Recommendations for opioid use in the management of chronic pain

1. Opioid therapy for the management of chronic non-cancer pain is not recommended according to new guidelines from the United States Department of Veterans Affairs and the Department of Defense.

2. Long-term opioid therapy is currently not recommended, especially for younger age groups. 

Evidence Rating Level: 1 (Excellent)

Study Rundown: Nearly 50 million adults in the United States experience chronic pain on most days and pain is a complaint at approximately 20% of all ambulatory primary care and specialty visits. Approximately 1 in 5 patients with non-cancer pain or pain-related diagnoses were prescribed opioids in an outpatient setting from 2000 until 2010. However, the absolute number of deaths associated with the use of prescribed and illicit opioids has increased by 400% between 2000 and 2014. The increase in illicit opioid use and overdose has also involved heroin and fentanyl (a synthetic opioid). In 2019, nearly 50,000 people died of opioid-involved overdoses in the United States. Additionally, it has been estimated that about 80% of persons who use heroin first misused prescription opioids. Therefore, it is important to have updated guidelines on opioid prescribing practices. Overall, this guideline reported that initiation of opioid therapy for the management of chronic non-cancer pain is not recommended, as is the use of long-term opioid therapy particularly for younger age groups. However, this study was limited by the need for more research examining the comparative effectiveness of different analgesic agents, the effectiveness of different tapering strategies, and the effectiveness of different risk mitigation strategies on managing patients receiving long-term opioid therapy. Nevertheless, the guidelines are significant, as they demonstrate that the use of opioids in daily chronic pain is not recommended and buprenorphine should instead be considered if long-term opioid therapy is required.

Click to read the study in AIM

Relevant Reading: Effects of State Opioid Prescribing Laws on Use of Opioid and Other Pain Treatments Among Commercially Insured U.S. Adults

In-Depth [clinical guideline]: This article written by the United States Department of Veterans Affairs and the Department of Defense studied the recommendations for pain management as an update from the 2017 guidelines. A group of multidisciplinary experts was included in the working group – including internal medicine, family medicine, neurology, nursing, pharmacy, psychology, physical therapy, social work, acupuncture, Chinese medicine, chiropractic, and interventional medicine. Through a consensus process, 12 key questions were framed to guide the evidence review. To manage conflicts of interest, the guideline development team was polled at the onset of the project and before each meeting to identify any conflicts. The study’s primary outcome was to provide updated recommendations for the use of opioids in managing chronic pain. Based on the study, key recommendations offered included recommending against the initiation of opioids for the management of chronic non-cancer pain, as well as recommending against long-term therapy, particularly for younger age groups. Additionally, they recommend prescribing the lowest dose as indicated by the patient if prescribing opioids. Overall, this study found that many of their recommendations from 2017 were consistent with 2022, including the recommendation against the use of opioid therapy for chronic non-cancer pain and avoidance of long-term opioid therapy when possible. Though, if required, recommend buprenorphine instead of full agonist opioids due to the lower risk for overdose and misuse.

Image: PD

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