauma, GRADE Grading of Recommendations Assessment, Development, and Evaluation, NICE National Institute for Health and Clinical Excellence, POQI Perioperative Quality Initiative, TAS Trauma anesthesiology society, Task Force Pain Management Best Practices Inter-agency Task Force, TJA Total joint. Arthroplasty, TKA Total knee arthroplasty
aThis source does not describe any method for classifying the level of evidence of recommendations