VA, DoD Recommend Buprenorphine for Chronic Pain

In its most recent guideline on the use of opioids to manage chronic pain, the U.S. departments of Veterans Affairs (VA) and Defense (DoD) recommend against using full agonist opioids (for example, morphine) for patients who require daily pain management. Rather, the guideline, which was approved in May 2022, recommends using buprenorphine for patients who require long-term opioid therapy.

“The updated guideline stresses the importance of individualized, person-centered care and a team-based approach to pain management,” said Jennifer Murphy, Ph.D., the VA’s director of pain management, in an email. Murphy co-authored a report summarizing the guideline published in the Annals of Internal Medicine in March. She was also a member of the VA/DoD Guideline Development Group, which was assembled by the VA/DoD Evidence-Based Practice Work Group in December 2020 to update the clinical practice guideline for opioid therapy for chronic pain. The guideline, which is updated every five years or more frequently as new evidence emerges, was last updated in 2017.

Compared with the 2017 recommendation against initiation of long-term opioid therapy, the 2022 guideline makes a broader recommendation against using opioid therapy in general. This update “reflects the evidence that opioid therapy for any duration may be harmful,” Murphy and her colleagues wrote in the Annals of Internal Medicine. For those patients with chronic pain for whom long-term opioid therapy may be appropriate based on a clinical assessment, the 2022 guideline recommends using buprenorphine. The VA and DoD define chronic pain as persistent and recurrent pain lasting longer than 90 days, and opioid therapy is considered long term when it continues longer than three months.

“The evidence suggests that use of buprenorphine in those with chronic pain may minimize some of the risks associated with full agonist opioids,” Murphy told Psychiatric News. “Specifically, it has a lower risk for respiratory depression and fatal overdose. In addition, while buprenorphine is a partial agonist, that does not mean partial analgesic efficacy. From a behavioral health perspective, it is particularly important to do everything possible to decrease risk and serious adverse events as well as the development of opioid use disorder (OUD).”

The 2022 guideline is consistent with the 2017 guideline in recommending that professionals use the lowest dose possible when prescribing an opioid. Further, the guideline recommends reevaluating patients at 30 days or less after initiating opioid therapy, as well as frequent follow-up visits when opioids are continued.

Smita Das, M.D., Ph.D., M.P.H., said that, with opioid overdose rates reaching all-time highs over the last few years, she appreciates that the guideline is moving toward encouraging safer opioid prescribing. Das is chair of APA’s Council on Addiction Psychiatry, and she formerly worked in the VA.

“While I was practicing at the VA, I worked with so many veterans who had OUD,” she said in an email. “In many cases, they had originally been prescribed opioids, then sought non-prescribed opioids or even met OUD criteria while being prescribed. Avoiding long-term full agonist opioids or limiting their use (length of time and dose) can help reduce the risk of developing OUD. While the risk of OUD among veterans compared to non-veterans is similar, there may be other comorbidities like posttraumatic stress disorder, which make circumstances more difficult for veterans.”

The updated guideline also makes several new recommendations for behavioral health assessments in all patients. It recommends screening for mental health conditions, history of traumatic brain injury, and psychological factors (such as pain catastrophizing) when considering long-term opioid therapy, as these conditions are associated with a higher risk for harm. In concurrence with the 2017 guideline, the 2022 guideline also recommends assessing patients for suicide risk and self-directed violence when initiating, continuing, changing, or discontinuing long-term opioid therapy.

Das emphasized the importance of having resources and referrals available to patients after screening. “In the VA, and in health care [systems] in general, screening for mental health needs is important and, when appropriately linked to referrals, can be life changing for our patients,” she said.

In an editorial also published in the Annals of Internal Medicine, Chinazo Cunningham, M.D., M.S., and Joanna Starrels, M.D., M.S., wrote that the new recommendations “are an important update in the changing and challenging landscape that clinicians and patients navigate to address chronic pain in the context of the worsening overdose epidemic.” Cunningham is a professor in the departments of Medicine, Family and Social Medicine, and Psychiatry and Behavioral Services at Albert Einstein College of Medicine, as well as the commissioner of the New York State Office of Addiction Services and Supports. Starrels is associate chief of research in the Division of General Internal Medicine at Albert Einstein College of Medicine.

In their editorial, Cunningham and Starrels pointed to the importance of clarity among clinicians about which condition they are treating with buprenorphine: chronic pain, OUD, or both. “In the United States, education and training in diagnosing and treating OUD and prescribing buprenorphine have been woefully inadequate,” they wrote. “Thus, as buprenorphine prescribing for chronic pain expands, it is important to ensure that clinicians are knowledgeable about the diagnosis and treatment of OUD and about buprenorphine’s unique pharmacologic properties.”

For patients without OUD, Murphy said that it is important to clarify why buprenorphine is being selected over other full agonist opioids. She noted that providers should be thoughtful regarding potential stigma around buprenorphine and clearly communicate why it is the clinician’s chosen medication. Shared decision-making is critical to successful treatment for chronic pain, OUD, and co-occurring pain and OUD, Murphy said. “Clarity around treatment should be the standard of care,” she said. ■