VA/DoD Guideline for the Management of Chronic Pain With Opioids

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      Copied from: PainMedicine News

      APRIL 4, 2023

      VA/DoD Guideline for the Management of Chronic Pain With Opioids

      The Department of Veterans Affairs and Department of Defense have updated a 2017 clinical practice guideline for the use of opioids in the management of chronic pain. The 2022 VA/DoD Clinical Practice Guideline provides new and revised recommendations on initiation, dosage, duration and risk mitigation for opioid therapy, specifically including preference of buprenorphine over full agonist opioids, mental and behavioral health screenings, and patient preoperative opioid and pain management education (Ann Intern Med March 2023. doi:10.7326/M22-2917).

      The VA/DoD Evidence-Based Practice Guideline Work Group

      “Overall, the VA/DoD guideline is well aligned with the recommendations by the clinical practice guideline for opioid therapy published by the CDC. There are several recommendations in the VA/DoD guideline worth highlighting. We recommend assessing for behavioral health conditions, pain catastrophizing and risk of suicide and self-directed violence, as these indicate increased potential for suboptimal outcomes including higher risk of harm,” Jennifer Murphy, MD, the VA’s director of pain management, in Washington, D.C., told Pain Medicine News. “Perhaps the most noteworthy [addition to the guideline] suggests the use of buprenorphine for patients receiving daily opioids instead of full agonist opioids due to lower risk of overdose and misuse. Of note, while the guideline recommends against initiating opioid therapy for the management of chronic pain, the authors emphasize that for patients already on opioids, any opioid tapering (if clinically indicated) should be done with a collaborative, patient-centered approach,” added Friedhelm Sandbrink, MD, the VA’s executive director of Pain Management, Opioid Safety and Prescription Drug Monitoring Program.

      Twenty recommendations were made for care using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. The multidisciplinary team also developed three one-page algorithms to assist clinical decision making.

      “We don’t cherry-pick the evidence,” guideline investigator James Sall, PhD, the director of Evidence-Based Practice in the Office of Quality and Patient Safety at the VA, told Pain Medicine News. “We set up a standard inclusion and exclusion criteria, and we look at all evidence that meets those criteria.”

      Opioid Initiation and Continuation

      For the management of chronic noncancer pain, the guideline development group recommended against the initiation of opioid therapy. In 2017, the team recommended against the initiation of “long-term” opioid therapy. The updated recommendation reflects the evidence researchers found showing any duration of opioid therapy may be harmful.

      Included in that evidence was a systematic review that included more than 26,000 patients from 96 randomized controlled trials (JAMA 2018;320[23]:2448-2460). Researchers found that opioids provided small and not clinically significant improvements in pain and physcial functioning compared with nonopioid controls. Patients receiving opioids also had an increased risk for vomiting compared with placebo (5.9% with opioids vs. 2.3% with placebo for trials that excluded patients with adverse events during a run-in period).

      The researchers stated comparisons of opioids with nonopioid alternatives suggested the benefit may be similar, such as nonsteroidal anti-inflammatory drugs, tricyclic antidepressants and anticonvulsants.

      Two other studies also revealed that treatment with an opioid was associated with only small improvements for patients with noncancer neuropathic pain (Eur J Pain 2020;24[1]:3-18; Cochrane Database Syst Rev 2016;10[10]:CD011605).

      The guideline team stated, as with all clinical decisions, the limited relief and small improvement in function must be weighed against the known risks associated with opioids.

      In another cited study, researchers found a greater risk for death by suicide among patients receiving higher doses of opioids (Pain 2016;157[5]:1079-1084). They suggested treatment providers view high opioid dose as an elevated risk for suicide marker.

      The guideline team decided the “potential for catastrophic harms of opioids and serious adverse events, especially with long-term use, outweighed any potential benefits of temporarily improved pain severity and functional status in patients with chronic pain.”

      However, the team also recognized that there may be instances, after clinical assessment, where long-term opioid therapy may be appropriate. For these patients receiving daily opioids, it suggests the use of buprenorphine is now recommended instead of full mu-opioid receptor agonist opioids due to a lower risk for overdose and misuse (J Clin Oncol 2019;37[20]:1742-1752).

      “Due to the pharmacologic properties of buprenorphine, it is a safer medication than full agonist opioids with similar analgesic efficacy. In particular, it has lower risk for respiratory depression and fatal overdose,” Sandbrink said. “Additionally, buprenorphine is less likely to cause euphoriant effects. Nevertheless, buprenorphine is an opioid and therefore still needs to be used with similar caution as all other opioids. In addition, since buprenorphine is also used to treat opioid use disorder (OUD), when using, providers should clarify whether the focus of treatment is pain management, OUD or both.”

      “Buprenorphine is safer, buprenorphine works, but it is a long-acting opioid. There are risks to long-acting opioids, and a long-acting opioid is not appropriate for everyone,” Steven P. Cohen, MD, a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, in Baltimore, told Pain Medicine News. “Someone who has just occasional pain when they go out and they do heavy activities shouldn’t be on a long-acting opioid.”

      Dosing, Duration and Tapering

      When prescribing an opioid, the guideline development group recommended healthcare providers use the lowest dose possible based on patient-specific risks and benefits, consistent with the 2017 guideline.

      The guideline team found the risk for prescription opioid overdose and overdose death existed even at low opioid dosage levels and increased in correlation with dosage. They also found a dose-related risk for OUD. The group reported patients receiving 20 morphine milligram equivalents (MMEs) to 50 MMEs had a lower risk for developing OUD compared with those taking more than 200 MMEs (Pain Med 2014;15[11]:1911-1929).

      The guideline team also stated the initiation of opioids in opioid-naive patients and opioid dose escalation in long-term opioid patients are associated with misuse, OUD development and overdose. Also consistent with the 2017 guideline, the team recommended clinicians prescribe opioids for the shortest duration possible.

      Follow-up is critical if the decision is made to initiate opioid therapy, the guideline team stated. Reevaluation at 30 days or less after initiating opioid therapy and frequent follow-up visits if opioids are continued are still recommended.

      When deciding to taper or discontinue opioid treatment, the team found current evidence still supports use of a collaborative, patient-centered approach, although they did not find evidence for or against any specific strategies for tapering.

      Screening and Evaluation

      Consistent with the 2017 guideline, the guideline team recommended assessing patients’ risk for suicidal ideation and self-harm when starting, continuing, changing or stopping long-term opioid therapy. Those who may be at an elevated risk for self-harm include individuals with psychotic disorders, mood disorders, pain disorders, headache, pain, neuropathy or a cancer diagnosis. The team also noted veterans on long-term opioids for chronic noncancer pain are more likely to die by suicide (Pain 2016;157[5]:1079-1084).

      They also stated the risk for adverse events increased with both the escalation of opioid dose and the discontinuation of an opioid prescription.

      Updates to the screening recommendations include screening for additional mental health conditions that may increase risk in chronic pain patients when contemplating long-term opioid therapy. The guideline team recommends screening for behavioral health conditions, history of traumatic brain injury and psychological factors (i.e., negative affect, pain catastrophizing). They said these conditions are associated with a higher risk for harm (Drug Alcohol Depend 2021;221:108601).

      Due to lack of evidence supporting periodic reevaluation of patients at specific intervals when prescribed an opioid, the team recommend ongoing reevaluation of the benefits and consequences of continuing opioid therapy based on the patient’s risk profile. As a starting point, they encouraged clinicians to abide by the CDC guidance of reevaluation every 90 days; however, some patients may need reevaluation more frequently.

      The guideline team also reported that evidence supporting specific risk mitigation strategies to improve outcomes is lacking: informed consent, risk assessment instruments, pill counts, misuse of deterrent formulations, diversion prevention interventions, pharmacogenetic testing, random callbacks, monitoring for aberrant or high-risk behaviors, or concomitant naloxone prescriptions to improve outcomes.

      Therefore, they removed checking prescription drug monitoring programs, prescribing naloxone rescue and accompanying education from the recommendation list; however, these continue to be the standard of care for long-term opioid therapy for the VA and DOD healthcare systems. The guideline team maintained urine drug testing for patients receiving long-term opioids decreased the risk for self-harm (J Gen Intern Med 2015;30:979-991).

      The team also found, based on data from a randomized controlled trial, that preoperative pain management and opioid education reduced the number of opioid refills and use in the short term and over a two-year follow-up (J Shoulder Elbow Surg 2020;29:1743-1750). They recommended patients receive preoperative opioid and pain management education to reduce the risk for prolonged opioid use for postsurgical pain, as the benefits are often small and outweighed by the potential risks.

      Commonplace Pain

      Healthcare providers can further reduce the risk by following the updated screening and evaluation recommendations.

      “One of my mentors when I started this used to say, ‘Jim, if it weren’t for evidence, we’d still be bleeding people to treat diseases.’ And while that’s a kind of a wild statement, it’s true; we would. We can’t advance healthcare if we’re not looking at the research and merging that with clinical practice,” Sall said.

      The guideline team stated further research is needed to fill in the recommendations where the evidence was lacking—including risk mitigation strategies.

      “We have to make sure clinicians understand that these aren’t mandates for care; these are recommendations based on evidence,” Sall added. “And so, there are a lot of reasons why you might not implement a particular recommendation with a patient. It may be their assessment says that that’s not the right thing to do, or it might be that the patient says, ‘I don’t want to do that.’”

      —Landon Gray

      TPC Community Moderator

      “The views or opinion(s) contained herein do not necessarily represent those of The Pain Community.”

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