Thursday, February 16, 2023

VA, DoD Recommend Buprenorphine Over Full Agonist Opioids for Chronic Pain

In their most recent guideline on the use of opioids to manage chronic pain, the U.S. departments of Veterans Affairs (VA) and Defense (DoD) recommend against using full agonist opioids (for example, morphine) for patients who require daily pain management. Rather, the guideline, which was approved in May 2022, recommends using buprenorphine for patients who require long-term opioid therapy. The guideline was summarized in a report published this week in the Annals of Internal Medicine.

“Chronic pain is common in the United States and continues to burden individuals, families, and society,” wrote Friedhelm Sandbrink, M.D., a member of the VA/DoD Guideline Development Group, and colleagues. “The benefits that opioids can provide are small and are outweighed by the risks to the patient.”

The VA/DoD Guideline Development Group was assembled by the VA/DoD Evidence-Based Practice Work Group in December 2020 to update the clinical practice guideline for opioid therapy for chronic pain, which was last updated in 2017. The guideline is updated every five years or more frequently as new evidence emerges. The VA and DoD define chronic pain as persistent and recurrent pain lasting longer than 90 days, and opioid therapy is considered long term when it continues longer than three months.

Compared with the 2017 recommendation against initiation of long-term opioid therapy, the 2022 guideline makes a broader recommendation against using opioid therapy in general. This update “reflects the evidence that opioid therapy for any duration may be harmful,” Sandbrink and colleagues wrote. For those patients with chronic pain for whom long-term opioid therapy may be appropriate based on a clinical assessment, the 2022 guideline recommends using buprenorphine. This is due to buprenorphine’s lower risk for overdose and misuse compared with full agonist opioids, as well as buprenorphine’s superior safety profile, the authors noted. The 2022 guideline is consistent with the 2017 guideline in recommending that professionals use the lowest dose possible when prescribing an opioid. Further, the guideline recommends reevaluating patients at 30 days or less after initiating opioid therapy, followed by frequent follow-up visits when opioids are continued.

The updated guideline also makes several new recommendations for behavioral health assessments in all patients. It recommends screening for mental health conditions, history of traumatic brain injury, and psychological factors (such as pain catastrophizing) when considering long-term opioid therapy, as these conditions are associated with a higher risk for harm. In concurrence with the 2017 guideline, the 2022 guideline also recommends assessing patients for suicide risk and self-directed violence when initiating, continuing, changing, or discontinuing long-term opioid therapy.

“These recommendations are an important update in the changing and challenging landscape that clinicians and patients navigate to address chronic pain in the context of the worsening overdose epidemic,” wrote Chinazo Cunningham, M.D., M.S., and Joanna Starrels, M.D., M.S., of Albert Einstein College of Medicine in an accompanying editorial.

“[T]he most potentially transformative VA/DoD recommendation is to prescribe buprenorphine instead of full opioid agonists for patients who are receiving daily opioids for treatment of chronic pain,” Cunningham and Starrels continued. “This recommendation is exciting, but underdeveloped, and many questions about implementation remain.”

For related information, see the Psychiatric News article “CDC Issues New Opioid Prescribing Guideline.”

(Image: iStock/AlexanderFord)

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