VA-DoD Guidelines on Opioids for Chronic Pain Recommend Dual Role for Buprenorphine

Buprenorphine, a partial μ-opioid receptor agonist, is recommended, not only for its customary application in opioid use disorder, but as a safer opioid analgesic when no other treatment modality or non-opioid suffices for a patient with chronic pain, in updated clinical practice guidelines of the Veterans Affairs and US Department of Defense.

In a synopsis of the guidelines in the February Annals of Internal Medicine, Friedhelm Sandbrink, MD, Veterans Health Administration, VA Medical Center and Department of Neurology, George Washington University, Washington, DC and colleagues point out that they are largely consistent with those of the Centers for Disease Control and Prevention, and in agreement that opioids are not the drug class or treatment of choice for the management of chronic noncancer pain.

They cite evidence that patients with chronic noncancer pain who are prescribed oral or transdermal opioids receive small, but not clinically significant improvement in pain and physical functioning, which is outweighed by adverse effects and risk of overdose.

“Ultimately, despite finding some evidence for a small improvement in musculoskeletal and noncancer neuropathic pain, the guideline development group maintained that the potential for catastrophic harms of opioids and serous adverse events, especially with long-term use, outweighed any potential benefits of temporarily improved pain severity and functional status in patients with chronic pain,” Sandbrink and colleagues indicate.

The VA-DoD guidelines recognize, however, that there may be no alternative to opioid analgesia for some patients with chronic pain, and—despite finding little evidence of comparative effectiveness, and acknowledging the need for additional study—recommend use of buprenorphine in place of full opioid agonists.

In an editorial accompanying the guideline synopsis, Chinazo Cunningham, MD, MS, New York State Office of Addiction Services and Supports, New York, and Joanna Starrels, MD, MS, Albert Einstein College of Medicine, Bronx, New York, characterize the guideline as “both conservative and radical."

They consider it conservative in agreeing with much of the CDC guideline, but radical (and “laudable”) for recommending that patients with chronic pain be assessed for behavioral health conditions, traumatic brain injury and psychological factors. They find the recommendation for buprenorphine “potentially transformative,” but caution that recommending its use as a safer opioid analgesic, with less risk of misuse and overdose, might disrupt the progress in reducing opioid prescribing for chronic pain.

“Consequently, one potential unintended consequence of the buprenorphine recommendation may be an excessive sense of assurance that benefits exceed risks, which could result in an overall increase in opioid prescribing,” they warn.

Reference: Sandbrink F, Murphy JL, Johansson M, et al. The use of opioids in the management of chronic pain: synpopsis of teh 2022 updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2023;176:388-397. doi.org/10.7326/M22-2917