Clinical Practice Guidelines for Opioid Therapy
Since the early 1990s, VA, through its Evidence-based Practice Program, has developed clinical practice guidelines (CPGs) on key issues impacting Veterans Health.
Many of these CPGs have been developed in partnership with the Department of Defense (DoD) via the VA/DoD Evidence-based Practice Work Group. As a result, 22 CPGs, which provide health care providers with an evidence-based framework by which to evaluate, treat and manage the individual needs and preferences of patients, are available on the CPG website (www.healthquality.va.gov) on six key areas important to Veterans' health: pain, rehabilitation, women's health, chronic disease in primary care, mental health, and military-related. The Work Group also makes recommendations to the VA/DoD Health Executive Council on whether these guidelines should be updated, and, upon approval by the council, accomplishes those updates.
In response to the growing epidemic of opioid misuse and use disorder in America and among service members and Veterans, the VA/DoD Work Group recently revised its clinical practice guideline, Opioid Therapy for Chronic Pain. Published in 2010, the CPG gave health care providers a framework to evaluate, treat and manage the individual needs and preferences of patients on or being considered for long-term opioid therapy (i.e., therapy involving drugs that act on the nervous system to relieve pain).
In 2015, VA's Evidence-based practice Work Group reached out to champions throughout VA and DoD to form a multidisciplinary work group. Members included primary care providers, pain specialists, nurses and others. The Work Group shepherded the process of preparing the CPG, which took 16 months. Veteran patients and family members participated in focus groups that helped frame key questions for study and reviewed various drafts as they were prepared.
The new guidelines recommend opioid therapy be used only when the benefits outweigh the risks. When that is the case, patients should then receive the lowest dosage and fewest number of opioids possible. Prescriptions should be limited to no longer than three days of opioids for acute pain and no longer than 30 days for chronic pain.
The guidelines caution that those under age 30 are at higher risk of dependency than those above 30. Other risk factors include a family history of dependency or abuse, mental health issues and a high level of tolerance to opiates. For those at risk of dependency, no more than two weeks' worth of opioids should be prescribed at one time. A risk assessment should be done on every patient for whom opioid therapy is being considered to determine the risk of dependency or abuse.
The guidelines also provide advice to clinicians for tapering opioid dosages when the risks outweigh the benefits of continued usage. If the clinician decides to continue prescribing opioids to a patient, the guideline recommends initiating several risk mitigation strategies. These strategies include educating patients on the dangers of opioids, the use of patient consent, urine drug screening and frequent follow up. Clinicians also need to check state databases to determine whether patients are receiving prescriptions for opioids from more than one provider. As an alternative to opioids, the guideline recommends alternative therapies such as acupuncture and massage.
Whereas the previous CPG focused provider attention on pain reduction, the newest CPG focuses its attention on helping Veterans improve to day-to-day functioning.
The new guidelines provide Veterans with the latest and best methods to manage pain. They recognize other — and possibly better — methods for pain management than opioid therapy, such as psychological therapies, exercise (including yoga), combinations of both treatments and non-opioid medications. Veterans will still receive opiates when they need them, but lowered dosages will keep them safer and reduce their chance of opioid addiction. Ultimately, they will receive better care, with decreased risk of addiction and other hazards.
To learn more about this tool, refer to the following information — VHA TRAIN VA/DoD Clinical Practice Guideline for Opiod Therapy for Chronic Pain