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

VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
Strong evidence supports the use of opioid agonist therapy (e.g., methadone, buprenorphine/naloxone) as
first-line treatment for moderate-to-severe OUD (see VA/DoD SUD CPG). 13 However, because this research
has been conducted primarily on persons addicted to heroin, the populations studied have had a higher
prevalence of co-occurring SUD and lower prevalence of chronic pain. Patients and their treating clinicians
may be concerned that treatments proven effective in different OUD populations may not be effective for
patients with chronic pain, or may not be necessary for patients who have become addicted to
prescription opioid analgesics. This concern has been unfounded and was addressed by Weiss and
colleagues in the Prescription Opioid Abuse Treatment Study (POATS).
Early research suggested that patients with prescription OUD may have a better prognosis than those who
are primarily addicted to heroin, implying that those with prescription OUD may not need MAT.[179,180]
However, in studies with patients with DSM-IV opioid dependence (which were conducted prior to use of
DSM-5), buprenorphine maintenance therapy is more effective than a four-week taper. One multicenter
RCT tested the hypothesis that patients with prescription OUD would respond well to a four-week tapering
of buprenorphine/naloxone to discontinuation plus two regimens of outpatient counseling.[181] Those
who did not achieve successful outcomes after buprenorphine taper in phase one were invited to
participate in phase two consisting of 12-weeks treatment using buprenorphine/naloxone followed by
taper to discontinuation. During both phases, patients were randomized to receive a manualized,
physician-delivered psychosocial intervention known as Standard Medical Management or Standard
Medical Management plus manually-driven opioid drug counseling delivered by a trained therapist. Only
6.6% of these patients achieved a successful outcome after tapering in phase one with no difference
between the groups. In phase two, while taking buprenorphine/naloxone, 49% of patients achieved a
successful outcome again with no difference between the counseling groups. Eight weeks after tapering
again, only 8.6% of patients achieved a successful outcome. This suggests that MAT with moderate dose
buprenorphine/naloxone and brief, structured counseling by the prescribing physician can be successful
for about half of selected patients with prescription OUD, whereas withdrawal management alone, even
with close weekly follow-up and counseling is successful for less than 10% of patients.
Furthermore, the presence of chronic pain does not seem to interfere with the success of MAT. The RCT by
Weiss et al. (2011) and a meta-analysis by Dennis et al. (2015) reached the same conclusion that the
presence of chronic pain did not influence response to opioid agonist therapy.[181,182] Given the high
mortality associated with OUD and the safety and efficacy of MAT for OUD in multiple clinical trials and
meta-analyses, we recommend MAT for those chronic pain patients who meet DSM-5 criteria for OUD.
Those who do not respond to minimal counseling may benefit from a comprehensive assessment and
more intensive treatment of OUD and any co-occurring conditions in SUD specialty care settings.
13 See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Available at:
http://www.healthquality.va.gov/guidelines/mh/sud/index.asp
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