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 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. February 2017 Page 70 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Appendix A: VA Signature Informed Consent For the most current information on informed consent, see the VA National Center for Ethics in Health Care website (http://www.ethics.va.gov/). February 2017 Page 71 of 192
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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