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AANS Neurosurgeon | Volume 25, Number 4, 2016

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DoD/VA Lead the Way in the Opioid Crisis

The views expressed in this article are those of the authors and do not reflect the official policy of the Departments of the Army/Navy/Air Force, the Department of Defense or the United States Government.

Everyone knows that the problem of pain is on the rise as is opioid prescribing (20 percent of visits in 2010 compared to 11 percent in 2000)(1) matched by a parallel increase in morbidity, mortality, opioid-related overdose death rates and substance abuse treatment admissions (2). The U.S. Department of Defense (DoD) and the U.S. Department of Veterans Affairs (VA) are equally impacted by this epidemic (4) where it has become a critical issue. The response to this crisis began in October 2015 with work on evidence-based clinical practice guidelines (CPG) for opioid therapy in treating chronic pain to replace the previous CPG from 2010. In the civilian world, such policy development becomes mired in political wrangling, territorial disputes and issues related to competition between facilities and physicians. However, the DoD/VA has the unique capacity to respond quickly and efficiently to initiate an action plan based on the best data available. After time for implementation and analysis of effectiveness, the lessons learned will help all understand how to better tackle the issues of pain, opioid use and abuse.

The 2010 CPG for the Management of Opioid Therapy for Chronic Pain was the foundation for the DoD/VA endeavor, considering the specific needs of the DoD and VA and new evidence regarding prescribing opioid medication for non-end-of-life related chronic pain. In addition, a patient focus group explored patient perspectives on a set of topics related to management of opioid therapy (OT) in the VA and DoD health care systems.

Recommendations were developed utilizing the quality standards and process in the “Guideline for Guidelines” published by the Evidence-Based Practice Working Group (EBPWG) (5). At the start of the guideline development, all team members were required to submit conflict-of-interest (COI) disclosure statements for relationships in the prior 24 months. Verbal affirmations of no COI were used periodically during the development process and web-based surveillance (e.g. ProPublica) was used to monitor for potential COIs. No work group members reported relationships and/or affiliations which had the potential to introduce bias, and none were found throughout the development of the guidelines.

The guidelines panel focused on a small number of topics considered to be the most clinically important and relevant with respect to long-term opioid therapy (LOT) for chronic pain, including:

  • Investigating how LOT compares to alternative pain modalities with regard to effectiveness and safety;
  • Evaluating the effectiveness and safety of various opioid formulations;
  • Which factors increase the risk of developing misuse or opioid use disorder;
  • Delineating which medical or mental health conditions are absolute or relative contraindications to prescribing LOT;
  • Effectiveness of risk mitigation strategies; and
  • Safety and efficacy of both treatment of Opioid Use Disorder (OUD) and different tapering strategies and schedules.

The CPG focuses on opioid therapy implementation while promoting robust risk reduction resulting in the development of four one-page algorithms which:

  • Provide recommendations on determination of appropriateness for opioid therapy; and
  • Stress initial utilization of non-pharmacologic and non-opioid pharmacologic therapies over opioid therapy for chronic pain.

Table 1 summarizes all 16 recommendations. The full guideline can be found at http://www.healthquality.va.gov/guidelines/Pain/cot/.

The work group conducted a systematic search of peer-reviewed literature published through January 2016. Emphasis was placed on randomized trials, systematic reviews and meta-analyses of at least fair quality. The guideline panel rated recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method (5,6,7).

The opioid crisis is upon us with enormous impact on active duty military and veterans as well as the civilian population. Quick to recognize the threat and respond to it, the DoD and VA have devoted considerable resources to addressing this epidemic and the results are clinical guidelines and approaches directly translatable to the civilian sector. 

Table 1: DoD/VA OT CPG Recommendations

#

Recommendation

Strength*

Category†

Initiation and Continuation of Opioids

1.        

a) We recommend against initiation of long-term opioid therapy for chronic pain.

b) We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments.

c) When pharmacologic therapies are used, we recommend non-opioids over opioids.

a) Strong against

b) Strong for

 

c) Strong for

Reviewed, New-replaced

 

2.        

For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14).

Strong for

Reviewed, New-replaced

3.        

For patients currently on long-term opioid therapy with evidence of untreated substance use disorder, we recommend close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering (see Recommendations 14 and 17).

Strong against

Reviewed, Amended

4.        

We recommend against the concurrent use of benzodiazepines and opioids.

Strong against

 

Reviewed, New-added

5.        

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

Reviewed, New-replaced

Risk Mitigation

6.        

We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors, prescribing of naloxone rescue and accompanying education

Strong for

Reviewed, New-replaced

Type, Dose, Follow-up and Taper of Opioids

7.        

If prescribing opioids, we recommend prescribing the lowest dose of opioids as indicated by patient-specific risks and benefits.

Note: There is no absolutely safe dose of opioids.

Strong for

Reviewed, New-replaced

8.        

As opioid dosage and risk increase, we recommend more frequent monitoring for adverse events including opioid use disorder and overdose.

Strong for

Reviewed, New- replaced

9.        

We recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of long-term opioid therapy.

Strong against

 

Reviewed, New- replaced

10.     

We recommend interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior.

Strong for

Reviewed, New- replaced

11.     

We recommend offering medication-assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder.

Strong for

Reviewed, New-replaced

Opioid Therapy for Acute Pain

12.     

a) We recommend alternatives to opioids for mild-to-moderate acute pain.

b) We suggest use of multimodal pain care including non-opioid medications as indicated when opioids are used for acute pain.

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.

Note: Patient education about opioid risks and alternatives to opioid therapy should be offered.

a) Strong for

 

b) Weak for

 

c) Strong for

Reviewed, New-added

*For additional information, please refer to the section on Grading Recommendations.
†For additional information, please refer to the section on Recommendation Categorization and Appendix H.

References
1. Daubresse, M., Chang, H., Yu, Y., Viswanathan, S., Shah, N. D., Stafford, R. S., . . . Alexander, G. C. (2013). Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Medical Care, 51(10), 870-878.

2. Centers for Disease Control and Prevention. (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. (2011, November 04).

3. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624.

4. Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in drug and opioid overdose deaths-United States, 2000-2014. American Journal of Transplantation, 16(4), 1323-1327.

5. Atkins, D., Best, D., Briss, P. A., Eccles, M., Falck-Ytter, Y., Flottorp, S., . . . Zaza, S. (2004). Grading quality of evidence and strength of recommendations. British Medical Journal, 328(754), 1490.

6. Andrews, J., Guyatt, G., Oxman, A. D., Alderson, P., Dahm, P., Falck-Ytter, Y., . . . Schünemann, H. J. (2013). GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. Journal of Clinical Epidemiology, 66(7), 719-725. 

7. Andrews, J. C., Schünemann, H. J., Oxman, A. D., Pottie, K., Meerpohl, J. J., Coello, P. A., . . . Guyatt, G. (2013). GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendations direction and strength. Journal of Clinical Epidemiology, 66(7), 726-735.

8. Annals of Surgery. (2017). Volume 265: Issue 4.

9. Brummett, C. M., Waljee, J. F., Goesling, J., Moser, S., Lin, P., Englesbe, M. J., . . . Nallamothu, B. K. (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery,152(6).

 

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