The Department of Veterans Affairs (VA) and the Department of Defense (DoD) recently released new opioid prescribing guidelines for chronic pain that are more stringent than those released last year by the Centers for Disease Control and Prevention (CDC). Most of the recommendations are widely supported practices for reducing opioid misuse and abuse, such as reducing the concurrent use of benzodiazepines and opioids, employing risk mitigation strategies and avoiding prescribing of extended release/long-acting opioids for acute pain. Other recommendations are highly concerning and may unintentionally and unnecessarily harm veterans, says Cindy Steinberg, U.S. Pain’s national director of policy advocacy. Supporting veterans and military service members with chronic pain is one of U.S. Pain Foundation’s key national policy priorities.
“The VA and DoD have a population in which the prevalence of chronic pain is much greater than the public-at-large. VA data shows that 50 percent of all veterans and 80 percent of veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom live with chronic pain,” says Steinberg. “Clearly, a significant portion of these soldiers and veterans are living with severe chronic pain as a result of serious and traumatic battlefield injuries. I am concerned that many of these veterans – who may be well-maintained on long-term opioid therapy as part of a multidisciplinary approach or who have already tried nonpharmacological and nonopioid therapies and found them insufficient – will lose access to the pain relief they need and deserve.”
Steinberg says that among her main concerns is the proposal that recommends against opioid therapy for patients less than 30 years of age. “The rationale for this was seven studies in the literature, three of which were rated as poor-quality evidence and four as fair-quality evidence. That strikes me as an extremely weak evidence base for such a sweeping recommendation. In addition, there is no mention of severity of pain condition, which is extremely relevant in this population of individuals, many of whom sustained devastating and gruesome battlefield injuries.”
Other problematic guidelines recommend dose limitations that are lower or equal to those supported by the CDC, urging caution at 20-50 morphine milligram equivalents (MME) per day and avoidance of greater than 90 MME per day or tapering of those who are now on doses over 90 MME. “This fails to recognize that patients differ widely in severity of pain, individual response to medication, body size and weight and tolerance for pain. I worry that as we have seen with the CDC guidelines, clinicians will begin tapering patients who may be well-maintained on stable doses of medication out of fear rather than what is clinically best for their patients. In addition, these limitations are in direct conflict with FDA-approved labeling, which is based on safety and efficacy trials and does not include dose thresholds.”
Lastly, Steinberg points out that, since unrelieved chronic pain itself is a risk factor for suicide, cautioning initiation of opioid therapy in those with suicide ideation may do more harm than good. “A survey of 2,000 pain patients conducted by Pain News Network in August, 2016, found that 50 percent had considered suicide as a way to end their pain.”
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