. Author manuscript; available in PMC: 2023 Feb 3.

Published in final edited form as: J Opioid Manag. 2016 May-Jun;12(2):109–118. doi: 10.5055/jom.2016.0322

Table 2.

Summary and GRADE score for studies of system-level opioid prescribing guidelines

Study	Target	Study design	Intervention	Results	Bias	GRADE
Saunders et al. (2015)²⁰	Physicians in Group Health (GH), health plan in Washington State	Prospective cohort	Chronic opioid therapy guidelines instituted with training on opioid prescribing. Control group of in-network physicians not exposed to intervention.	Intervention physicians decreased the daily MED by 35 percent (74.1–48.3 mg) over the study period. In contrast, the control group of network physicians fell 14 percent (88.2–75.7 mg).	Did not adjust for physician characteristics or patient characteristics.	Moderate
Westanmo et al. (2015)²¹	VA Health System (one hospital and 11 clinics), Minnesota	Time series	Opioid Safety Initiative: guidelines to decrease high dose opioid prescriptions. Involved provider education and detailing.	Total number of patients on >200 mg/d MED decreased from 342 (0.67 percent) to 65 (0.12 percent); mean dose among those who received an opioid decreased from 43 to 23 mg MED daily (−47 percent).	Did not adjust for physician characteristics or patient characteristics. Patients could have left the VA health system.	Moderate
Holman et al. (2014)²²	Orthopedic patients in Utah	Prospective cohort	Perioperative counseling and opioids prescribed for a maximum of 6 weeks post-op.	Patients in the intervention group were more likely to stop using opioids by week 6 compared with the control group (RR = 0.74 (95% CI 0.58–0.93)). However, there was no difference in opioid use past 12 weeks (RR = 0.98 (0.71–1.35)).	Treatment assigned based on one of two surgeons; the surgeon is a major source of confounding. Patients in the control group tended to be slightly older, with a lower proportion of women. Preoperative opioid use not measured.	Very low
Fox et al. (2013)⁹	Emergency physicians treating patients with dental pain	Retrospective chart review	Emergency department opioid prescribing guidelines	Opioid prescribing for patients with dental pain decreased by 17 percent (95% CI: 7–25 percent) after the policy.	Abstractors not blinded to study aims. No adjustment for physician or patient characteristics. Only 16 physicians in the practice.	Low
Naliboff et al. (2011)²³	Pain clinic at a VA hospital in California	RCT	Compared liberal (dose escalation) and conservative opioid (stable dosing) prescribing guidelines for treatment of chronic pain.	No difference in prevalence of misuse the stable dose (22/67 (33 percent)) and the escalating dose group (16/62 (26 percent)) of the escalating dose group. The opioid dose in the escalating group increased 80 percent compared to 16 percent in the stable group. No difference in functional outcomes.	Loss to follow-up.	Moderate

GRADE, Grading of Recommendations Assessment, Development and Evaluation rating of evidence; VA, veterans affairs; MED, morphine equivalent dose; mg, milligrams; CI, confidence interval; RR, relative risk.