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 VII. Guideline Work Group Guideline Work Group* Department of Veterans Affairs Jack Rosenberg, MD, FASAM (Co-Chair) Michael O. Chaffman, PharmD, BCPS Karen Drexler, MD Franz Macedo, DO Aram Mardian, MD Anthony J. Mariano, PhD Ilene Robeck, MD Friedhelm Sandbrink, MD Maria Silveira, MD, MA, MPH Nancy Wiedemer, MSN, RN, ANP-BC Office of Quality, Safety and Value Veterans Health Administration Eric Rodgers, PhD, FNP, BC James Sall, PhD, FNP-BC Rene Sutton, BS, HCA Lewin Group Clifford Goodman, PhD Christine Jones, MS, MPH, PMP Erika Beam, MS Anjali Jain, MD Sigma Health Consulting, LLC Frances Murphy, MD, MPH Department of Defense Christopher Spevak, MD, MPH, JD (Co-Chair) Elizabeth Rees Atayde, RN, MSN, FNP, CCM, CPHM MAJ Robert Brutcher, PharmD, PhD Corinne Devlin, MSN, RN, FNP-BC LTC William Grief, MD James Hardin, LCSW-C, MAC Connie Kurihara, RN CDR Marisol Martinez, PharmD Capt Erick C. Messler, PhD LTC Jason Silvernail, DPT, DSc, FAAOMPT CAPT Necia Williams, MD Office of Evidence Based Practice U.S. Army Medical Command Corinne K. B. Devlin, MSN, RN, FNP-BC ECRI Institute Kristen E. D'Anci, PhD Nancy M. Sullivan, BA James Reston, PhD, MPH Mrin Joshi, MS Erin Payne, MS Raj Stewart, PhD Stacey Uhl, MS Allison Gross, MLS Duty First Consulting Anita Ramanathan, BA Megan McGovern, BA *Additional contributor contact information is available in Appendix I. February 2017 Page 38 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain VIII. Discussion of Recommendations A. Initiation and Continuation of Opioids Recommendation 1. a) We recommend against initiation of long-term opioid therapy for chronic pain. (Strong against) b) We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. (Strong for) c) When pharmacologic therapies are used, we recommend non-opioids over opioids. (Strong for) (Reviewed, New-replaced) Discussion As outlined in this CPG, there is a rapidly growing understanding of the significant harms of LOT even at doses lower than 50 mg oral morphine equivalent daily dose [MEDD], including but not limited to overdose and OUD. At the same time there is a lack of high-quality evidence that LOT improves pain, function, and/or quality of life. The literature review conducted for this CPG identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain. Patient values, goals, concerns, and preferences must be factored into clinical decision making on a case-by-case basis. When considering the initiation or continuation of LOT, it is important to consider whether LOT will result in clinically meaningful improvements in function such as readiness to return to work/duty and/or measurable improvement in other areas of function, such that the benefits outweigh the potential harms. While there is currently no evidence in the literature documenting the benefit of LOT that demonstrates improvement in pain and function, we recognize that in a rare subset of individuals a decision to initiate LOT may be considered (e.g., for intermittent severe exacerbations of chronic painful conditions). If a decision is made to initiate LOT, a careful assessment of benefits and risks should be made to ensure that the benefits are expected to outweigh the well-documented risks. In addition, prior to this consideration, a multimodal treatment plan should be integrated into the patient’s care. Once opioid therapy is initiated, all opioid risk mitigation strategies outlined in this guideline (see Recommendation 7) should be put into place. In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the HHS National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly. Psychological therapies (e.g., cognitive behavioral interventions such as Cognitive Behavioral Therapy [CBT], biofeedback) have been found to be effective for pain reduction in multiple pain conditions.[80-82] February 2017 Page 39 of 192
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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