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Opioid Treatment: New Guidance for Providers on Risks, Recommendations

Graphic by Defense Centers of Excellence for Psychological Heath & Traumatic Brain Injury

Doctors may prescribe opioid medications to treat severe or chronic pain. But using them comes with notable risks – especially for those coping with posttraumatic stress disorder (PTSD), traumatic brain injury (TBI) or substance misuse.

The Departments of Defense and Veterans Affairs (VA) recently updated PDF: clinical guidelines on opioid therapy. These guidelines recommend assessing the risks of using opioid therapy, and address concerns such as managing withdrawal, misuse and overdose in the military.

Overdose is of particular concern for anyone who uses opioids. Certain mental health conditions such as PTSD, depression, anxiety and substance use disorder, present additional risk factors. One study found significantly higher rates of opioid misuse in veterans with PTSD.

A history of TBI may also increase the risk of misuse, according to Christopher Spevak, director of the Opioid Safety Program at Walter Reed National Military Medical Center in Bethesda, Maryland.

“We know that TBI can cause a certain amount of brain structural changes,” Spevak said. “The brain may have chemical changes that predispose individuals to substance use disorder.”

The 2017 guidelines offer 18 recommendations for opioid therapy including:

  • Know the risks – Before deciding on any form of treatment for chronic pain, patients and providers should discuss the risks of opioid therapy.
  • Discuss alternatives first – Patients and providers should work together and first explore non-pharmacological treatments, or non-opioid medications, especially in cases of mild or moderate pain.
  • Avoid long-term use – Limit treatment to 90 days or less.
  • Begin with the lowest dosage possible.
  • Avoid opioids with patients under 30.
  • Monitor use regularly – Schedule regular check-ins with patients during opioid treatment. Increase the number of check-ins if dosage increases or if the therapy extends beyond 90 days.

According to Ilene R. Robeck, director of Virtual Pain Care at Richmond VA Medical Center, Virginia, there isn’t a perfectly safe way to administer opioids and all use requires close monitoring by providers.

“Even patients who take opioids as directed are at risk for adverse events and even death,” Robeck said.

Learn more about the new guidelines:




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This page was last updated on: September 14, 2017.