ATLANTA — VA clinicians and their patients might find themselves in a difficult position related to proposed opioid prescribing guidelines from the national Centers for Disease Control and Prevention (CDC).

The CDC did a limited initial release of the guidelines in September with a two-day comment period and was immediately criticized for placing greater emphasis on reducing opioid abuse than relieving pain.

After the document was published in the Federal Register in December and controversy continued, the CDC announced it was reopening a 30-day comment period, which ended in mid-January. The primary concerns were whether the guidelines had a strong enough evidence basis and that the initial panel included too many experts in the substance abuse field and too few in the pain management area.

In whatever form the guidelines end up, however, the VA will have to follow them because of a requirement of the agency’s spending bill that went into law late last year.

More than 4,300 comments were received before the January 13 deadline. The National institute of Health’s Interagency Pain Research Coordinating Committee, which includes representatives of the VA and DoD as well as the Food and Drug Administration, Agency for Healthcare Research and Quality and the CDC, had expressed concerns about the low quality of evidence used as the basis for strong recommendations in the guidelines even before the comment period.

In response to the broad-based concerns, the CDC’s National Center for Injury Prevention and Control’s Board of Scientific Counselors appointed a 10-person expert review panel, which includes Erin Krebs, MD, MPH, an investigator with the VA’s Center for Chronic Disease Outcomes Research in Minneapolis. She joins other national leaders in pain, geriatrics, public health, pharmacy, primary care and emergency medicine.

The appointment of Krebs might be the best chance for the 50% of male veterans and 70% of female veterans who experience chronic pain — as well as the physicians who treat them — to gain a voice in the revised guidelines.

Not Voluntary for VA

While the guidelines are specifically noted to be voluntary and are still under review, Congress mandated that VA follow them in the $1.1 trillion spending bill passed in December.

The legislation requires the VA take four steps regarding opioid prescriptions ”to address mounting concerns about prescription drug abuse and an overdose epidemic among veterans,“ according to Sen. Barbara Mikulski (D-MD), vice chairwoman of the Senate Appropriations Committee. The bill directs VA to “adopt the opioid prescribing guidelines developed by the Centers of Disease Control; to develop IT systems to track and monitor opioid prescriptions; to ensure all VA medical facilities are equipped with opioid receptor antagonists to treat drug overdoses; and to provide additional training to medical personnel who prescribe controlled substances.”

The December legislation also called on the VA to report to Congress within 90 days on alternative treatments to opioids and its use of complementary and integrative health therapies to manage pain.

The CDC’s draft guidelines also call for physicians to offer alternatives to opioids, including physical therapy and non-opioid analgesics. The VA has increased use of these alternatives and also expanded access to other options that may reduce pain such as meditation, acupuncture and acupressure, massage and cognitive behavior therapy in the last two years.

“VA continues to work with members of Congress and others, as both chronic pain and opioid misuse continue to present major health problems for not just for our veterans, but a major public health concern for our nation’s healthcare professionals,” VA Spokesperson Ndidi Mojay told U.S. Medicine.

The VA has already undertaken efforts to reduce the excessive use of opioids via the Opioid Safety Initiative rolled out nationwide in 2014. It has also sought to balance the needs of patients with persistent pain.

“The VA healthcare system has identified and broadly responded to the many challenges of pain management through policies supporting clinical monitoring, education and training of health professionals and teams, and expansion of clinical resources and programs,” Mojay said.

Veterans often have different issues and more severe pain than most other patients. “Our veterans’ pain is often more complex,” she said. “Many of our veterans have survived severe battlefield injuries, some repeated, resulting in life-long moderate to severe pain related to damage to their musculoskeletal system and permanent nerve damage, which can not only impact their physical abilities but also impact their emotional health and brain structures.”

Pilot programs showed a 99% drop in OxyContin prescriptions and 50% drop in high-dose opioid use, according to information provided by Mojay. Since July 2012, the number of veterans receiving any opioids has declined by 115,575, while the number on the long-term opioid therapy targeted by the CDC draft guidelines has dropped by 100,074.

The sharp drop raised concerns about under-treatment of pain and the possibility that patients who were unable to refill opioid prescriptions might obtain the drugs or other opiates illegally.

At a Congressional hearing in June, Rep. Beto O’Rourke, (D-TX), discussed the unintended consequence of the tighter opioid prescription guidelines currently followed by the VA. “Veterans are now required to see a prescriber every 30 days, but at the El Paso VA, they are unable to get an appointment, so they go without, or they do something they shouldn’t — they buy them on the street.”

Similar concerns about lack of pain treatment or pushing patients to illegal drugs have been expressed by commenters on the draft CDC guidelines.