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VA research helps lay groundwork for new CDC guidelines on opioids

November 21, 2018


Photo: ©iStock/SteveColeImages

Between 1999 and 2016, more than 200,000 Americans died from overdoses related to prescription opioids, and millions more suffered adverse consequences. (Opioids are a class of drugs used to reduce pain. They can have serious side effects.)

VA has worked hard to address the problem of opioid overuse among its Veteran patients. In 2013, the department launched an Opioid Safety initiative, the first of several swystemwide initiatives to address opioid overuse. These initiatives reduced the use of opioid medications and improved the safety of opioid prescribing, while expanding alternative pain therapies.

In a study published in 2016, a team of researchers from the VA Ann Arbor Healthcare System and the University of Michigan found that the difference between controlling pain and dying from an overdose may come down to how strong a prescription the physician wrote. The team examined health records of 221 Veterans who died from accidental opioid painkiller overdoses, and an equal number of Veterans who took opioids for chronic pain but did not overdose.

The average dose the overdose victims were prescribed was far higher than what the comparison patients had received. While the team did not find a specific dose that clearly differentiated between patients at risk of overdose and those who were not at risk, they suggested changing clinical practices to avoid raising doses for patients with chronic pain could significantly reduce the number of patients who die.

As a result, in part, of the researchers’ work, the Centers for Disease Control and Prevention (CDC), the nation’s health protection agency, changed its opioid prescription guidelines. These guidelines provide recommendations for physicians on clinical practices they should use related to prescribing opioids for chronic pain.

CDC now recommends clinicians prescribe the lowest effective dosage when starting patients on opioids; use caution when prescribing opioids at any dosage; and carefully reassess the evidence of individuals’ benefits and risks when considering increasing patients’ dosage to 50 morphine milligram equivalents (mme) per day or more. They should avoid increasing anyone’s dosage to 90 mme/day. A “pocket card” with this and other information has been sent to all American clinicians licensed to prescribe opioids by the U.S. Surgeon General.

Principal investigator: Amy S. Bohnert, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System

Selected publications and additional information:

Bohnert AS, Logan JE, Ganoczy D, Dowell D. A detailed exploration into the association of prescribed opioid dosage and overdose deaths among patients with chronic pain. Med Care, 2016 May;54(5):435-41.

Gellad WF, Good CB, Shulkin DJ. Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs. JAMA Intern Med. 2017 May 1;177(5):611-612.

CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016

Turn the tide: prescribing opioids for chronic pain, U.S. Surgeon General’s Office, Center for Disease Control

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