Buprenorphine for Chronic Pain, Not Full Agonist Opioids, New VA Guidance Says

Buprenorphine, rather than a full agonist opioid, should be used for patients taking daily opioids for chronic pain, given its lower risk for overdose or misuse, new guidelines from the Department of Veterans Affairs (VA) and Department of Defense (DoD) recommended.

But "the guideline development group does not recommend use of opioid analgesics in the daily management of chronic pain," wrote James Sall, PhD, of the VA in New Braunfels, Texas, and co-authors in Annals of Internal Medicine.

"The benefits that opioids can provide are small and are outweighed by the risks to the patient," they continued. "If the decision is made to use long-term opioid therapy for a patient, then buprenorphine should be considered because of its lower risk profile."

The updated guideline also calls for behavioral health assessments for all chronic pain patients and preoperative opioid and pain management education.

The field of pain medicine is likely to embrace this new buprenorphine recommendation, noted Chinazo Cunningham, MD, MS, of the New York State Office of Addiction Services and Supports in New York City, and Joanna Starrels, MD, MS, of the Albert Einstein College of Medicine in New York City, in an accompanying editorial.

"The updated VA/DoD guideline is both conservative and radical," Cunningham and Starrels observed -- conservative because much is consistent with the CDC's guidance but "potentially transformative" by recommending buprenorphine instead of full agonist opioids.

"Although the VA/DoD guideline recommends that buprenorphine be prescribed for chronic pain if daily opioids are prescribed, the recommendation itself is likely to change decision-making about whether opioids should be prescribed," Cunningham and Starrels pointed out.

While the guideline is specific to the VA/DoD, "its influence is likely to expand into the greater U.S. healthcare system," they noted.

"Because buprenorphine is an opioid, with long-term risks like physical dependence, it will be important to take precautions to clearly and carefully message to patients and clinicians, closely monitor buprenorphine prescribing patterns by indication and formulation, evaluate public health benefits and harms, and identify unintended consequences," the editorialists continued.

Importantly, the quality of evidence for the buprenorphine recommendation is low and the recommendation is not clear about formulation, dosing, and the target patient population, they added.

VA and DoD leadership approved the joint clinical practice guideline in May 2022. The guideline development group used data from a systematic evidence review and graded recommendations and evidence as strong or weak. Besides using buprenorphine, the group recommended:

• Screening for additional mental health conditions that potentially increase risk in chronic pain patients
• Assessing for behavioral health conditions, history of traumatic brain injury, and psychological factors associated with higher risk for harm
• Screening for pain catastrophizing and co-occurring behavioral health conditions to identify those at higher risk for negative outcomes when opioids are being considered in acute pain patients
• Providing patients with pre-operative opioid and pain management education to reduce the risk for prolonged opioid use after surgery

The guidance is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain, Sall and colleagues noted. It includes three one-page algorithms to help guide clinical decision-making.

"The guideline development group identified that more studies are needed examining the comparative effectiveness of different analgesic agents, the effectiveness of different tapering strategies, and the effectiveness of different risk mitigation strategies on the management of patients receiving long-term opioid therapy," they added.

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