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

VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain
Recommendation
18. a. We recommend alternatives to opioids for mild-to-moderate acute pain. (Strong for)
b. We suggest use of multimodal pain care including non-opioid medications as indicated when
opioids are used for acute pain. (Weak for)
c. If take-home opioids are prescribed, we recommend that immediate-release opioids are used at
the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if
adjustments or continuing opioid therapy is indicated. (Strong for)
(Reviewed, New-added)
Discussion
Note: Patient education about opioid risks and alternatives to opioid therapy should be offered.
As this guideline is related to LOT, the use of opioids for acute pain will not be reviewed in detail. However,
because acute OT can be a gateway to LOT, it is part of this CPG. A review of the literature indicates that
LOT can result from acute opioid use initially intended for short-term therapy. Further, there is a risk of
opioid-related overdose even during acute OT. While it is understood that acute OT for severe pain due to
injuries or surgery is the most effective option for many patients, the risks associated with acute therapy
must be addressed when opioids are prescribed or considered.
The risks of acute OT extending into LOT are increased in patients with mood disorders, those who refill
the initial prescription, higher prescribed dose (greater than 120 MEDD), and initiation using long-acting
opioids.[183-185] The risk of acute post-operative OT progressing into LOT is increased with a history of
depression, SUD, catastrophizing, higher preoperative total body pain, history of back pain, and
preoperative use of sedative-hypnotics or antidepressants.[186,187]
In addition, the risk of overdose includes the use of opioids for acute pain. Factors that increase overdose
risk when opioids are used for acute pain include high prescribed dose, history of SUD, and history of
mental health concerns. While the risk of overdose increases at doses above 20 MEDD or greater, this risk
increases even further as doses increase to over 50 or 100 MEDD.[58,59,188]
There are situations in which opioids may be necessary therapy for acute pain, even when substantial risk
factors exist. It is important to incorporate opioid risk mitigation strategies into opioid prescribing for acute
pain. These strategies should include patient education, use of non-opioid adjunctive therapy, and
structured reassessment of opioid risks and benefits for all on acute OT. Also, consider checking the PDMP
and performing a UDT.
For those at higher risk of adverse events related to opioid therapy, the following strategies may help to
decrease opioid-related overdose events and unintended long-term use: checking the PDMP, performing a
UDT, placement in an inpatient setting or monitored environment, and/or providing OEND.
Monitoring standards with administration of OT for acute pain vary depending on a number of factors
including the setting, specifics of the painful insult, patient medical factors, and selected medication
potency/dose/route of administration/adjunct selection.
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