Posted on: Aug 19, 2020
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Dr. Jason Busse
Zoe Knowles
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The opioid epidemic is one of the greatest challenges for Veterans in Canada and the United States.

Canada is the world’s second highest per-capita consumer of opioids, after the United States, which has contributed to increased rates of misuse, dependence, and addiction.

On August 18, 2020, my team and I published two articles in the Annals of Internal Medicine where we explored factors associated with persistent opioid use after musculoskeletal injuries causing acute pain (read the full article here), and then compared the effectiveness of opioids against other pain management treatments for acute injuries (read the full article here). These projects involved researchers from McMaster University, University of Toronto, University of British Columbia, Columbia, Stanford, and other universities across the US, Ireland, and Iran.

Our research found that Veterans are at a higher risk for prolonged use of opioids after an acute musculoskeletal injury (i.e. ankle sprain). Our research also shows that opioids are no more effective at managing acute pain in comparison to other treatments like anti-inflammatories, and have greater risk of harms than other treatments. Put simply, opioids are not more effective than alternatives, and cause more harm, so why use them in the first place?

All chronic pain starts out as acute and improving the treatment of an acute injury may limit progression into chronic pain.

Finding #1: Veterans Are at a Higher Risk for Prolonged Opioid Use after an Acute Injury

Our first article analyzes the prevalence of prolonged opioid use once they have been prescribed for an acute injury, and what factors put a patient at a higher risk for persistent use.

We found that Veterans who file health claims with the US Department of Veterans Affairs (USVA), patients with prior or current substance use disorder, or those receiving of wage replacement benefits are more likely to progress to prolonged opioid use, as opposed to acute pain patients without these features (27% vs. 6%).

Clinicians prescribe opioids to provide pain relief – however, prolonged use of opioids leads to physical dependence, which means you need to keep taking them to avoid symptoms of withdrawal. At that point, it can be hard to quit opioids even if you want to.

The USVA provides tips on how to reduce your risk of opioid dependency here.

Our research also found that avoiding prescribing opioids for acute musculoskeletal injuries among patients with past or current substance use disorder, and restricting duration to 7 days or less and using lower doses when they are prescribed, may be helpful ways to limit prolonged opioid use.

Finding #2: Opioids Are No More Effective than Alternatives for Acute Pain Management but Are More Harmful

There are many treatment options for managing acute pain after a musculoskeletal injury, and ideally patients would choose therapies that are among the most effective and least harmful.

This seems simple, but it’s more complex than it sounds because most clinical trials assess the effectiveness of pain management strategies by comparing them against a placebo. But when a patient is suffering from acute pain, they are not thinking: “I’ll either take this medication or nothing at all.” So, my team and I evaluated how effective a treatment is by ranking each treatment’s performance against other treatments in what is called a comparative analysis or “network meta-analysis.”

We learned that opioids are no more effective than non-opioid treatment options for acute non-lower back pain. In fact, no opioid achieved greater benefit than topical (i.e. cream-based) or oral (i.e. pill-based) anti-inflammatories called “Nonsteroidal anti-inflammatory drugs” or NSAIDs. These topical or oral anti-inflammatories result in similar pain management in both the short and long-term and with fewer negative side effects like stomach pain, nausea, dizziness, and fatigue.

At the Centre of Excellence, we are currently applying a network meta-analysis to evaluate the effectiveness of pain management treatments for different chronic pain conditions. While some patients do benefit from continuing to use opioids for chronic pain management in consultation with their care team, prolonged opioid use is associated with harms, including constipation, problems breathing when asleep, fractures, hormonal changes, and overdose.

How This Research Can Be Used to Help Veterans in Pain

Our findings can help improve the way clinicians treat Veterans in pain, by encouraging clinicians to limit an opioid prescription to 7 days or less following an acute injury, and reconsider prescribing opioids to high-risk groups like Veterans.

In 2013, the USVA rolled out the Opioid Safety Initiative (OSI), a national program designed to decrease opioid prescriptions for Veterans by aggregating electronic medical record data into a single dashboard so that clinicians and VA clinical leaders can review any high-risk factors that would cause an individual patient to develop an opioid use disorder. The policy has been a huge success: as of 2019, OSI has reduced opioid dispensing by more than 50%. Instead of starting a Veteran’s pain management treatment with opioids, the program encourages clinicians to offer Veterans complementary pain management therapies, like yoga, chiropractic medicine, tai chi, bio-feedback, and using topical or oral NSAIDs (i.e. anti-inflammatories).

Do you have research ideas that you think might improve the well-being of Veterans living with chronic pain? Send us your research recommendations to info@vcp-vdc.ca

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