McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

11. National Advisory Panel (NAP) Consultation

11.1 Need for the National Advisory Panel

The available evidence on safe and effective use of opioids for managing CNCP was necessary but not sufficient to create practical clinical guidance. Clinical expertise was also required. In response to this need, NOUGG created a process to capture expert opinion through consultation with a variety of experts and stakeholders. NOUGG’s intent was to create a well-balanced advisory panel so that multiple perspectives and experience were included in feedback for the developing guideline. Participation and selection requirements included:

  • Representation from:
    • across Canada
    • the target audience (family physicians and other physicians who manage CNCP)
    • other healthcare providers who work with physicians in using opioids to manage CNCP (e.g., pharmacists, nurses, psychologists)
    • patients with CNCP
  • Specific relevant expertise: clinical focus in pain and/or addictions, research, or teaching in pain and/or addictions

11.2 Establishing NAP

MRAs participating in NOUGG invited potential participants from their jurisdiction (see Appendix A-6 for selection criteria).The College of Physicians & Surgeons of Alberta (CPSA), on behalf of NOUGG, coordinated NAP activities. A total of 49 individuals agreed to participate on the Panel. All NAP members returned a signed conflict of interest disclosure to CPSA. (See Appendix A-7 for a copy of the form, and Appendix A-3 for NAP members and their declared competing interests.)

11.3 NAP Consultation Process

Throughout the initiative, NOUGG’s process for NAP consultation was transparent. Before the consultation started, all NAP members received background information describing the NOUGG initiative, the rationale for MRA’s involvement, the approach for guideline development, the role of the panel, and NOUGG’s intent to pursue implementation strategies that included knowledge transfer and evaluation.

For the consultation process details, see Table A-11.3.

Table A-11.3 NAP Consultation Tasks and Outcomes

  Material Provided to NAP NAP Task Outcomes

First Consultation

Oct 2008

Background, methods, evidence summary from RCTs and references.

Task: Respond to the following questions:

  1. What questions do you have after reviewing the enclosed document with background and context for the draft guideline?
  2. What clarifications would be helpful in the document?
  3. Are there any references missing that should have been considered for Section A of Guideline?

75% of Panel members (37 individuals) responded.

  • Constructive comments on how to improve description of methods.
  • Suggestions of other relevant literature.
  • CPSA summarized all NAP feedback for submission to the Research Group (Note: NAP responders not identified).

Modified Delphi Round 1

Mar 2009

49 draft practice recommendations with discussion notes and evidence summaries.

Modified Delphi Process was used. See Appendix A-8.

Task: using an electronic survey tool:

  • Rate opinion on clarity, feasibility and agreement for each of 49 recommendations (See Appendix A-9 for detail)
  • Provide narrative feedback.

84% of Panel members (41 individuals) responded.

  • 29/49 recommendations supported by consensus.
  • 20/49 recommendations unsupported.
  • Qualitative analysis of narrative feedback organized into specific themes and used to revise unsupported recommendations.

Modified Delphi R2

June 2009

  • Individual responses and NAP aggregate response from Round 1.
  • For each of the 211 revised recommendations:
    • Original recommendation
    • Revised recommendation
    • NAP feedback from Round 1 , organized into themes.

Task: using an electronic survey tool:

  • Rate opinion on clarity, feasibility and agreement for 21 revised recommendations
  • Provide narrative feedback

80% of Panel members (402 individuals) responded.

  • 9/21 recommendations supported by consensus
  • 12/21 recommendations unsupported.
  • Three grade C-only recommendations eliminated.
  • Narrative feedback organized in themes and used to revise (some merged) unsupported recommendations for NAP Modified Delphi Round 3.

Modified Delphi R3 Nov 2009

  • Substantively revised Guideline including:
    • 20 supported recommendations
    • 4 recommendations that required voting
  • NAP feedback from Round 2, organized into themes.

Task: using an electronic survey tool:

  • Rate opinion on clarity, feasibility and agreement for 4 revised recommendations
  • Provide narrative feedback.

65% of Panel members (32 individuals) responded.

  • 2/4 recommendations supported by consensus.
  • 2/4 recommendations unsupported.
  • Narrative feedback organized in themes and used to revise 2 unsupported recommendations for NAP Modified Delphi Round 4.

Modified Delphi R4 Dec 2009

  • 2 recommendations that required voting
  • NAP feedback from Round 2, organized into themes.

Task:

  • Participate in a real time virtual meeting to address topics/issues identified by NAP members.
  • Agree on core concepts for Guideline.
  • Final 2 recommendations approved.

60% of Panel members (29 individuals) responded.

  • 2/2 recommendations supported by consensus.

1 One of the 20 unsupported recommendations from previous round had been split into 2 recommendations.

2 Includes one partially completed response.

11.4 Overview: Revising with NAP Input

NAP input included quantitative and qualitative data.

  • Quantitative data, i.e., the scoring of degree of support for a given recommendation, was used to identify recommendations targeted for revision.
  • Qualitative data, i.e., narrative comment from NAP members, guided the evolution of the recommendations at both macro and micro levels. At the macro level, dominant themes in NAP feedback influenced revisions. See Table A-11.4 for a summary of themes and resulting modifications.

11.4.1 NAP Feedback at the Macro Level

Table A-11.4 NAP-Response Dominant Themes and Modifications

No. Dominant Theme Canadian Guideline Modification

1

Background/Methods section too long; methods section confusing, grading system not clear.

  • Part A streamlined; Methods section revised with more detailed information moved to Appendix
  • Grading system and insertion of grades in recommendation statements clarified

2

Guideline lacks a clear opening, stating purpose and fundamental position on opioids and pain.

  • Executive summary written

3

Guideline too long; too many recommendations: redundancy and overlap.

  • 49 recommendations reduced to 24
  • 8 clusters reduced to 5

4

Guideline too "universal," i.e., too often directed physicians toward actions that "should" or "must" always be followed:

  • This creates an unnecessary burden, especially on family physicians, making them even less likely to use opioids for CNCP – this runs contrary to Guideline goal of increasing prescriber comfort and confidence in using opioids for this population.
  • In some cases the "universal" approach assumed access to resources inaccessible across the country.
  • Recommendations modified to provide latitude for prescriber judgment
  • More "how to" guidance provided without the indication of "must" or "should", e.g., urine drug screening, use of screening tools, use if treatment agreements, seeking consultation, selecting opioids

5

Guideline too "addiction-focused;" concern that it included recommendations more appropriate in an addiction guideline than a CNCP guideline.

  • More focus on preventing misuse and  screening for risk
  • Addiction management recommendations merged into a single recommendation that provides information about treatment options. (See Recommendation 21, Part B.)

6

  • Confusing and inappropriate use of terminology, e.g., dependence and addiction
  • Glossary and appendices need greater clarity
  • Terms clarified and used consistently
  • Glossary clarified with the majority of definitions referenced
  • Appendices culled
  • Professional editor engaged

11.4.2 NAP Feedback at the Micro Level

Panelist’s comments were organized into themes, preserving the comments in their entirety. Strong themes were incorporated into recommendation revisions, and individual suggestions were used where possible to add useful detail and clarity.

In a few cases the Panel’s comments were polarized. This was observed most often where there was a lack of evidence and the recommendation was advocating a specific approach. Modifications were made in these cases to reflect the range of clinical opinion. This is illustrated in the urine drug screening recommendation (Recommendation 3) that carries forward the opposing views and provides the prescriber with decision-making options.