DoD/VA Lead the Way in the Opioid Crisis

hs4Christopher 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
Bethesda, MD

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
Bethesda, MD

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.

To view Table 1 which summarizes all 16 recommendations, click here. Additionally, the full guideline can be found here.

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.

References:

  1. 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.
  2. Centers for Disease Control and Prevention. (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. (2011, November 04).
  3. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
Posted in Cross Post, Guest Post, Health, Pain | Tagged , , , , , , , , , , |

Cross Post – CDC Launches Rx Awareness Campaign

cdcFrom time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places when we believe they hit the mark on an issue. Since we are smack dab in the middle of our focus-month on topics related to pain, we wanted to bring attention to the Centers for Disease Control and Prevention’s (CDC) Rx Awareness campaign. To raise awareness of prescription opioid abuse and overdose, this campaign is evidence-driven and tells the real stories of people whose lives were torn apart by opioid abuse. To read more about this effort, click here.

Posted in Cross Post, Health, Pain | Tagged , , , , , , |

DRG Stimulation: Evidence-based Strategy for the Treatment of Severe Chronic Neuropathic Pain

winfreeChristopher J. Winfree, MD, FAANS
Department of Neurological Surgery, Columbia University
New York, NY

Neurosurgeons have played an important role in the management of neuropathic pain since the inception of the field of neurological surgery over a century ago. Most early neurosurgical pain therapies were ablative in nature. The non-ablative neuromodulation strategies were introduced in the 1960s and have been a valuable tool for neurosurgeons for the treatment of chronic neuropathic pain.

Spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have been used for decades to treat one particular type of neuropathic pain, called complex regional pain syndrome. Unfortunately, there are some limitations to the effectiveness of the surgical techniques, and thus, they only are effective in a fraction of the patients considered to be good candidates for the procedures.

Some experimental studies have implicated the dorsal root ganglion (DRG) as the site of some significant pathophysiology in the origin and persistence of neuropathic pain in patients with complex regional pain syndrome (CRPS). Thus, the DRG makes an attractive target for neurostimulation therapy. If we could target the DRG with stimulation, then perhaps we could utilize DRG stimulation to treat CRPS.

Since the early 2000s, neurosurgeons have been placing electrodes along the spinal nerve roots and DRGs to treat pain confined to the spinal dermatomes. This technique is called spinal nerve root stimulation (SNRS). Distal lower extremity pain in the setting of CRPS is generally confined to the L4-S1 dermatomes and is particularly well-suited to treatment with SNRS. The electrodes used in SNRS procedures are repurposed SCS stimulator electrodes, designed for placement in the epidural space over the dorsal columns. The spaces along the spinal nerve roots and DRGs, however, are curved and somewhat more confined. Thus, the relatively thick and stiff SCS electrodes have a suboptimal configuration for placement along the nerve roots. They can be difficult to place for the surgeon, and uncomfortable to use by the patient. Not surprisingly, outcomes were poor with SNRS techniques.

DRGRecently, neurosurgeons have played a role in the development of a new form of neurostimulation, called DRG stimulation, that has proven to be more effective in the treatment of CRPS (and other dermatomal pain syndromes) than other types of neurostimulation. DRG stimulation targets the spinal nerve roots with small, percutaneously-placed electrodes, which limit stimulation to very focused regions of the body such as the lower legs and feet. The electrodes, which were designed specifically for placement along the DRG, are smaller, thinner, and easier to place along the spinal nerve root than SCS electrodes. The stimulation paresthesia overlap is easier to obtain initially and maintain long-term, unlike SCS and PNS. Patients also report better pain relief with DRG stimulation than with other forms of neurostimulation.

A recent clinical trial, called the ACCURATE Study, highlighted the use of DRG stimulation in patients with CRPS. This was a prospective, randomized, multi-center, controlled clinical trial comparing DRG stimulation to SCS in patients (N = 152) with lower extremity CRPS at 1-year of follow-up. The DRG patients reported 74 percent reduction in pain compared with the SCS patients who reported a 53 percent reduction in their pain. Also, the DRG stimulation restricted stimulation paresthesias to the painful area in 95 percent of patients, while SCS could only restrict the paresthesias to the painful area in 61 percent of patients.

DRG stimulation has become an important, evidence-based strategy for the treatment of severe, medically refractory CRPS. Working with our pain management colleagues, neurosurgeons continue to develop, test and utilize novel pain management strategies for patients with chronic neuropathic pain.

Editor’s note: During the month of September, we encourage everyone to join the conversation online by using the hashtag #painfacts.

Posted in Guest Post, Health, Pain | Tagged , , , , , , , , , , |