Augusto Caraceni (MD Professor of Palliative Medicine) and Alessandra Pigni (MD), Palliative Care, Pain Therapy and Rehabilitation, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy, and European Palliative Care Research Center (PRC) Norwegian University of Science and Technology, explain more about the EAPC recommendations on opioids for cancer pain.
Why did we make the recommendations?
As described by Geoffrey Hanks in his lively post (12 July 2012), the EAPC guidelines on opioids are deeply rooted in the history of palliative care, of the EAPC and of the EAPC Research Network and many people contributed to their development in the past, as well as today. (The online version of the recommendations and the supporting papers can be downloaded from the EAPC website).
The opportunity offered by the European Palliative Research Collaborative (EPCRC), established in 2006, was unique in allocating specific resources to the process of critically revising and updating the EAPC guidelines through the enhancement of their quality and refinement of methods. It was also a great way of sharing, across Europe and beyond.
How we made the recommendations
The first step in this revision process was to review existing guidelines, describe their quality and develop a comprehensive list of relevant key points to be the object of the new guidelines. We accomplished the second step with systematic literature reviews on each key point and final guidelines on production. We found that 14 guidelines on cancer pain treatment had been published or updated after 2000. Further guidelines were not considered because they were unavailable electronically (‘Palliative treatment of cancer’ by the Finnish Medical Society) or not in English (Norwegian guidelines ‘Lindring av smerter hos kreftpasienter’, CeVEAS; Italy ‘Morfina orale e altri oppioidi nel dolore oncologico’; French guidelines ‘Féderation Nationale des centres de lutte contre le cancer. Standards, options et recommandations sur les traitements antalgiques médicamenteux des douleurs canceréuses par excès de nociception chez l’adulte, mise à jour’; German guidelines ‘Therapieempfehlung Tumorschmerzen der Arzneimittelkommission der Deutschen Ärzteschaft). The content and quality of these national and international guidelines were assessed and compared with the 20 EAPC recommendations.
Many guidelines included additional subjects not covered by EAPC recommendations; eg indications about when to use adjuvant drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), bisphosphonates, radionuclides and radiotherapy. The comparison of all guidelines led to the formulation of 31 key points and local and steering group members suggested six further statements. A list of 37 key points was submitted to the panel of experts for a Delphi process. Forty international experts were involved and after two Delphi rounds a final list of 30 key points was used to identify the 22 outcomes.
The recommendation development process for each of the 22 identified topics followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system:
Step 1: Systematic literature review development.
Step 2: Evidence synthesis for each important outcome.
Step 3: Development of the recommendation statement.
This process was strictly followed for each of the 22 outcomes, which were assigned to different groups and a number of recognised specialists in the field to ensure interdisciplinary representation. Each of them worked with other researchers in their centres and published an independent systematic review on their topic in the special issue of Palliative Medicine published in July 2011 (Palliative Medicine 2011; 25: 389-605). The final text of the recommendation was written by the Opioid guidelines steering group within the EPCRC project and submitted to all co-authors and to the EAPC board of directors for approval and endorsement.
What does this mean?
If you calculate the number of people involved – from the Delphi study, which reviewed previous guidelines, to developing the individual systematic reviews and publishing them, to presenting and discussing intermediate results at conferences and meetings – you easily reach a number in excess of 100.
Number does not mean quality, but we believe that the independent multiprofessional and multinational community represented by the EAPC has provided added value to the final version of the recommendations. And we hope that the palliative care community, and particularly those reading this post, will feel that their contributions are valued. With this rather emphatic but sincere comment, it is a pleasure to be part of this community and to try to share with you our work, feelings and efforts.