Often, patients being treated for opiate pain management ask me, “How often does the VA random test work?” The answer is that the test is designed to be used only some of the time, but rather it’s used as a monitoring tool for moderate risk. Generally speaking, this means that the test is performed once every six months to once a year. However, some patients may be asked to return more frequently.
Monitoring of moderate risk
During the development of the CDC’s Guideline for Monitoring Moderate Risk Opiate Pain Management Patients, a stakeholder review was conducted to identify experts with expertise and relevant experience. The resulting guideline aims to reduce opioid overdose deaths. Its recommendations are voluntary and include strategies to minimize the risk of overdose. The policy consists of a risk assessment tool, which measures misuse/abuse in various ways. It focuses on the patient’s overall health, including physical and mental functioning, as well as the history of substance use and major depression. The tool helps identify individuals at increased risk of overdose. However, it also has its limitations. It has not been proven to identify patients who benefit from interventions accurately.
The overdose risk depends on the total dose and type of opioid prescribed. A higher total opioid amount is associated with a higher risk of overdose. A large retrospective cohort study found a dose-dependent association between total opioid doses and overdose risk. The adjusted odds ratio was 2.88 for a high total dose compared with a low total amount. The risk of overdose was significantly reduced with abuse-deterrent formulations.
Among the risk factors for continued opioid use after surgery is preoperative pain, history of alcohol and drug use, and medical comorbidities. Age-related changes can lead to a smaller therapeutic window between safe dosages, which may increase the risk of overdose. Risk mitigation techniques include urine drug testing, patient education, and risk assessment instruments. It is essential to discuss with patients the circumstances in which opioids may be discontinued or tapered and set expectations in advance.
The guidelines also recommend a “universal precautions” approach, which includes the following practices: an investigator assessment/plan, a treatment agreement, and a PDMP (prescription drug monitoring program). These practices are intended to identify patients at high risk for opioid overdose. They include using PDMP data, increased monitoring intervals, and the implementation of a pill count.
In addition, the guidelines urge clinicians to use patient-centered functional goals in assessing the benefits and risks of opioid therapy. Despite these practices, clinicians still need to apply them consistently. In addition, the guideline does not address patients undergoing active cancer treatment. Therefore, additional research is encouraged.
The Opioid Guideline Workgroup consists of representatives from the following groups: primary care clinicians, pain medicine, behavioral health, and representatives of the delivery system. These stakeholders provide input on the draft guideline submitted to the BSC. They will give written comments and provide observations. The CDC will summarize these comments and publish them in the Federal Register.
To help reduce the risk of opioid overdose, the guideline calls for prescriptions to be given only when necessary and for the shortest duration is possible. The recommendations are based on emerging evidence. The guideline’s suggestions are voluntary, and the CDC encourages additional clinical trial research to improve understanding of how opioids can be safely used.
Current recommendations and best practices
During the era of the opioid crisis, several professional organizations have developed guidelines and best practices for opiate pain management. These guidelines range from dosing thresholds to risk mitigation strategies. These guidelines aim to inform clinicians and provide safer treatment. However, these recommendations vary greatly. They differ in their use of evidence, degree of scientific rigor, and audience. They also differ in their approach to conflict of interest.
Although various guidelines have been developed, most are based on something other than the latest evidence. Instead, they use expert opinion and a systematic review of the most relevant research. Depending on the audience, the guideline may or may not have a specific focus.
The Centers for Disease Control and Prevention (CDC) recently published a guideline on the most appropriate prescription of opioids. This guideline is designed to reduce opioid overdose and help improve patient outcomes. CDC used a combination of clinical evidence, epidemiology research, and expert recommendations to create the guideline. The guideline is voluntary and is aimed at improving pain management, not addressing pain itself. The policy is designed to be an evidence-based tool to help clinicians prescribe opioids in the outpatient setting.
The CDC gathered experts with a high scientific standing and clinical experience to develop the guideline. It then incorporated its recommendations into a draft guideline, which a federal advisory committee reviewed. The policy is intended to inform clinicians and reduce opioid overdose and misuse.
The most important recommendation is to start an opioid regimen at the lowest effective dose. This dosage can be determined using product labeling and other clinical factors. For patients who are already on opioids, it is recommended that the amount be tapered. It is also advisable to consider nonpharmacologic approaches to pain management. For example, clinicians should consider whether treating patients with psychological comorbidities is appropriate with validated instruments. If this is not possible, patients should be evaluated for these conditions before starting opioids.
The CDC guideline was developed based on a systematic review of the most relevant evidence. This included clinical evidence, the harms and benefits of different treatments, opioid dosages, and risk mitigation strategies. In addition, CDC considered the benefits and risks of various other therapies, including hypnosis, acupuncture, and massage. The CDC reviewed more than 4,350 comments received by the agency. The agency then compiled and published the most valuable recommendations in the Federal Register.
The CDC also released a clinical evidence review and a context-specific evidence review. These reviews explored the most effective approaches to preventing overdose and misusing opioids. They found that opioids are most likely misused if the dose is increased or the duration is prolonged. Other factors that increase the risk of misuse include a history of alcohol or drug abuse, lower socioeconomic status, and medical comorbidities.