Christopher Spevak, MD, MPH, JD (left)
Chair of the DoD/VA Opioid Clinical Practice Guideline
Medical officer at Walter Reed National Military Medical Center where he directs the National Capital Region Opioid Safety Program
Randy Bell, MD, FAANS, MC, USN (right)
Associate professor and chief of neurosurgery at Walter Reed National Military Medical Center AANS/CNS Joint Committee of Military Neurosurgery
The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.
Everyone knows that the problem of pain is on the rise as is opioid prescribing (20 percent of visits in 2010 compared to 11 percent in 2000)(1) matched by a parallel increase in morbidity, mortality, opioid-related overdose death rates, and substance abuse treatment admissions (2). The U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) are equally impacted by this epidemic (4) where it has become a critical issue. The response to this crisis began in October 2015 with work on an evidence-based clinical practice guideline (CPG) for opioid therapy in treating chronic pain to replace the previous CPG from 2010. In the civilian world, such policy development becomes mired in political wrangling, territorial disputes and issues related to competition between facilities and physicians. However, the DoD/VA has the unique capacity to respond quickly and efficiently to initiate an action plan based on the best data available. After time for implementation and analysis of effectiveness, the lessons learned will help all understand how to better tackle the issues of pain, opioid use and abuse.
The 2010 CPG for the Management of Opioid Therapy for Chronic Pain was the foundation for the DoD/VA endeavor, considering the specific needs of the DoD and VA and new evidence regarding prescribing opioid medication for non-end-of-life related chronic pain. In addition, a patient focus group explored patient perspectives on a set of topics related to management of opioid therapy (OT) in the VA and DoD health care systems.
Recommendations were developed utilizing the quality standards and process in the “Guideline for Guidelines” published by the Evidence-Based Practice Working Group (EBPWG) (5). At the start of the guideline development, all team members were required to submit conflict-of-interest (COI) disclosure statements for relationships in the prior 24 months. Verbal affirmations of no COI were used periodically during the development process and web-based surveillance (e.g. ProPublica) was used to monitor for potential COIs. No work group members reported relationships and/or affiliations which had the potential to introduce bias, and none were found throughout the development of the guidelines.
The guidelines panel focused on a small number of topics considered to be the most clinically important and relevant with respect to long-term opioid therapy (LOT) for chronic pain, including:
- Investigating how LOT compares to alternative pain modalities with regard to effectiveness and safety;
- Evaluating the effectiveness and safety of various opioid formulations;
- Which factors increase the risk of developing misuse or opioid use disorder;
- Delineating which medical or mental health conditions are absolute or relative contraindications to prescribing LOT;
- Effectiveness of risk mitigation strategies; and
- Safety and efficacy of both treatment of Opioid Use Disorder (OUD) and different tapering strategies and schedules.
The CPG focuses on opioid therapy implementation while promoting robust risk reduction resulting in the development of four one-page algorithms which:
- Provide recommendations on determination of appropriateness for opioid therapy; and
- Stress initial utilization of non-pharmacologic and non-opioid pharmacologic therapies over opioid therapy for chronic pain.
The work group conducted a systematic search of peer-reviewed literature published through January 2016. Emphasis was placed on randomized trials, systematic reviews and meta-analyses of at least fair quality. The guideline panel rated recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method (5,6,7).
The opioid crisis is upon us with enormous impact on active duty military and veterans as well as the civilian population. Quick to recognize the threat and respond to it, the DoD and VA have devoted considerable resources to addressing this epidemic and the results are clinical guidelines and approaches directly translatable to the civilian sector.
Editor’s note: The content of this post originally appeared in the AANS Neurosurgeon which is a publication of the American Association of Neurological Surgeons (AANS). We encourage everyone to join the conversation online by using the hashtag #painfacts.
- Daubresse, M., Chang, H., Yu, Y., Viswanathan, S., Shah, N. D., Stafford, R. S., . . . Alexander, G. C. (2013). Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Medical Care, 51(10), 870-878.
- Centers for Disease Control and Prevention. (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. (2011, November 04).
- Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624.
- Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in drug and opioid overdose deaths-United States, 2000-2014. American Journal of Transplantation, 16(4), 1323-1327.
- Atkins, D., Best, D., Briss, P. A., Eccles, M., Falck-Ytter, Y., Flottorp, S., . . . Zaza, S. (2004). Grading quality of evidence and strength of recommendations. British Medical Journal, 328(754), 1490.
- Andrews, J., Guyatt, G., Oxman, A. D., Alderson, P., Dahm, P., Falck-Ytter, Y., . . . Schünemann, H. J. (2013). GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. Journal of Clinical Epidemiology, 66(7), 719-725.
- Andrews, J. C., Schünemann, H. J., Oxman, A. D., Pottie, K., Meerpohl, J. J., Coello, P. A., . . . Guyatt, G. (2013). GRADE guidelines: 15. Going from evidence to recommendation—determinants of a recommendations direction and strength. Journal of Clinical Epidemiology, 66(7), 726-735.