The U.S. Department of Defense (DoD) and the Department of Veterans Affairs (VA) have strengthened a recommendation against the use of opioids for chronic pain that was first made public in 2017.
The agencies’ updated clinical practice recommendation continues to advise against the use of opioids to treat patients with short-term, acute pain and against the use of long-acting opioids to treat patients with chronic non-cancer pain, especially in younger patients.
Millions of military personnel, veterans, and their families might be impacted by the VA/DoD recommendation. Over 800,000 Americans are National Guard and Reserve members, making up nearly 1.5 million total military personnel. Another 6 million veterans and their families receive health services from the Veterans Administration.
The amended recommendation was secretly made public in May 2022, but it has only recently come to light thanks to a generally positive review that was published in the Annals of Internal Medicine.
In comparison to the 2017 advice against starting long-term opioid therapy, the updated advice against opioid therapy in general for chronic pain is more comprehensive and takes into account the mounting evidence that opioid therapy of any length may be hazardous.
The guideline development group maintained that the possibility of catastrophic opioid harms 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, despite finding some evidence for a small improvement in musculoskeletal and noncancer neuropathic pain.
POTENTIALLY TRANSFORMATIVE FOR AMERICAN HEALTHCARE
There are 20 recommendations in the updated opioid guideline, nine of which are supported by scant or conflicting data. Contrary to the CDC opioid guideline that was recently changed, there were no public hearings or chances for the public to voice their opinions or offer suggestions. No mention of dosage thresholds or morphine milligram equivalents (MME) is made either, which may indicate that the authors think any dose of opioids is potentially dangerous.
The new VA/DoD guideline includes three additional recommendations: buprenorphine use for pain relief, mental health assessments, and tapering opioid use.
For patients who require full agonist opioids daily for chronic pain, the recommendation recommends physicians think about using buprenorphine instead of such drugs. The VA/DoD thinks buprenorphine as a partial agonist offers less risk for overdose and misuse and is less likely to generate euphoria, even if the quality of the evidence for this recommendation was rated “insufficient.”
FDA-approved for pain relief when used alone, buprenorphine is a Schedule III opioid. When paired with naloxone in medications like Suboxone, buprenorphine is additionally used to treat opioid use disorder. Buprenorphine’s “X-Waiver” program was recently terminated by the DEA, which is anticipated to result in a major rise in the number of patients and physicians who prescribe it.
The recommendation to use buprenorphine for pain was referred to in an editorial in the Annals of Internal Medicine as “potentially transformational” and “likely to grow throughout the wider U.S. healthcare system.”
The latest VA/DoD policy, according to co-authors Chinazo Cunningham, MD, and Joanna Starrels, MD, both of Albert Einstein College of Medicine, “is both conservative and radical.” Although the VA/DoD guideline advises prescribing buprenorphine for chronic pain if daily opioids are prescribed, the advice itself is likely to alter the choice of whether to administer opioids.
The VA/DoD guideline determined there is “insufficient evidence to recommend for or against any specific tapering strategy,” despite the fact that numerous recent studies have revealed that opioid tapering greatly increases the risk of an overdose, withdrawal, or mental health crisis. It simply suggests that patients and doctors “collaborate” on lowering opioid dosages and that tapering should not be compelled.
According to the recommendations, “the potential advantages of opioid tapering outweighed the possible hazards of opioid withdrawal.”
The recommendation is that patients’ mental health should be assessed for suicidal ideation, depression, anxiety, and psychotic illnesses before opioids are provided for either acute or chronic pain. Although some patients may object to being evaluated for mental health issues, the recommendation states that “it is better for doctors to know about underlying behavioral health comorbidities than to commence long-term opioids without this clinical knowledge.”
The updated suggestion reiterates earlier advice to avoid prescribing benzodiazepines together with opioids and to routinely test patients receiving long-term opioid therapy for drugs of abuse “to reduce the risk of self-directed violence.”
In recent years, as it has for the general community, the prescribing of opioids to veterans, family members, and active service personnel has drastically decreased. Without even a trace of irony, the updated VA/DoD guideline indicates that lower prescription rates have caused veterans to take more illegal opioids and more frequently overdose.