Trustworthiness of chronic pain clinical practice guidelines ‘should not be assumed’
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DESTIN, Fla. — Clinical practice guidelines for chronic pain sometimes emerge through flawed processes, present conflicting statements, and warrant close evaluation, according to a speaker at the Congress of Clinical Rheumatology East.
“Clinical practice guidelines on chronic pain, on the same topic, unfortunately, provide conflicting recommendations,” Jason W. Busse, DC, PhD, a professor of anesthesia at McMaster University, in Hamilton, Canada, told attendees. “It’s really unfortunate for you, because you have to sort your way through all of this.
“Trustworthiness of recommendations should not be assumed and should be explored, like any other document,” he added.
In his talk, Busse explored the differences between separate guidelines on the same topic — the use of opioids for chronic noncancer pain — and outlined possible reasons that they do not make the same recommendations.
Differences can arise depending on the use of evidence-based vs. consensus-based methods, with the latter being “twice as likely to make a strong recommendation,” he said. Additionally, consideration of patient values and preferences across clinical practice guidelines is “variable and often inadequate.”
“You can say that you acquired values and preferences, but I think there are stronger ways to do it, and there are less strong ways to do it,” Busse said. “You should have a clear statement that allows readers to understand how it impacted recommendations.”
Another common issue is recommendations being labeled as “strong” with little to back them up, he added.
“‘Strong’ recommendations based on low-certainty evidence are problematic because it gives people a certainty,” Busse said. “‘Strong’ means ‘just do it.’ You better be sure it’s based on strong underpinnings. However, that is not always the case.”
According to Busse, four of the CDC’s “weak” recommendations on chronic pain from 2022, and six from the Department of Defense, were considered to be “strong” by those agencies in 2016. These recommendations were later downgraded because they were “originally made on the basis of low-quality evidence,” he said.
Good guidelines make it easy to find the evidence they were based on, and determine how they were formulated, Busse said.
“The idea of a guideline is it should be very transparent,” he said. “You should be able to look at a recommendation and understand exactly how they came up with that recommendation based on the supporting evidence, values and preferences.”
Busse highlighted a forthcoming digital resource intended to bring clarity to conflicting recommendations. The Chronic Pain Recommendation Map will provide “a synthesis” of the recommendations and offer “insights as to why they differ,” he said.
The project is led by Andrea Darzi, MD, PhD, of McMaster University, and has been funded by a $750,000 grant from the Canadian Institute of Health Research.
“That could be a resource that patients and clinicians could go to,” Busse said. “I hope this is going to get underway soon.”
Reference:
Dr. Andrea Darzi awarded grant to develop e-Chronic Pain RecMap. https://npc.healthsci.mcmaster.ca/dr-andrea-darzi-awarded-grant-to-develop-e-chronic-pain-recmap/. Published Feb. 20, 2024. Accessed May 15, 2024.
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Busse JW. Untangling Clinical Practice Guidelines for Chronic Pain that Provide Discrepant Recommendations. Presented at The Congress of Clinical Rheumatology East; May 9-12, 2024; Destin, Florida (hybrid meeting).
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