VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain D. Module D: Patients Currently on Opioid Therapy February 2017 Page 14 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain V. Background A. Opioid Epidemic Chronic pain is a national public health problem as outlined in the 2011 study by the National Academy of Medicine (previously the Institute of Medicine [IOM]).[3] At least 100 million Americans suffer from some form of chronic pain. Until recently, the treatment of chronic pain with opioids was increasing at an alarming rate. The increase in prescriptions of these medications has been accompanied by an epidemic of opioid-related adverse events. From 2000 through 2010, the proportion of pain visits during which opioid and non-opioid pharmacologic therapies were prescribed increased from 11.3% to 19.6% and from 26% to 29%, respectively.[4] In 2012, for every 100 persons in the United States (U.S.), 82.5 opioid prescriptions and 37.6 benzodiazepine prescriptions were written by healthcare providers.[5] In the emergency department, at least 17% of discharges included prescriptions for opioids.[6,7] There has been limited research on the effectiveness of LOT for non-end-of-life pain. At the same time, there is mounting evidence of the ill effects of LOT, including increased mortality, OUD, overdose, sexual dysfunction, fractures, myocardial infarction, constipation, and sleep-disordered breathing.[8-10] Despite increasing awareness of the known harms of opioids, 259 million opioid prescriptions were still written in 2012.[11] The increase in opioid prescribing is matched by a parallel increase in morbidity, mortality, opioid-related overdose death rates, and substance use disorders (SUD) treatment admissions from 1999 to 2008.[12,13] In 2009, drug overdose became the leading cause of injury-related death in the U.S., surpassing deaths from traffic accidents.[14] In 2014, 1.9 million Americans were affected by an OUD related to non-medical use of prescription pain relievers,[15] and in the same year, 18,893 individuals died as a result of a prescription drug overdose.[16] There has been a four-fold increase in the absolute number of deaths associated with use of opioids since 2000, and a 14% increase between 2013 and 2014 alone.[17] In a survey of patients prescribed opioids for chronic non-cancer pain (CNCP) and their family members, 34% of patients reported that they thought they were “addicted” or “dependent” on opioid pain medication, 34% said that they used the medication for “fun” or to “get high,” while 22% used the medication to relieve day-to-day stress.[18] Concurrent with the increase in prescription opioid use, the rate of heroin overdose deaths increased nearly four-fold between 2000 and 2013.[19] According to a survey of patients entering SUD treatment for heroin use, the prescription opioid epidemic has resulted in a marked shift in how and which opioids are abused. In the 1960s, 80% of people entering treatment for heroin use started using heroin as their first opioid, while in the 2000s, 75% of people entering treatment for heroin use started using prescription opioids as their first opioid.[20] This increase in the use of opioids, as well as associated morbidity, February 2017 Page 15 of 192
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Appendix D: Drug Tables A. Short-ac
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Short-Acting Opioid Initial Oral Do
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Short-Acting Opioid Initial Oral Do
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Short-Acting Opioid Tramadol (alone
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Long-Acting/ER Opioids 1 Buprenorph
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Long-Acting/ER Opioids 1 Hydrocodon
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Long-Acting/ER Opioids 1 Initial Do
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3 CYP-3A4 inhibiting agents include
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DRAFT 3 - DO NOT DISTRIBUTE VA/DoD
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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