Revised VA Guidelines for Opioids May Not Go Far Enough

Timely, newly revised guidelines on prescribing opioids for the management of chronic noncancer pain from the Department of Veterans Affairs (VA) and the Department of Defense do not provide an adequate explanation of available nonopioid, FDA-approved treatment options, according to A. Thomas McLellan, PhD.

“Since about 2012, overdose deaths from prescription opioids are killing as many or more people than car accidents,” said Dr. McLellan, former CEO of the Treatment Research Institute, in Philadelphia. “More disconcerting, though, is that these deaths result directly or indirectly from a physician’s prescription. In other words, this is a crisis that we made ourselves.”

On the other hand, using opioids as first-line therapy for chronic noncancer pain is “easy and quick for a doctor and covered by insurance,” Dr. McLellan said. “Most patients also like opioids—indeed, ask for them—and opioids are relatively inexpensive.”

Today, opioids are the largest class of prescribed medication, “eclipsing satins,” Dr. McLellan said. “And while the research shows that opioids are quite good for treating most forms of acute pain, they are not that effective for chronic pain much longer than about 90 days.”

Despite opioids losing their analgesic effects after three months, “they retain all their physical and public health side effects, including constipation; potentially slowing respiration to the point of overdose, especially if used in conjunction with alcohol or certain other medications; diversion; and addiction,” Dr. McLellan said.

Dr. McLellan applauds “Management of Opioid Therapy (OT) for Chronic Pain (2017),” (www.healthquality.va.gov/?guidelines/?pain/?cot/?), which is a revision of VA guidelines from 2010. “This information is timely, important and good for patients and providers,” he said. “However, they are just guidelines, without enough practical suggestions for practitioners as to what else they can do. Those options exist, although admittedly not always covered by insurance. But that is less of a concern for the VA and the Department of Defense.”

Dr. McLellan noted that prescribers need to know more about alternatives to opioids. “This is going to affect day-to-day practice,” he said. “For example, if a patient with back pain asks for his oxycodone to be represcribed, the doctor will now have to inform the patient he is reluctant to do that because of the revised guidelines.”

Dr. McLellan would have preferred that the new guidelines list FDA-approved therapies for chronic pain, as do the current guidelines from the CDC. “These alternative treatments include nonsteriodals, antidepressants, massage and stretching,” he said.

Dr. McLellan also is concerned by the guidelines’ suggestion that the millions of military and veteran patients on opioids for chronic pain should be tapered off opioid treatment. “I endorse the concept. However, it can be uncomfortable and even medically dangerous to stop opioid use abruptly,” Dr. McLellan said.

Few Courses in Addiction

Some patients are going to have withdrawal symptoms. “They will not be addicted to opioids, but they will show withdrawal symptoms and be very uncomfortable,” Dr. McLellan said. “No guidance is given to physicians about how to taper someone from those medications.”

Additionally, clinicians are going to find that some proportion of patients on chronic opioids have developed “an opioid use disorder that may be difficult for these patients to overcome without assistance from their physicians,” Dr. McLellan said. “Again, doctors are not given guidance on what to do, how to refer and what is appropriate. Furthermore, most doctors never learned it in school. Less than 10% of U.S. medical schools have a course in addiction.”

Dr. McLellan said the direction of the guidelines is “absolutely the right way to go. I just think there needs to be a lot more guidance to help physicians effect the changes that are so desirable.”

Nonetheless, if the current guidelines are implemented, “we should see better pain management, less diversion of opioids, fewer overdose deaths and fewer addictions,” said Dr. McLellan, whose comments and concerns about the guidelines are scheduled to appear in an upcoming issue of Annals of Internal Medicine. “However, getting to that point is going to require more guidance and assistance to doctors than the guidelines envisioned.”

Jeff Gudin, MD, director of pain management and palliative care at Englewood Hospital and Medical Center, in Englewood, N.J., does not agree with Dr. McLellan that there is lost efficacy with opioids. “I would argue there are patients who achieve long-term efficacy from opioids,” he said. “The challenge is prospectively selecting the correct patient—the patient without comorbid psychiatric disease. Although this disease affects most returning veterans from combat, it is unjust to patients not to consider opioids for valid chronic pain issues.”

Dr. Gudin said within any medically based pain medicine center, there is a subset “that does really well and thrives on chronic opioid therapy. I understand, though, why the VA guidelines are much more sensitive to limiting opioid prescribing.”

Like Dr. McLellan, Dr. Gudin advocates alternative treatments. “However, although alternative therapies are helpful as part of a multimodal treatment plan, they are rarely satisfactory by themselves to provide adequate analgesia,” he said.

As for the guidelines stating that misuse and addiction are a function of dose and duration, “that is only in patients who are susceptible to the euphoric effects,” Dr. Gudin said.

Overall, Dr. Gudin “applauds” the guidelines’ efforts to improve the safety of opioid analgesics in the VA population. “However, I think it would be a travesty to completely eliminate this useful therapeutic class, especially in patients who lack risk factors for misuse, abuse or addiction,” he said.

—Bob Kronemyer