Attachment 3 VA DoD Opioids CPG Patient Summary.pdf

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VA/DoD CLINICAL PRACTICE

GUIDELINE FOR THE USE OF OPIOIDS IN THE

MANAGEMENT OF CHRONIC PAIN

Department of Veterans Affairs

Department of Defense

Patient Summary

I. Chronic Pain

· Pain is a complex human experience that is strongly affected by physical factors. It is also strongly affected by what you think, feel, and do when you hurt.

· Acute pain acts as an instant warning from the nervous system telling you that you may be hurt. It lets you know that you need to stop doing what you are doing to stay safe. It also tells you that you may need to seek medical attention. The reasons for acute pain can usually be found. Reasons may include an injury, a fracture, a heart attack, surgery, or other acute medical conditions. Acute pain usually does not last long. It usually responds to treatments such as short-term medications, rest, casting, specified safe movement programs (e.g., physical therapy), or surgery.

· Chronic pain is pain that stays after your body should have healed from the injury. This is usually three months or longer. Chronic pain can be caused by conditions that have no cures, like diabetes. Certain lifestyle factors can make chronic pain worse. These include inactivity, stress, nicotine dependence, poor sleep, unhealthy eating, or substance use.

· Pain related to certain types of cancer may be both acute and chronic. The pain may be related to the cancer itself or cancer treatments such as surgery, diagnostic testing, and radiation therapy.

· Acute and chronic pain can often feel the same. Both can be very painful. However, they are different problems with different solutions. Treating chronic pain problems with acute pain solutions may make your pain worse.

Did You Know?

· Chronic pain is very common. In the U.S., about 50.2 million adults experience chronic pain on most days or every day.(1)

· Pain is associated with about 20% of ambulatory primary care and specialty visits in the U.S.(2-4)

· Some types of chronic pain include low back pain, neck pain, and other muscle and joint pain.

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· The medical conditions that cause acute pain may threaten your life or health. Chronic pain threatens your lifestyle and all aspects of your life. Others may not notice your chronic pain or understand how the pain affects you. However, chronic pain may make it hard for you to carry out day-to-day activities. It could make other medical problems worse. Chronic pain may make it hard for you to carry out physical activities. Chronic pain can make you stressed or impact your sleep. Chronic pain can also impact your personal relationships and your work.

· The treatment of chronic pain begins with ways you can help manage your pain and ways you can reduce the effects the pain has on other parts of your life. This is called self-management.

Follow your treatment plan. Also, think about how you can use self-management strategies to improve your day-to-day life. More information on self-management and other treatments for chronic pain is included below.

A. What causes chronic pain?

Chronic pain can be caused by many different factors. We do not always fully understand what causes chronic pain. Conditions that come with normal aging may affect bones and joints in ways that cause chronic pain. Injuries that fail to heal properly, nerve damage, or ongoing medical conditions can also cause chronic pain. Chronic pain can also occur without a known cause. Medical tests may not completely explain the reason for the pain or the intensity of the pain. This does not mean that your pain is not real. It

is. No matter the cause of your chronic pain, how you respond when you hurt is important. Many efforts to reduce pain in the short term may create more pain, suffering, and disability in the long term. These efforts may include taking more medication or avoiding activities that make your pain worse.

B. How is chronic pain diagnosed?

Pain is a private and personal experience. It cannot be measured by tests or machines. The level of your pain is whatever you say it is. Pain is different for every person. Discuss the type, timing, and location of your pain with your healthcare provider. Also discuss other aspects of your health. These can include other medical conditions, treatments you have tried for your pain, your daily activities, and how you cope with your pain on a day-to-day basis. Your healthcare provider will help tell whether your pain is chronic. If it is chronic, the important questions are: how does pain affect your life and how can your healthcare providers help you move forward? Discuss your personal goals and purpose in life with your healthcare provider. You can work together to determine steps to reach your health goals and maximize your enjoyment of life.

II. Treatment A. What are the goals of chronic pain treatment?

The goal of chronic pain treatment is to lessen your pain and improve your daily functioning and quality of life. Work with your healthcare provider to set reachable goals and develop your individual treatment plan. In general, goals should focus on what you can do for yourself to help lessen the impact of your chronic pain, improve your quality of life, and reach your goals. Goals should focus less on what your healthcare provider can do with medications, surgeries, and other treatments. By focusing on ways to improve your reaction to the effects of chronic pain, you can improve your day-to-day functioning and overall quality of life.

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Potential Goals of Chronic Pain Treatment

· Restore your physical function (your ability to move, exercise, and participate in life)

· Restore your emotional function (happiness and satisfaction with life)

· Restore your social function (activities and connections with others)

· Improve the overall quality of your life

· Reconnect with what is important to you (your personal goals, aspirations, and purpose)

· Understand why you want to be healthy (your goals)

· Improve how well you can manage your pain and return to a healthy lifestyle (e.g., healthy diet, weight, and sleep patterns)

· Gain understanding of the nature of your chronic pain

· Address any underlying injuries that might help you feel better

B. How can I manage my chronic pain?

It may not be possible to be completely pain-free. However, you can manage many symptoms by exercising, using coping skills, and maintaining a healthy weight and lifestyle. In addition, there are several non-medication and non-opioid treatment options that can help you manage your chronic pain and reach your goals. Treatment of chronic pain requires a comprehensive approach. Talk with your healthcare provider to learn more about the possible treatment options and decide which ones are best for you.

a. Self-management Self-management is important in any chronic condition. Self-management refers to everything you can do on your own to manage your health problems and live your life as fully as possible. You must make many decisions every day about medications, exercise, managing stress, and dealing with life problems. There are ways you can help yourself feel more in control of your pain and lessen your pain’s negative effects on your life. You are the most important person on your care team. Self-management is the basis for managing your day and making sure that other treatments work as well as possible. For example, you can use treatments such as ice and heat at home on your own schedule. You can also break up daily activities, such as mowing the lawn, into shorter periods with breaks to not worsen your pain.

b. Non-medication Treatments Non-medication treatments help patients reduce their pain and improve their quality of life. Non-medication treatments also help patients avoid increasing their risk of side effects.

Some side effects of medications are serious. These could be addiction, injury, or death. Behavioral therapies can help patients learn to react to pain in ways that help them function better and reduce their pain. Exercise programs given to you by healthcare providers can slowly improve physical function and reduce your sensitivity to pain. Exercise programs can include physical therapy or gentle whole-body movement programs like yoga or tai chi. Complementary medical treatments like acupuncture, meditation/mindfulness practices, and biofeedback may also be helpful. Work with your healthcare provider to make a treatment plan that includes non-medication treatments. Considering non-medication treatments can help you develop a longer-term plan that makes sense for you. You should be able to carry out the plan over a long period of time to help cope with your pain.

Did you know there are many options for non-medication treatment for chronic pain? Some common treatments are physical therapy, acupuncture, and yoga.

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c. Non-opioid Medication Treatments Some non-opioid medication treatments (medications other than opioids) can also help reduce chronic pain. Examples of non-opioid medications are anti-inflammatory, antidepressant, and anticonvulsant medications. For most people, non-opioid medication treatments are safer than opioids. However, they are generally not as safe as the non-medication treatments described above. Following the directions of your healthcare provider can help you reduce your chances of negative side effects from non-opioid medication treatments.

d. Opioids Opioids are natural or manmade chemicals that can reduce pain. Prescription opioids work by changing the way your brain senses pain. Some common prescription opioids are Vicodin (hydrocodone/acetaminophen), Percocet (oxycodone/acetaminophen), OxyContin (oxycodone), and morphine (morphine sulfate). Researchers and medical professionals have learned two key things through studying opioids and chronic pain. No matter how much you take, opioids can only “take the edge” off the pain. You will not be pain-free long-term. Also, there are serious risks that come with using opioids. Higher doses have more risks. In most cases, using more opioids is not better for pain. Instead, using more opioids can be unsafe and result in worse side effects. While opioids can have an important role in acute and cancer pain management, their place in chronic pain treatment is very limited.

Did You Know?

· Healthcare providers used to think that opioids alone were safe and effective in treating chronic pain. Now we know this isn’t true.

· New information has shown that chronic pain treatment requires a multimodal approach. This type of approach includes various treatment options and disciplines working together to help a patient with their pain condition.

It also includes self-management options.

· Long-term opioid use can lead to multiple problems including loss of pain-relieving effects, increased pain, accidental death, opioid use disorder or addiction, and problems with sleep, mood, hormones, and the immune system.

· It is now understood that the best treatments for chronic pain are not opioids.

· When considering the benefits and harms of various treatments, non-medication treatments may provide the most benefit with the least risk of harm.

III. Safety A. What is an opioid overdose? Is there any way to prevent an overdose?

Opioids have many effects in addition to reducing pain. Opioids affect the part of the brain that helps you breathe normally. When people take high doses of opioids, it can lead to an overdose. Overdoses can slow or stop someone’s breathing and sometimes cause death. Overdose can occur even when following your prescription correctly. The best way to prevent overdose is to use opioids as infrequently as possible and at the lowest dose. Talk to your provider about your dose if you are concerned about the risk of overdose.

B. How can I improve my own safety when I am using opioids?

Always follow the plan you and your provider have developed when using opioids. If your dose is not working for you, contact your provider. Do not make any changes to your dose on your own. Do not mix

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May 2022 Page 5 of 7 opioids with other medications or substances like alcohol. It is important to regularly communicate with your provider and go to follow-up appointments. This helps keep you safe when using opioids. Safely store your medications. This helps protect others (especially children) when you are using opioids. Safely dispose of any opioid prescriptions you do not use.

You may want to talk to your healthcare provider about naloxone. Naloxone is a medication that can be given by injection or nasal spray. It can be used to treat an overdose in emergencies. Naloxone combined with basic life support can quickly and easily reverse an opioid overdose. It is simple to use and causes no harm if given when not experiencing an overdose. This medication is available over the counter. Your healthcare provider can also prescribe it for you. Your healthcare provider can provide instruction on how to administer it.

IV. Questions to Ask Your Provider A. Other than opioids, what options do I have to manage my chronic pain?

There are many options for treating chronic pain. No matter what treatment option you use, you must be involved in your own care. Non-opioid medications, physical therapy, nerve blocks, and sometimes surgery can be helpful. Both exercise and learning to respond to pain differently through behavioral therapy help many people. In general, the better you take care of your physical and mental health, the better you will be able to manage your chronic pain and its effects on your life.

B. Why have doctors and other healthcare providers changed their viewpoint on the use of opioids for chronic pain?

New information clearly shows that opioid medications are not as safe and are not as effective as we once thought. The Centers for Disease Control and Prevention (CDC) has shown that there is an epidemic in the U.S. related to the overprescribing and overuse of opioids.1 This new information has changed medical practice.

C. Have healthcare providers been told they must take everyone off opioids?

No. But the new information about the risks of opioids means that steps must be taken to provide safer care for patients. Providers need to think more carefully about how opioids are used. Many patients who are using opioids now can start using other treatments instead. They can also start using fewer opioids.

These patients will get equal or better pain relief and function with fewer risks.

D. Are opioids right for me?

Short-term use of opioids may be a useful tool as one small part of a comprehensive pain treatment plan when there are few risk factors. Opioids rarely work when they are used by themselves. It is important to understand that being “pain-free” is not possible when you use opioids for a long time.

1 For more information on the opioid epidemic, see: https://www.cdc.gov/opioids/basics/epidemic.html https://www.cdc.gov/opioids/basics/epidemic.html

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E. I have been on opioids for years, and I am doing fine. Will my healthcare provider stop giving me my medications?

This is a question that can only be answered after your healthcare provider does a detailed “risk-benefit analysis” of your situation. Your risks depend on your general health, your pattern of opioid use, and other factors. Your pattern of opioid use relates to how much opioid medication you take and how closely you follow your directions for using opioids. Other factors can include conditions such as a history of alcohol or other substance misuse or serious emotional or social problems. Benefits are determined by how much these medications help you function better. Safety and long-term benefit are more important than short-term pain relief in making decisions about your use of opioids.

F. Am I at risk if I only take my medications as prescribed?

There is no absolutely safe dose of opioids. An overdose is possible even when you are using your opioids as prescribed. Previously safe doses may become dangerous if you develop health problems or if your body’s ability to process these medications changes with age.

G. What is opioid use disorder? How can I tell whether I am developing an opioid use disorder?

Opioid use disorder is a complex condition with physical and mental components. People can develop this condition when they use opioids for a long time. Speak with your healthcare provider if you are worried about your opioid use. Your provider can assess your situation and refer you for help if needed.

V. Resources for More Information

· VHA Pain Management, from VA: https://www.va.gov/painmanagement/

· Pain Management, from the Military Health System: https://health.mil/Military-Health- Topics/Conditions-and-Treatments/Pain-Management

· Chronic Pain Information Page, from the National Institute of Neurological Disorders and Stroke:

https://www.ninds.nih.gov/Disorders/All-Disorders/Chronic-Pain-Information-Page

· Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain, from the VA National Pain Management Program: https://www.va.gov/PAINMANAGEMENT/docs/TakingOpioidsResponsibly20121017.pdf

· Opioids Information for Patients, from the Centers for Disease Control and Prevention:

https://www.cdc.gov/opioids/patients/index.html

· VA/DoD Clinical Practice Guidelines, from VA: https://www.healthquality.va.gov/guidelines/

· Unhealthy Drug Use: Screening, from the U.S. Preventive Services Task Force:

https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening https://www.va.gov/painmanagement/ https://health.mil/Military-Health-Topics/Conditions-and-Treatments/Pain-Management https://health.mil/Military-Health-Topics/Conditions-and-Treatments/Pain-Management https://www.ninds.nih.gov/Disorders/All-Disorders/Chronic-Pain-Information-Page https://www.va.gov/PAINMANAGEMENT/docs/TakingOpioidsResponsibly20121017.pdf https://www.cdc.gov/opioids/patients/index.html https://www.healthquality.va.gov/guidelines/ https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening

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VI. References

1. Yong RJ, Mullins PM, Bhattacharyya N. Prevalence of chronic pain among adults in the United

States. Pain. 2022;163(2):e328-e32.

2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. Jama. 2016;315(15):1624-45.

3. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of internal medicine. 2015;162(4):276-86.

4. Baldini A, Von Korff M, Lin EH. A review of potential adverse effects of long-term opioid therapy: a practitioner’s guide. The primary care companion to CNS disorders. 2012;14(3).