By Pat Anson, Editor
It’s going to be even harder for U.S. military service members and veterans – especially younger ones -- to obtain opioid pain medication.
The Department of Veterans Affairs and the Department of Defense have released a new clinical practice guideline for VA and military doctors that strongly recommends against prescribing opioids for long-term chronic pain – pain that lasts longer than 90 days.
The new guideline is even more stringent than the one released last year by the Centers for Disease Control and Prevention (CDC).
It specifically recommends against long-term opioid therapy for patients under the age of 30. And it urges VA and military doctors to taper or discontinue opioids for patients currently receiving high doses.
The 192-page guideline (which you can download by clicking here) is careful to note that the recommendations are voluntary and “not intended as a standard of care” that physicians are required to follow.
But critics worry they will be implemented and rigidly followed by military and VA doctors, just as the CDC guidelines were by many civilian doctors.
“I am concerned that many of these veterans with moderate to severe pain who may be well-maintained on long-term opioid therapy as part of a multidisciplinary approach or whom have already tried non-pharmacological and non-opioid therapies and found them insufficient will be tapered off their medication for no good reason except that their physicians will be fearful to run afoul of these new guidelines,” says Cindy Steinberg, National Director of Policy and Advocacy for the U.S. Pain Foundation, a patient advocacy group.
Although much of the research and clinical evidence used to support the new guideline was considered “low or very low” quality, a panel of experts found “mounting evidence” that the risk of harm from opioids -- such as addiction and overdose – “far outweighed the potential benefits.”
“There is a lack of high-quality evidence that LOT (long term opioid therapy) improves pain, function, and/or quality of life. The literature review conducted for this CPG (clinical practice guideline) identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain.”
The panel of experts was comprised of a diverse group of doctors, nurses and pharmacists within the Departments of Defense and Veterans Affairs, including specialists in pain management and addiction treatment.
“We recommend against initiation of long-term opioid therapy for chronic pain,” reads the first of 18 recommendations of the expert panel, which said that only “a rare subset of individuals” should be prescribed opioids long term.
Instead of opioids, the panel recommends exercises such as yoga and psychological therapies such as cognitive behavioral therapy to treat chronic pain, along with non-opioid drugs such as gabapentin (Neurontin).
“In light of the low harms associated with exercise and psychological therapies when compared with LOT these treatments are preferred over LOT, and should be offered to all patients with chronic pain including those currently receiving LOT.”
Another strong recommendation of the panel is that opioids not be prescribed long-term to anyone under the age of 30, because of the damage opioids can cause to developing brains.
“Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD (opioid use disorder) and overdose.”
Of the seven studies used to support this claim, four were rated as “fair quality” and three were considered “poor quality.”
“That strikes me as an extremely weak evidence base for such a sweeping recommendation,” said Steinberg. “There is no mention of severity of pain condition which is extremely relevant in this population, many of whom sustained devastating and gruesome battlefield injuries such as blown off limbs.”
The panel recommends alternatives to opioids for mild-to-moderate acute pain. If opioids are prescribed temporarily for acute short-term pain, immediate release opioids are preferred.
Risk of Suicide Discounted
Pain is a serious problem for both active duty service members and veterans. A study found that nearly half the service members returning from Afghanistan have chronic pain and 15 percent reported using opioids – rates much higher than the civilian population.
The incidence of pain is even higher among veterans being treated at VA facilities. Over half suffer from chronic pain, as well as other conditions that contribute to it, such as depression and post-traumatic stress disorder. Even more alarming is a recent VA study that found an average of 22 veterans committing suicide each day.
The new guideline recommends that patients be monitored for suicide risk before and during opioid therapy, but curiously there is no mention that undertreated or untreated pain is also a risk for suicide. For patients being tapered or taken off opioids, doctors are advised not to take a threat of suicide too seriously.
“Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However, continuing LOT to ‘prevent suicide’ in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases. In such cases, it is essential to involve behavioral health to assess, monitor, and treat a patient who becomes destabilized as a result of a medically appropriate decision to taper or cease LOT.”
Many patients could find themselves being tapered or taken off opioids if the guideline is taken literally by their doctors. The expert panel strongly recommends against opioid doses greater than a 90 mg morphine equivalent (MME) daily dose and urges caution for doses as low as 20 MME.
“This again fails to recognize that patients differ widely in severity of pain, individual response to medication, body size and weight and tolerance for pain,” says Steinberg.
“I worry that, as we have seen with the CDC guidelines, clinicians will begin tapering patients who may be well-maintained on stable does of medication for fear of running afoul of sanctioned limitations rather than being guided by what is best for their patients. These limitations are in direct conflict with FDA approved labeling which is based on safety and efficacy trials and does not include dose thresholds.”
The VA and Department of Defense opioid guideline will affect millions of service members, veterans and their families. Nearly 1.5 million Americans currently serve in the armed forces and over 800,000 in the National Guard and Reserves. The Veterans Administration provides health services to another 6 million veterans and their families.
The guideline is the second major initiative by the federal government so far this year aimed at reducing opioid prescribing. As Pain News Network has reported, the Centers for Medicare and Medicaid Services (CMS) has announced plans to fully implement the CDC’s opioid prescribing guidelines.
CMS is taking those voluntary guidelines a step further by mandating them as official Medicare policy and taking punitive action against doctors and patients who don’t follow them. CMS provides health insurance to about 54 million Americans through Medicare and nearly 70 million through Medicaid.