VA, DoD guidelines recommend buprenorphine over full agonist opioids

The U.S. Departments of Veterans Affairs and Defense recently updated their clinical practice guidelines for the use of opioids in patients with chronic pain, the first update in 5 years.

“The thoughtful and judicious prescribing of opioids is important for many reasons, including to decrease the number of patients who transition to illicit drug use, but also to minimize risk and maximize safety and quality of life for those with chronic pain,” Friedhelm Sandbrink, MD, the acting national program director for pain management in the Veterans Health Administration, and colleagues wrote in Annals of Internal Medicine.

The updated guidance, which was approved by the departments in May 2022, includes four new recommendations, which advocate for physicians to:

• use buprenorphine instead of a full agonist opioid for patients who are receiving daily opioids for chronic pain;
• assess co-concurring psychological factors and behavioral health of all patients with chronic pain before initiating opioid treatment;
• screen for pain catastrophizing and behavioral health in patients with acute pain to determine those at higher risk for adverse outcomes; and
• provide patients with preoperative opioid and pain management education to reduce the risk for prolonged opioid use for postsurgical pain.

Despite sparse evidence on the comparative effectiveness between buprenorphine and full agonist opioids for chronic pain management, Sandbrink and colleagues noted that “buprenorphine has a superior safety profile, especially for respiratory depression, even in nondependent persons and fatal overdose.”

“In addition, excluding those who are opioid-naive, buprenorphine is less likely to cause euphoriant effects and is a first-line treatment of opioid use disorder [OUD],” they wrote.

The guidance to screen for behavioral health and psychological factors was based on previous evidence suggesting that mood disorders were associated with higher risks for death by intentional opioid overdose.

“The work group recognizes that this recommendation may be challenging to implement, as it could result in more referrals to behavioral health providers in areas where availability is already critically low,” the researchers wrote. “In addition, there is the risk that some patients may associate their mental health symptoms with their chronic pain.”

Compared with the departments’ 2017 recommendation against long-term opioid therapy for chronic noncancer pain, the updated guidance discouraging opioid therapy in general for chronic pain “is broader and reflects the evidence that opioid therapy for any duration may be harmful,” according to Sandbrink and colleagues.

The 2022 update was consistent with several of the 2017 recommendations, including the recommendation to use the lowest opioid dosage as indicated by patient-specific risks and benefits and the shortest duration possible.

“Current evidence suggests that a longer duration of opioid therapy is associated with a higher risk for subsequent treatment of OUD and a higher risk for fatal opioid overdose,” the researchers wrote.

The updated guidance also continues to recommend reevaluating patients 30 days or fewer after opioid initiation and discourages long-term opioid use for acute pain.

In a related editorial, Chinazo O. Cunningham, MD, MS, and Joanna L. Starrels, MD, MS, both professors of medicine at the Albert Einstein College of Medicine, referred to the update as both “conservative and radical.”

“It is conservative because much of the guideline remains consistent with the [CDC] guideline that cautions against initiating opioid treatment for chronic pain, particularly with long-acting or high-dose opioids or with concurrent benzodiazepines,” they wrote.

Its radicalness, Cunningham and Starrels added, comes from its recommendation to assess “patients with chronic pain for behavioral health conditions, traumatic brain injury, and psychological factors.”

The “most potentially transformative” recommendation is to use buprenorphine instead of full agonist opioids, according to the authors, although they acknowledged that many questions about its implementation remain.

“Few studies have compared buprenorphine to other opioids for the treatment of chronic pain. Even fewer data are available to guide clinicians on how pharmacologic, clinical, and patient characteristics may affect buprenorphine's effectiveness in treating chronic pain,” they wrote.

Cunningham and Starrels added that the recommendation lacks clarity in terms of formulation, dosing and frequency of dosing in addition to an unclear target population.

“Although the field of pain medicine is likely to embrace this new buprenorphine recommendation, more clearly specifying how it should be implemented — and improving and expanding buprenorphine research, along with OUD and buprenorphine education and training — will likely improve the lives of persons with chronic pain,” they concluded.

References:

• Cunningham C, Starrels J. Ann Intern Med. 2023;doi:10.7326/M23-0229
• Sandbrink F, et al. Ann Intern Med. 2023;doi:10.7326/M22-2917