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VA/DoD CLINICAL PRACTICE GUIDELINE FOR 

OPIOID THERAPY FOR CHRONIC PAIN

Department of Veterans Affairs

Department of Defense

Patient Summary

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best 

information available at the time of publication. They are designed to provide information and assist 

decision making. They are not intended to define a standard of care and should not be construed as one. 

Neither should they be interpreted as prescribing an exclusive course of management. 

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological 

evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical 

relationships between various care options and health outcomes while rating both the quality of the 

evidence and the strength of the recommendation. 

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of

individual patients, available resources, and limitations unique to an institution or type of practice. Every 

healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of 

applying them in the setting of any particular clinical situation.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for 

specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of 

civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil 

or by contacting your regional TRICARE Managed Care Support Contractor.

Version 3.0 – 2017
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I. Description of Chronic Pain

• Pain is a complex human experience that is strongly

influenced not only by physical factors but also by

what you think, feel, and do when you hurt.

• Acute pain acts as an immediate warning from the

nervous system telling you that you may be injured.

It lets you know that you need to stop doing what

you are doing to stay safe and that you may need to 

seek medical attention. The reasons for acute pain can generally be identified. Reasons may

include trauma, fracture, heart attack, appendicitis, surgery, or other acute medical conditions. 

Acute pain is usually temporary. It usually responds to various treatments such as surgery, shortterm medications, rest, immobilization, physical therapy, certain exercise programs, or 

acupuncture. 

• Chronic pain is pain that persists after your body has healed most tissue damage (usually three

months or longer). Chronic pain can also be caused by conditions that have no cures, like

arthritis or diabetes. It may be worsened by some lifestyle factors (such as inactivity, stress,

nicotine dependence, poor sleep, unhealthy eating, or substance use).

• Acute and chronic pains feel the same. Both types of pain can be severe. However, they are

entirely different problems with entirely different solutions. In fact, treating chronic pain

problems with acute pain solutions may actually make your problems worse.

• The medical conditions that cause acute pain may threaten your life or aspects of your health.

Chronic pain threatens your life style. Chronic pain can impact all aspects of your life. It may

make it hard for you to carry out day-to-day activities, even if others do not notice the pain or

the effects the pain has on you. It could also make other medical problems worse. Chronic pain

may make it hard for you to carry out physical activities, make you more stressed, or make it

hard for you to sleep or rest. Chronic pain can also impact your personal and work relationships.

• The treatment of chronic pain begins with ways you can help manage your own pain and ways

you can reduce the effects the pain has on other parts of your life. This is called selfmanagement. Self-management includes taking care of yourself in ways other than taking

medications, having surgery, or using other medical treatments. More information on selfmanagement and other treatments for chronic pain is included below.

Did You Know?

 Chronic pain is one of the most common 

medical conditions. In the U.S., 

approximately 100 million adults 

experience chronic pain.[1,2] 

 Some types of chronic pain include low 

back pain, neck pain, and other muscle 

and joint pain.

II. What Causes Chronic Pain?

Chronic pain is a problem of the sensitivity of your body's danger-reporting system (a problem with the 

way your body reacts to danger). It can be caused by an injury, a degenerative process, or an ongoing 

medical condition. However, we do not fully understand why these causes lead to chronic pain. Chronic 

pain can also occur without a known cause. Medical tests sometimes may not completely explain the 

reason for the pain or the intensity of the pain. No matter what the cause of your chronic pain is, it is very 

clear that how you respond when you hurt is important. Many efforts to reduce pain in the short-term 
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(such as taking more medication or avoiding activities that make your pain worse) create more pain, 

suffering, and disability in the long-term.

III. How is Chronic Pain Diagnosed?

Pain is a private and personal experience. It cannot be measured by tests or machines. Your pain is 

whatever you say it is because pain is different for every person. It is important that you discuss the type, 

timing, and location of your pain with your healthcare provider. It is also important to discuss other 

aspects of your health. These can include other medical conditions and treatments you have already 

received for your pain, your daily activities, and how you cope with your pain on a day-to-day basis. Once 

your healthcare provider has determined that your pain is chronic (the result of sensitivity rather than 

tissue damage that needs to be repaired or healed), the important question is: What are the effects of the 

pain on your life and how can we help you move forward?

IV. Treatment 

A. What are the Goals of Chronic Pain Treatment?

You should work with your healthcare provider to set reachable goals and to develop your individual 

treatment plan. In general, your goals should be to focus more on what you can do for yourself to help 

lessen the impact of your chronic pain and improve your quality of life. You should focus less on what your 

healthcare provider can do with medications, surgeries, and other treatments. By focusing on ways to 

improve your reaction to the effects of chronic pain, you can improve your day-to-day functioning and 

overall quality of life. You can also lessen your distress from pain and improve your coping skills. 

Potential Goals of Chronic Pain Treatment 

 Restore your physical function (your physical ability to move, exercise, and participate in life)

 Restore your emotional function (happiness and satisfaction with life)

 Restore your social function (activities and connections with others)

 Improve the overall quality of your life 

 Reconnect with what is important to you 

 Improve your ability to manage your pain and return to a healthy lifestyle

 Gain understanding of the nature of your chronic pain

 Address any underlying body tissue injuries that might help you feel better

 Correct other medical issues that result from chronic pain (e.g., muscle weakness, poor sleep, poor diet)

B. What are the Options for Treating Chronic Pain?

There are multiple chronic pain treatment options that can help you reach your goals. No single treatment 

is right for everyone. By talking with your healthcare provider, you can learn more about the possible

treatment options and decide which ones are best for you.

a. Self-management

Self-management is important in any chronic condition. Self-management refers to everything you can do

on your own to manage your health problems and live your life as fully as possible. You have to make 

many decisions every day about medications, exercise, managing stress, and dealing with life problems. 

You also have to decide how these will affect your pain, suffering, and disability. Most importantly for 
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chronic pain, you have to become active in your own rehabilitation efforts. You cannot wait for medical 

solutions. Treatments to address body tissue injuries do not help improve chronic pain problems very 

much. Treatment of chronic pain requires a more comprehensive approach.

b. Non-drug treatments

Many non-drug treatments have helped patients reduce their pain and improve their quality of life. Nondrug treatments have also helped patients avoid increasing their risk of side effects. Some side effects of 

drugs are serious, such as addiction, serious injury, or even death. Behavioral therapies can help people 

learn to react to pain in ways that help them function better and reduce their pain. Exercise programs 

prescribed by healthcare providers slowly improve physical function and reduce pain sensitivity. 

Complementary medical treatments like acupuncture, spinal manipulation therapy, and yoga are helpful 

for many people. Work with your healthcare provider to make a treatment plan that includes non-drug

treatments. This type of treatment plan can help you develop a longer term plan, which should make 

sense for you, should be doable for you over a long period of time, and should help keep you safe. 

c. Non-opioid drug treatments

Some non-opioid drug treatments (medications other than opioids) can also help reduce chronic pain. 

Examples of non-opioid drugs are anti-inflammatory, antidepressant, and anticonvulsant medications. For 

most people, non-opioid drug treatments are safer than opioids. However, they are generally not as safe 

as the non-drug treatments described above. Following the directions of your healthcare provider can help 

you lessen your chances of harmful side effects from non-opioid drug treatments.

d. Opioids

We have learned two key things through studying opioids and chronic pain. First, no matter how much 

opioid medication you take, opioids can only “take the edge” off pain. You will not be pain-free over the 

long-term. Second, there are very significant risks that come with using these medications. These risks are 

directly related to dose. Higher doses carry greater risks with very little evidence of any greater benefit. So 

in most cases, using more is not better for pain, and using more is worse for risks and side effects. While 

opioids have an important role in acute pain management, their place in chronic pain treatment is very 

limited.

Did You Know?

 Healthcare providers used to think that opioids were safe and could help reduce chronic pain when used for long 

periods of time. 

 New information has taught us that long-term opioid use may not be helpful or safe in treating chronic pain. 

 Long-term opioid use can also lead to multiple problems including loss of pain relieving effects, increased pain, 

unintentional death, opioid use disorder or addiction, and problems with sleep, mood, hormones, and the immune 

system.

 We now know that the best treatments for chronic pain are not opioids. The best treatments for chronic pain are 

non-drug treatments.
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V. Questions to Ask Your Provider 

Other than opioids, what are the options I have to manage my chronic pain?

There are many options for treating chronic pain. No matter what treatment option you use, you must be 

involved in your own care. Non-opioid drugs, physical therapy, nerve blocks or other procedures, and 

sometimes surgery can be helpful. Different kinds of exercise and learning to respond to pain differently 

through cognitive behavior therapy help many people. In general, the better you take care of your physical 

and mental health and deal with the effects of chronic pain on your lifestyle, the better you will be able to 

manage your chronic pain.

What are opioids? 

Opioids are natural or manmade chemicals that can reduce pain. Prescription opioids work by changing 

the way your brain senses pain. Some common prescription opioids are Vicodin, Percocet, OxyContin, and 

morphine.

Why have doctors and other healthcare providers changed their viewpoint on opioid therapy?

Medical science has found new information. This new information clearly shows that opioid medications 

are not as safe and are not as effective as we once thought. The Centers for Disease Control and 

Prevention (CDC) has documented an epidemic in the United States related to the over prescribing and 

overuse of opioids. This new information has changed medical practice.

Have healthcare providers been told they have to take everyone off of opioids? 

No. But the new information about the risks of opioids means that we must take steps to provide safer 

care for our patients. We need to think more carefully about how we use opioids. Many patients who are 

using opioids now can start using other treatments instead of using opioids or can start using less opioids. 

These patients will get equal or better pain relief and functioning with fewer risks.

Is opioid therapy right for me?

Short-term use of opioids may be a useful tool as one small part of a comprehensive pain treatment 

program when risk factors are minimal. Opioids rarely work when they are used by themselves. When 

opioids are helpful, patients understand that being “pain-free” is not possible when opioids are used over 

the long term and that they are a small part of their overall pain care plan.

I’ve been on opioids for years and I’m doing fine. Will my healthcare provider stop giving me my 

medications?

This is a question that can only be answered after your healthcare provider does a detailed “risk-benefit 

analysis” of your particular situation. Your risks depend on your general health, your pattern of opioid use,

and other risk factors. Your pattern of opioid use relates to how much opioid medication you take and how 

closely you follow your directions for using opioids. Other risk factors can include conditions such as a 

history of alcohol or other substance misuse or serious emotional or social problems. Benefits are 

determined by how much these medications help you function better in your daily life. Safety and longterm benefit are more important than short-term pain relief in making decisions about your use of opioids. 
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What is an opioid overdose? Is there any way to prevent an overdose?

Opioids have many effects in addition to reducing pain. Opioids slow your mind and body. They can 

actually make you stop breathing. The best way to prevent overdose is to use opioids as seldom as 

possible and at the lowest dose. 

Am I at risk if I only take my medications as prescribed?

There is no absolutely safe dose of opioids. An overdose is possible even when you are using your opioids 

as prescribed. Previously safe doses may become dangerous if you develop other health problems or if 

your body’s ability to process these medications changes with age.

What is opioid use disorder? How can I tell whether I am developing an opioid use disorder? 

Opioid use disorder is a complex condition with both physical and psychological components. People can 

develop this condition when they use opioids for a long period of time. If you are worried about your 

opioid use you should speak with your healthcare provider. Your provider can assess your situation and 

refer you for help if needed.

How can I improve my own safety when I am using opioid therapy?

Always follow your healthcare provider’s instructions when using opioids. Take the correct dose of opioids. 

Do not mix opioids with other medications or substances like alcohol. Communicate regularly with your 

provider and go to follow-up appointments to help improve your safety when using opioids. To help 

protect others when you are using opioids, especially children, safely store or dispose of your medications.

VI. You Can Find More Information on Chronic Pain and Treatment of 

Chronic Pain Here: 

• Veterans Administration Pain Management website: https://www.va.gov/painmanagement/

• Defense and Veterans Center for Integrative Pain Management website: 

http://www.dvcipm.org/ 

• Chronic Pain Information Page from the National Institute of Neurological Disorders and Stroke: 

https://www.ninds.nih.gov/Disorders/All-Disorders/Chronic-Pain-Information-Page

• The patient information guide titled Taking Opioids Responsibly for Your Safety and the Safety of 

Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain: 

https://www.va.gov/PAINMANAGEMENT/docs/TakingOpioidsResponsibly20121017.pdf 

VII. References

1. Institute of Medicine Committee on Advancing Pain Research, Care Education. The National 

Academies Collection: Reports funded by National Institutes of Health. Relieving pain in America: A 

blueprint for transforming prevention, care, education, and research. Washington (DC): National 

Academies Press (US); 2011.

2. Reuben DB, Alvanzo AAH, Ashikaga T, et al. National Institutes of Health Pathways to Prevention 

Workshop: The role of opioids in the treatment of chronic painthe role of opioids in the treatment 

of chronic pain. Annals of Internal Medicine. 2015;162(4):295-300.