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

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]
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