Summary of VA/DoD guidelines for management of chronic pain provides new recommendations on opioid use and mental health evaluations

Abstract: https://www.acpjournals.org/doi/10.7326/M22-2917

Editorial: https://www.acpjournals.org/doi/10.7326/M23-0229

URL goes live when the embargo lifts

In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. These updated guidelines include recommendations about the use of buprenorphine instead of full agonist opioids during chronic pain management. A summary of key recommendations and a related review of published evidence are published in Annals of Internal Medicine.

Chronic pain is common and affects quality of life. Opioid medications have been used for the treatment of pain but can have serious harms from overdose and substance use disorder. Thus, physicians need to be careful about reducing the risk and exposure to prescription opioids while still caring for their patients with chronic pain. The authors summarize the recommendations that have the most clinical impact, including recommendations about the use of buprenorphine, assessing patients for behavioral health conditions, and education related to pain and opioids.

The amount of research on long- and short-term opioid use for pain conditions has grown substantially since the previous recommendations issued in 2017. This updated guideline has important new recommendations for behavioral health assessment in all patients; a recommendation for preoperative opioid and pain management education; and a recommendation to use buprenorphine instead of a full agonist opioid for patients who are receiving daily opioids for chronic pain.

Researchers from ECRI conducted a systematic evidence review that the guideline panel used to develop recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. The guideline group newly recommends the use of buprenorphine instead of full agonist opioid because of a lower risk for overdose and misuse. They recommend screening for additional mental health conditions that potentially increase risk in patients with chronic pain when considering long-term opioid therapy. They additionally recommend assessing for behavioral health conditions, history of traumatic brain injury, and psychological factors because these conditions are associated with higher risk for harm. The guideline group also recommends screening for pain catastrophizing and co-occurring behavioral health conditions to identify those at higher risk for negative outcomes when opioids are being considered in patients with acute pain. Finally, the group recommends providing patients with preoperative opioid and pain management education to reduce the risk for prolonged opioid use for postsurgical pain.

An accompanying editorial by authors from the Albert Einstein College of Medicine highlight that the quality of available evidence for the buprenorphine recommendation is low, and the recommendation lacks clarity in terms of formulation, dosing, and frequency of dosing, along with an unclear target population. They add that the buprenorphine recommendation seems to conflict with other recommendations, including caution against prescribing long-acting opioids in opioid-naive patients. The authors add that, although the field of pain medicine is likely to embrace this new buprenorphine recommendation, more clearly specifying how it should be implemented—and improving and expanding buprenorphine research, along with OUD and buprenorphine education and training—will likely improve the lives of persons with chronic pain.

Media contacts: For an embargoed PDF, please contact Angela Collom at [email protected]. To author of the synopsis, James Sall, PhD, please email [email protected]. To speak with someone from ECRI, please contact Laurie Menyo at [email protected].