The use of opioids in the management of chronic pain: Synopsis of the 2022 Updated U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight. In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance. This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.

Successful Treatment of Medial Tibial Stress Syndrome with Interosseous Membrane Acupuncture: A Case Series.

Background: Medial tibial stress syndrome (MTSS), otherwise known as shin splints, frequently causes pain and disability in the physically active population and can be recalcitrant to treatment. Interventional and alternative therapies, specifically acupuncture, for treatment of MTSS have been poorly described in the literature. The aim of this case series is to describe an acupuncture technique for the treatment of MTSS. Cases: Patients who received the diagnosis of MTSS were treated in an outpatient military treatment facility. One Hwato® 0.30 mm × 75 mm needle was placed 1 cun distal and 1 cun lateral to the tibial tuberosity of the affected leg and was inserted deeply through the plane of the interosseous membrane. A second needle was then placed 2 cun distal to the first needle in the same trajectory and at the same depth. Needles were then irregularly stimulated for 5 minutes before needle removal. After treatment, the patient vigorously moved the affected leg before reassessing pain. Results: Both patients noted a clinically significant decrease in pain immediately after intervention, which lasted for 4 weeks. Conclusions: Interosseous membrane acupuncture is a clinically significant, effective means to decrease MTSS-associated pain in physically active adults. This case series demonstrates a technique to augment conservative therapy of patients with MTSS.