VA-DoD 2022 Recommendations on Use of Opioids for Management of Chronic Pain: A Guideline Topline
The US Veterans Affairs / Department of Defense Clinical Practice Guideline for the Use of Opioids in the Management of Chronic Pain was updated in 2022 to reflect an extensive review of new evidence since the last publication in 2017.
In this Guideline Topline, find highlights of new recommendations in the 2022 iteration that include conducting behavioral and mental health assessments for all patients before initiation of opioids for acute or chronic pain and, importantly, a suggestion that use of buprenorphine be expanded beyond its role in treatment for opioid use disorder to include pain management in patients on daily long-term opioid therapy. There is also a short review of VA guidance based on its publication Buprenorphine Formulations for Pain Management Recommendations for Use.
Before opioid initiation and during ongoing treatment, perform behavioral health assessment to reduce potential for misuse, harm.
Provide education on opioids and pain management prior to surgical procedures to decrease risk for prolonged use.
Consider buprenorphine for patients on long-term opioid therapy for chronic pain (see rationale to follow).
Before prescribing opioids and when continuing, changing, or discontinuing long-term use, assess patients for risk of suicide and other self-directed violence; particulary be concerned with patients with mood or pain disorders, neuropathy, cancer.
Behavioral health assessment should include behavioral health conditions, history of TBI, psychological factors including affect, pain catastrophizing.
Use lowest opioid dose as indicated by patient-specific risks & benefits, for the shortest duration (consistent with VA/DoD 2017 recommendations).
After prescribing an opioid analgesic, follow-up should occur at no later than 30 days to review/adjust plan, including whether opioids should be continued.
The VA/DoD guideline Work Group determined that the benefits of long-term use of buprenorphine with regard to overdose, addiction, and mortality compared with full agonist opioid therapy warranted a recommendation to consider its use for chronic pain.
Buprenorphine tradeoff: evidence was low on comparative efficacy for chronic pain managment compared with full agonist opioids but the Work Group noted "there is reason to consider buprenorphine a first-line agent" in carefully selected patients.
Buprenorphine formulations/indications (VA/DoD 2022 Buprenorphine Recommendations for Use)
Buprenorphine dosing: morphine dose equivalence estimates (VA/DoD 2022 Buprenorphine Recommendations for Use)
Buprenorphine dosing: cautions to avoid precipitating opioid withdrawal (VA/DoD 2022 Buprenorphine Recommendations for Use)
For further information, see the US Veterans Affairs / Department of Defense Clinical Practice Guideline for the Use of Opioids in the Management of Chronic Pain , and the separate Buprenorphine formulations for chronic pain management in patients wtih opioid use disorder or on long-term opioid therapy with physiologic tolerance recommendations for use.
