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Initiation of opioids not recommended for chronic pain
In a synopsis of the latest U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) clinical practice guideline, published online Feb. 14 in the Annals of Internal Medicine, updated recommendations are presented for the use of opioids for chronic pain.
Friedhelm Sandbrink, M.D., from the Veterans Health Administration in Washington, D.C., and colleagues developed guidelines to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. Twenty recommendations for care were issued.
The authors strongly recommend against initiation of opioid therapy for the management of chronic noncancer pain. Furthermore, there is a strong recommendation against long-term opioid therapy, especially in younger age groups, since age is inversely linked to the risk for opioid use disorder and overdose, and in patients with chronic pain who have a substance use disorder.
The concurrent use of benzodiazepines and opioids for chronic pain is not recommended. In the case of opioids being prescribed, the lowest dose is recommended as indicated by patient-specific risks and benefits. If any increase in dosage is considered, patient-specific risks and benefits should be reevaluated. The shortest duration indicated is recommended when prescribing opioids.
After initiation of opioid therapy, reevaluation is recommended at 30 days or earlier, and frequent follow-up visits are recommended if opioids are to be continued. A new addition to the guideline involves buprenorphine. The authors suggest that practitioners consider the use of buprenorphine instead of full agonist opioids for patients receiving daily opioids for chronic pain, as the risk for overdose and misuse is lower.
"The guideline development group does not recommend use of opioid analgesics in the daily management of chronic pain," the authors write. "The benefits that opioids can provide are small and are outweighed by the risks to the patient."
More information: Friedhelm Sandbrink et al, The Use of Opioids in the Management of Chronic Pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline, Annals of Internal Medicine (2023). DOI: 10.7326/M22-2917
Chinazo O. Cunningham et al, Guideline Promoting Buprenorphine for Treatment of Chronic Pain: Transformative Yet Underdeveloped, Annals of Internal Medicine (2023). DOI: 10.7326/M23-0229
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