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

VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring
chronic pain. VA-DoD Clinical Practice Guideline for Management of PTSD recommends against
benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD.
Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of
PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and
evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially
improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing
doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation
of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to
initiation of OT.
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with
caution. While the evidence for harm associated with the combination of opioids and Z-drugs is not as
strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we
suggest not prescribing “Z-drugs” (e.g., zolpidem, eszopiclone) to patients who are on LOT, as moderatequality
evidence demonstrates that the combination of zolpidem and opioids increases the AOR of
overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose)
with the combined use of antidepressants and opioids in patients who do not have depression.[66] This
particular study did not differentiate between classes of antidepressants, limiting the ability of the Work
Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such,
there is no recommendation in this guideline with respect to using specific classes of antidepressants and
LOT.
Recommendation
6. a. We recommend against long-term opioid therapy for patients less than 30 years of age
secondary to higher risk of opioid use disorder and overdose. (Strong against)
b. For patients less than 30 years of age currently on long-term opioid therapy, we recommend
close monitoring and consideration for tapering when risks exceed benefits (see
Recommendations 14 and 17). (Strong for)
(Reviewed, New-replaced)
Discussion
All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are
younger than 30 years of age. Seven studies were identified that examined age as a predictor of OUD,
respiratory/CNS depression, and/or overdose. Four of the seven studies were rated as fair-quality
evidence,[59,86,88,92] while three were rated as poor-quality evidence.[58,62,87] Six of the seven studies
demonstrated that age was inversely associated with the risk of OUD and overdose.[59,62,86-88,92] One
of the three low-quality studies showed that older subjects had a higher HR of overdose.[58] The Work
Group’s overall confidence in the quality of the evidence was moderate.
Similar to other risk factors, age