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What is the stance regarding alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments? | recommend | [
"a) We recommend against initiation of long-term opioid therapy for chronic pain. (Strong against) b) We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. (Strong for) c) When pharmacologic therapies are used, we recommend non-opioids over opioids.... | cpgqa | en | true | [
"1000"
] | true | [
"We strongly recommend against initiation of long-term opioid therapy for chronic pain. We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. When pharmacologic therapies are used, we recommend non-opioids over opioids. If prescribing opioid therapy... |
What was the mission of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG)? | to advise the “…Health Executive Council on the use of clinical and epidemiological evidence to improve the health of the population across the Veterans Health Administration and Military Health System,” by facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations | [
"The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the “…Health Executive Council on the use of clinical and epidemiological evidence to improve the health of the population across ... | cpgqa | en | true | [
"1001"
] | true | [
"The current document is an update to the 2010 VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. The methodology used in developing the 2017 CPG follows the VA/DoD Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG. The VA/DoD Guideline for Guideline... |
What can UDT results do? | help identify active SUD or possible diversion | [
"As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Ava... | cpgqa | en | true | [
"1002"
] | true | [
"Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed ... |
What to do after initiating OT? | frequent visits contribute to the appropriate use and adjustment of the planned therapy | [
"Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three mon... | cpgqa | en | true | [
"1003"
] | true | [
"Patients should be informed that progression from acute to long-term OT is associated with little evidence for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient... |
In which areas the National Pain Strategy made recommendations? | prevention and care, professional education and training, and population research | [
"With the passage of the Patient Protection and Affordable Care Act (PPACA) in March 2010, the Interagency Pain Research Coordinating Committee was created to coordinate pain research efforts throughout federal government agencies. The Committee was tasked with summarizing advances in pain care research, identif... | cpgqa | en | true | [
"1004"
] | true | [
"In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] ... |
How was OT used prior to 1980s? | rarely used outside of severe acute injury or post-surgical pain, primarily due to concern for tolerance, physical dependence, and addiction | [
"A paradigm shift in the use of OT for chronic non-terminal pain has paralleled this transformation in pain care. Prior to the 1980s, OT was rarely used outside of severe acute injury or post-surgical pain, primarily due to concern for tolerance, physical dependence, and addiction. As the hospice and palliative ca... | cpgqa | en | true | [
"1005"
] | true | [
"There is a paradigm shift occurring in approaches to ensuring and documenting patient and provider understanding and expectations regarding the risks and benefits of LOT. The 2010 OT CPG reflected prior practice of using opioid treatment (or pain care) agreements. OTAs have been described as coercive rather tha... |
What is an example of true allergy to opioid agents? | anaphylaxis | [
"True allergy to opioid agents: Morphine causes a release of histamine that frequently results in itching, but this does not constitute an allergic reaction. True allergy to opioid agents (e.g., anaphylaxis) is not common, but does occur. Generally, allergy to one opioid does not mean the patient is allergic to ... | cpgqa | en | true | [
"1006"
] | true | [
"Synthetic opioids such as fentanyl analogs, potent opioid receptor agonists, are responsible for a recent rise in death rates. Fentanyl analogs that may be used to create counterfeit opioid analgesic pills can cause a toxidrome characterized by significant CNS and profound respiratory depression requiring multip... |
What contributed to strong recommendations in multiple instances? | these factors | [
"Given the relevance of all four domains in grading recommendations, the Work Group encountered multiple instances in which confidence in the quality of the evidence was low or very low, while there was marked imbalance of benefits and harms, as well as certain other important considerations arising from the domain... | cpgqa | en | true | [
"1007"
] | true | [
"The framework for recommendations in this CPG considered factors beyond the strength of the evidence, including balancing desired outcomes with potential harms of treatment, equity of resource availability, the potential for variation in patient values and preferences, and other considerations (see Methods for ... |
What was associated with depressed mood? | high dose chronic opioid therapy for pain | [
"Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorde... | cpgqa | en | true | [
"1008"
] | true | [
"Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of div... |
What should be done for patients for whom LOT is initiated? | should be carefully monitored, and ongoing assessment of risk should be performed with vigilance for the development of additional risk factors and adverse outcomes | [
"The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insuffic... | cpgqa | en | true | [
"1009"
] | true | [
"While there is currently no evidence in the literature documenting the benefit of LOT that demonstrates improvement in pain and function, we recognize that in a rare subset of individuals a decision to initiate LOT may be considered (e.g., for intermittent severe exacerbations of chronic painful conditions). If ... |
What should be considered when a closer follow-up is needed? | healthcare resources and patient adherence should be considered | [
"Recognizing the lack of evidence of long-term benefit associated with LOT used alone and the risks of harms with use of opioids without risk mitigation, dosing determinations should be individualized based upon patient characteristics and preferences, with the goal of using the lowest dose of opioids for the sh... | cpgqa | en | true | [
"1010"
] | true | [
"Follow-up for tapering should be done with PACT Team. Follow-up for tapering is recommended to be a team function with various team members taking on roles in which they have demonstrated specific competencies. Mental health practitioners may need to be included in the follow-up plan. During the slowest taper, fol... |
When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day three of the rapid opioid tapering? | 30 mg SR (15 mg x 2) Q8h | [
"Rapid Taper is done over days. Rapid tapers can cause withdrawal effects and patients should be treated with adjunctive medications to minimize these effects; may need to consider admitting the patient for inpatient care. If patients are prescribed both long-acting and short-acting opioids, the decision about whic... | cpgqa | en | true | [
"1011"
] | true | [
"Faster Taper is done over weeks. In faster taper, reduce opioid by 10 to 20% every week. An example of the faster taper is given below. During the first week in the faster taper, 16% reduction of morphine SR 90 mg Q8h = 270 MEDD consists of 75 mg SR Q8h. The subsequent weekly dosage for the faster taper is 60 mg ... |
For what purpose state database queries are used throughout the country? | detection of multi-sourcing of controlled substances | [
"State database queries for detection of multi-sourcing of controlled substances are used throughout the country. Data comparing states with an implemented state database program to states without one showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly checks of the ... | cpgqa | en | true | [
"1012"
] | true | [
"With the passage of the Patient Protection and Affordable Care Act (PPACA) in March 2010, the Interagency Pain Research Coordinating Committee was created to coordinate pain research efforts throughout federal government agencies. The Committee was tasked with summarizing advances in pain care research, identif... |
What to do if prior medical records are available for review? | review data and re-assess risks and benefits of continuing OT and consider strength and number of risk factors | [
"Module D is for patients currently on opioid therapy. For patients currently on OT, look for factors that would require immediate attention and possible discontinuation of OT due to unacceptable risk. If there are factors that would require immediate attention, then admit/provide treatment to stabilize, including ... | cpgqa | en | true | [
"1013"
] | true | [
"Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of div... |
What was the purpose of the OSI toolkit? | provide clinicians with materials to inform clinical decision-making regarding opioid therapy and safe opioid prescribing | [
"Other initiatives are aimed at improving the safe use of opioids, including the OSI Toolkit and the patient guide “Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain”. The OSI Toolkit was developed to provide clinicians with... | cpgqa | en | true | [
"1014"
] | true | [
"Government agencies, including the VA, DoD, and Substance Abuse and Mental Health Services Administration (SAMHSA), have also launched initiatives to improve the study and treatment of pain and adverse events associated with opioid analgesics such as OUD and overdose. By August 2013, the VA deployed the Opioid ... |
When to follow up with the Veteran during the rapid taper? | daily before each dose reduction or if available offer inpatient admission | [
"Follow-up for tapering should be done with PACT Team. Follow-up for tapering is recommended to be a team function with various team members taking on roles in which they have demonstrated specific competencies. Mental health practitioners may need to be included in the follow-up plan. During the slowest taper, fol... | cpgqa | en | true | [
"1015"
] | true | [
"Follow up in the first 1 to 4 weeks of taper. If Veteran feels supported and is adjusting to the dose reduction, continue the strategy of reducing to morphine SR 30 mg every 8 hours, follow up in 1 to 4 weeks to determine the next step in the taper. If Veteran strongly resists reduction, then request mental health... |
Why exercise and psychological therapies are preferred over LOT? | In light of the low harms associated with exercise and psychological therapies when compared with LOT | [
"Psychological therapies (e.g., cognitive behavioral interventions such as Cognitive Behavioral Therapy [CBT], biofeedback) have been found to be effective for pain reduction in multiple pain conditions.[80-82] Exercise treatments, including yoga, also have evidence of benefit for reducing pain intensity and disab... | cpgqa | en | true | [
"1016"
] | true | [
"Similar to other risk factors, age <30 years should be weighed heavily in the risk-benefit determination for initiating LOT. Age <30 years is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks of OUD and overdose. Hospitalized patients reco... |
What to do when patients are displaying other aberrant behaviors during the taper? | providing follow-up in a clinic visit may be more optimal than a telephone visit | [
"Follow-up for tapering should be done with PACT Team. Follow-up for tapering is recommended to be a team function with various team members taking on roles in which they have demonstrated specific competencies. Mental health practitioners may need to be included in the follow-up plan. During the slowest taper, fol... | cpgqa | en | true | [
"1017"
] | true | [
"When considering an opioid taper, monitor for conditions that may warrant evaluation and arrange primary care and/or emergency department follow-up when indicated. If a patient is taking more than their prescribed dosage of opioids or showing signs of aberrant behavior, before deciding to change therapy, look for ... |
In response to the recognition of pain and its management as a public health problem in 2011, what was investigated and reported by the National Academy of Medicine? | the state of pain research, treatment, and education in the U.S. | [
"In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] ... | cpgqa | en | true | [
"1018"
] | true | [
"Chronic pain is a national public health problem as outlined in the 2011 study by the National Academy of Medicine (previously the Institute of Medicine [IOM]). At least 100 million Americans suffer from some form of chronic pain. Until recently, the treatment of chronic pain with opioids was increasing at an alar... |
What is CARA? | the Comprehensive Addiction and Recovery Act | [
"On July 22, 2016, the Comprehensive Addiction and Recovery Act (CARA) was enacted with the aim of addressing the epidemic of overdoses from prescription opioids and other prescription drugs and heroin. While this act was primarily focused on opioid abuse treatment and prevention, it also gave specific instruction ... | cpgqa | en | true | [
"1019"
] | true | [
"With the passage of the Patient Protection and Affordable Care Act (PPACA) in March 2010, the Interagency Pain Research Coordinating Committee was created to coordinate pain research efforts throughout federal government agencies. The Committee was tasked with summarizing advances in pain care research, identif... |
When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week five of the faster opioid tapering? | 15 mg SR Q8h | [
"Faster Taper is done over weeks. In faster taper, reduce opioid by 10 to 20% every week. An example of the faster taper is given below. During the first week in the faster taper, 16% reduction of morphine SR 90 mg Q8h = 270 MEDD consists of 75 mg SR Q8h. The subsequent weekly dosage for the faster taper is 60 mg ... | cpgqa | en | true | [
"1020"
] | true | [
"Slower Taper is done over months or years. In the slower taper, reduce opioid by 5 to 20% every 4 weeks with pauses in taper as needed. Slower taper is the most common taper. An example of the slower taper is given below. During the first month in the slower taper, 16% opioid reduction of morphine SR 90 mg Q8h = ... |
At what dose do risks for opioid use disorder begin? | any | [
"If prescribing opioids, we recommend prescribing the lowest dose of opioids as indicated by patient-specific risks and benefits. (Strong for | Reviewed, New-replaced) Note: There is no absolutely safe dose of opioids. As opioid dosage and risk increase, we recommend more frequent monitoring for adverse events incl... | cpgqa | en | true | [
"1021"
] | true | [
"As opioid dosage and risk increase, we recommend more frequent monitoring for adverse events including opioid use disorder and overdose. Note: Risks for opioid use disorder start at any dose and increase in a dose dependent manner. Risks for overdose and death significantly increase at a range of 20- 50 mg morphin... |
What maybe included in interdisciplinary services? | mental health, SUD, primary care, and specialty pain care | [
"When safety allows, a gradual taper rate (5-10% reduction every 4 weeks) allows time for neurobiological, psychological, and behavioral adaptations. When there are concerns regarding risks of tapering (e.g., unmasked OUD, exacerbation of underlying mental health conditions), consider interdisciplinary services tha... | cpgqa | en | true | [
"1022"
] | true | [
"Patient access to physical, psychological, and pain rehabilitation modalities should be considered. In some cases access to care may be limited; all VA and DoD clinics may not have access to multidisciplinary pain services. Still, all avenues for obtaining these treatments (e.g. Internet based CBT) and all appro... |
What was the amount of risk of developing OUD or overdose in patients 30-39 years old compared to subjects 18-29 years old? | roughly half | [
"The added risk that younger patients using opioids face for OUD and overdose is great. Edlund et al. (2014) found that, compared to patients ≥65 years old, patients 18-30 years old carried 11 times the odds of OUD and overdose. Patients 31-40 years old carried 5 times the odds of OUD and overdose compared to tho... | cpgqa | en | true | [
"1023"
] | true | [
"An age of 30 years was chosen based on how age was categorized in the six studies that showed an inverse relationship between age and OUD or overdose. One of those six studies found that patients with OUD were younger than patients without OUD, but did not find a statistically significant relationship.[87] Two o... |
What are the requirements in the policy issued by the VHA to further promote safety and patient centered care? | standardized education and signature informed consent for all patients receiving LOT for non-cancer pain | [
"Other initiatives are aimed at improving the safe use of opioids, including the OSI Toolkit and the patient guide “Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain”. The OSI Toolkit was developed to provide clinicians with... | cpgqa | en | true | [
"1024"
] | true | [
"Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA pr... |
In which instances more rapid tapers may be required? | drug diversion, illegal activities, or situations where the risks of continuing the opioid outweigh the risks of a rapid taper | [
"When formulating an opioid taper plan, determine if the initial goal is a dose reduction or complete discontinuation. If the initial goal is determined to be a dose reduction, subsequent regular reassessment may indicate that complete discontinuation is more suitable. Several factors go into the speed of the selec... | cpgqa | en | true | [
"1025"
] | true | [
"Follow-up for tapering should be done with PACT Team. Follow-up for tapering is recommended to be a team function with various team members taking on roles in which they have demonstrated specific competencies. Mental health practitioners may need to be included in the follow-up plan. During the slowest taper, fol... |
What to do if there is presence of combined sedating medication that increases risk of adverse events (e.g., benzodiazepine)? | proceed to module C | [
"Module D is for patients currently on opioid therapy. For patients currently on OT, look for factors that would require immediate attention and possible discontinuation of OT due to unacceptable risk. If there are factors that would require immediate attention, then admit/provide treatment to stabilize, including ... | cpgqa | en | true | [
"1026"
] | true | [
"There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor fo... |
What specific information can this guideline provide to guide a patient encounter? | looking up the dosing of a medication used less frequently or the meaning of the urine drug testing (UDT) result | [
"This guideline can be used in a variety of ways. This guideline can be used by general clinicians or specialists to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice. It can be used to provide specific informa... | cpgqa | en | true | [
"1027"
] | true | [
"The system-wide goal of this guideline is to improve the patient’s health and well-being by providing evidence-based guidance to providers who are taking care of patients on or being considered for LOT. The expected outcome of successful implementation of this guideline is to assess the patient’s condition, provid... |
Why can benzodiazepines be challenging to discontinue once initiated? | due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety | [
"There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor fo... | cpgqa | en | true | [
"1028"
] | true | [
"Harms may outweigh benefits for the concurrent use of benzodiazepines and LOT. There is moderate quality evidence that concurrent use of benzodiazepines with prescription opioids increases the risk of overdose and overdose death.[66] In a retrospective cohort study, the adjusted odds ratio (AOR) for drug overdos... |
For whom ongoing risk mitigation strategies are recommended? | patients currently on long-term opioid therapy | [
"If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we rec... | cpgqa | en | true | [
"1029"
] | true | [
"We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and includ... |
What can be associated with pain severity and the presence of psychiatric comorbidities? | Worsening of some of these factors (e.g., quality of life, change in employment status) | [
"A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and function... | cpgqa | en | true | [
"1030"
] | true | [
"Medical comorbidities that can increase risk are lung disease, sleep apnea, liver disease, renal disease, fall risk, advanced age. Consider tapering opioids when there is concomitant use of medications that increase risk (e.g., benzodiazepines). Mental health comorbidities that can worsen with opioid therapy are P... |
How to decide the frequency of follow-up visits? | based on risk stratification | [
"Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three mon... | cpgqa | en | true | [
"1031"
] | true | [
"Follow-up for tapering should be done with PACT Team. Follow-up for tapering is recommended to be a team function with various team members taking on roles in which they have demonstrated specific competencies. Mental health practitioners may need to be included in the follow-up plan. During the slowest taper, fol... |
When to stop rapid tapering? | after day 11 | [
"Rapid Taper is done over days. Rapid tapers can cause withdrawal effects and patients should be treated with adjunctive medications to minimize these effects; may need to consider admitting the patient for inpatient care. If patients are prescribed both long-acting and short-acting opioids, the decision about whic... | cpgqa | en | true | [
"1032"
] | true | [
"We recommend tapering to reduced dose or to discontinuation of long-term opioid therapy when risks of long-term opioid therapy outweigh benefits. Note: Abrupt discontinuation should be avoided unless required for immediate safety concerns. We recommend individualizing opioid tapering based on risk assessment and p... |
Which approach to follow when initiating OT? | short duration (e.g., 1 week initial prescription; no more than 3 months total), use the lowest effective dose recognizing that no dose is completely safe, long-acting opioids should not be prescribed for opioid-naive individuals, consider alternatives to methadone and transdermal fentanyl, assessment of improvement in... | [
"Module B is about treatment with opioid therapy. The treatment of opioid therapy is provided to the candidate for trial of OT with consent (in conjunction with a comprehensive pain care plan). Initiate OT using the following approach: short duration (e.g., 1 week initial prescription; no more than 3 months total),... | cpgqa | en | true | [
"1033"
] | true | [
"Patients should be informed that progression from acute to long-term OT is associated with little evidence for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient... |
For whom is this guideline intended? | VA and DoD healthcare practitioners including physicians, nurse practitioners, physician assistants, physical and occupational therapists, psychologists, social workers, nurses, clinical pharmacists, chaplains, addiction counselors, and others involved in the care of Service Members and their beneficiaries, retirees... | [
"This OT CPG is in line with the efforts described above to improve our understanding and treatment of pain, as well as to mitigate the inappropriate prescribing and ill effects of opioids. It is intended for VA and DoD healthcare practitioners including physicians, nurse practitioners, physician assistants, phys... | cpgqa | en | true | [
"1034"
] | true | [
"The system-wide goal of this guideline is to improve the patient’s health and well-being by providing evidence-based guidance to providers who are taking care of patients on or being considered for LOT. The expected outcome of successful implementation of this guideline is to assess the patient’s condition, provid... |
What needs to be better determined by researchers? | the impact of systematic reductions in MEDD in terms of pain relief, specific pain and medical conditions, overdose morbidity and mortality as well as potential adverse outcomes (e.g., the incidence of associated OUD, infectious diseases related to intravenous drug use disorder, and drug-related crime and diversion)... | [
"Future Research: Future research is needed to better determine the impact of systematic reductions in MEDD in terms of pain relief, specific pain and medical conditions, overdose morbidity and mortality as well as potential adverse outcomes (e.g., the incidence of associated OUD, infectious diseases related to i... | cpgqa | en | true | [
"1035"
] | true | [
"Future research is needed to ascertain whether abuse deterrent formulations actually reduce OUD when used for chronic pain, and whether said formulations differ across clinical outcomes such as pain, function, and adverse events. ",
"Given the increasing use of cannabis among patients with chronic pain and th... |
What are some examples of comprehensive pain care plan? | non-opioid treatments, self-management strategies | [
"Module B is about treatment with opioid therapy. The treatment of opioid therapy is provided to the candidate for trial of OT with consent (in conjunction with a comprehensive pain care plan). Initiate OT using the following approach: short duration (e.g., 1 week initial prescription; no more than 3 months total),... | cpgqa | en | true | [
"1036"
] | true | [
"In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] ... |
What to do if an SUD is not identified and there is use of opioids to modulate emotions or an untreated or undertreated psychiatric disorder? | engage the patient in appropriate behavioral and/or psychiatric treatment, ideally in an interdisciplinary setting, consider reduced rate of taper or pause in taper for patients actively engaged in skills training | [
"Module C is on tapering or discontinuation of opioid therapy. If there is indication to taper to reduced dose or taper to discontinuation, repeat comprehensive biopsychosocial assessment. Then see if the patient demonstrates signs or symptoms of SUD. If the patient demonstrates signs or symptoms of SUD, then see w... | cpgqa | en | true | [
"1037"
] | true | [
"Opioids are associated with many risks and it may be determined that they are not indicated for pain management for a particular Veteran. Re-evaluate the risks and benefits of continuing opioid therapy when there is no pain reduction, no improvement in function or patient requests to discontinue therapy, severe un... |
How much does the risk increase at a daily dosage range of 20 to <50 mg MEDD? | approximately 1.5 times | [
"There is moderate quality evidence from retrospective cohort and retrospective case-control studies indicating that risk of prescription opioid overdose and overdose death exists even at low opioid dosage levels and increases with increasing doses. Significant risk (approximately 1.5 times) exists at a daily dosa... | cpgqa | en | true | [
"1038"
] | true | [
"Subgroups at higher risk: Risk of prescription opioid overdose is elevated across MEDD dosage levels in patients with co-occurring depression (moderate quality evidence).[66,133] Following an elevated baseline adjusted risk ratio (ARR) of 3.96, depressed patients taking 1-19 mg, 20 to <50 mg, 50 to <100 mg, and ≥1... |
What does preclude the safe use of self-administered LOT? | Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder | [
"Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorde... | cpgqa | en | true | [
"1039"
] | true | [
"Some patients with SUD may disagree with the recommendation to use non-opioid modalities in lieu of LOT to treat their pain. However, the lack of evidence of efficacy of LOT and considerable evidence of significant harms of overdose, death from overdose, and increased risk of suicide outweigh any potential mode... |
What was the statistics of the events related to OUD or prescription drug overdose in 2014? | 1.9 million Americans were affected by an OUD related to non-medical use of prescription pain relievers, and in the same year, 18,893 individuals died as a result of a prescription drug overdose | [
"The increase in opioid prescribing is matched by a parallel increase in morbidity, mortality, opioid-related overdose death rates, and substance use disorders (SUD) treatment admissions from 1999 to 2008. In 2009, drug overdose became the leading cause of injury-related death in the U.S., surpassing deaths from ... | cpgqa | en | true | [
"1040"
] | true | [
"The Edlund et al. (2014) study of 568,640 commercial health plan patients (see Recommendation 2 and 3) found that those diagnosed with CNCP and an alcohol use or non-opioid drug use disorder had higher rates of OUD (OR: 3.22, 95% CI: 1.79-5.80 for patients with pre-index alcohol use disorder compared to no alco... |
What includes personal history of SUD? | alcohol use disorder (AUD), opioid use disorder (OUD), and/or a use disorder involving other substances | [
"Medical comorbidities that can increase risk are lung disease, sleep apnea, liver disease, renal disease, fall risk, advanced age. Consider tapering opioids when there is concomitant use of medications that increase risk (e.g., benzodiazepines). Mental health comorbidities that can worsen with opioid therapy are P... | cpgqa | en | true | [
"1041"
] | true | [
"Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of div... |
Which tapers may be required in certain instances like illegal activities? | More rapid tapers | [
"When formulating an opioid taper plan, determine if the initial goal is a dose reduction or complete discontinuation. If the initial goal is determined to be a dose reduction, subsequent regular reassessment may indicate that complete discontinuation is more suitable. Several factors go into the speed of the selec... | cpgqa | en | true | [
"1042"
] | true | [
"When considering an opioid taper, monitor for conditions that may warrant evaluation and arrange primary care and/or emergency department follow-up when indicated. If a patient is taking more than their prescribed dosage of opioids or showing signs of aberrant behavior, before deciding to change therapy, look for ... |
Where can the OSI toolkit materials be found? | https://www.va.gov/PAINMANAGEMENT/Opioid_Safety_Initiative_Toolkit.asp | [
"Other initiatives are aimed at improving the safe use of opioids, including the OSI Toolkit and the patient guide “Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain”. The OSI Toolkit was developed to provide clinicians with... | cpgqa | en | true | [
"1043"
] | true | [
"Government agencies, including the VA, DoD, and Substance Abuse and Mental Health Services Administration (SAMHSA), have also launched initiatives to improve the study and treatment of pain and adverse events associated with opioid analgesics such as OUD and overdose. By August 2013, the VA deployed the Opioid ... |
Which long-acting agents can be used for acute pain? | oxycodone/acetaminophen extended release [ER] tablets | [
"Short-acting versus Long-acting Opioids: Avoid use of long-acting agents for acute pain (with exception of oxycodone/acetaminophen extended release [ER] tablets), on an as-needed basis, or for initiation of OT.[10,137-139] There is very low quality evidence to recommend for or against short-acting versus long-acti... | cpgqa | en | true | [
"1044"
] | true | [
"Long-acting opioids, as further discussed below, should not be used for treatment of acute pain, on an as needed basis, or during initiation of LOT (see Short-acting versus Long-acting Opioids). In general, however, no single opioid or opioid formulation is preferred over the others. However, individuals may hav... |
Why exercise and psychological therapies should be offered to all patients with chronic pain including those currently receiving LOT? | In light of the low harms associated with exercise and psychological therapies when compared with LOT | [
"Psychological therapies (e.g., cognitive behavioral interventions such as Cognitive Behavioral Therapy [CBT], biofeedback) have been found to be effective for pain reduction in multiple pain conditions.[80-82] Exercise treatments, including yoga, also have evidence of benefit for reducing pain intensity and disab... | cpgqa | en | true | [
"1045"
] | true | [
"Patient access to physical, psychological, and pain rehabilitation modalities should be considered. In some cases access to care may be limited; all VA and DoD clinics may not have access to multidisciplinary pain services. Still, all avenues for obtaining these treatments (e.g. Internet based CBT) and all appro... |
What is the first-line treatment option for autonomic symptoms? | clonidine 0.1 to 0.2 mg oral every 6 to 8 hours | [
"Consider use of adjuvant medications during the taper to reduce withdrawal symptoms. The first-line treatment option for autonomic symptoms such as sweating, tachycardia, myoclonus is clonidine 0.1 to 0.2 mg oral every 6 to 8 hours; hold dose if blood pressure <90/60 mmHg (0.1 to 0.2 mg 2 to 4 times daily is commo... | cpgqa | en | true | [
"1046"
] | true | [
"Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorde... |
During the first day in the rapid taper what does consist of 33% reduction of morphine SR 90 mg Q8h = 270 MEDD? | 60 mg SR (15 mg x 4) Q8h | [
"Rapid Taper is done over days. Rapid tapers can cause withdrawal effects and patients should be treated with adjunctive medications to minimize these effects; may need to consider admitting the patient for inpatient care. If patients are prescribed both long-acting and short-acting opioids, the decision about whic... | cpgqa | en | true | [
"1047"
] | true | [
"Faster Taper is done over weeks. In faster taper, reduce opioid by 10 to 20% every week. An example of the faster taper is given below. During the first week in the faster taper, 16% reduction of morphine SR 90 mg Q8h = 270 MEDD consists of 75 mg SR Q8h. The subsequent weekly dosage for the faster taper is 60 mg ... |
What was the amount of risk of developing OUD or overdose in patients ≥70 years old compared to subjects 18-29 years old? | far less risk (nearly 1/17) | [
"The added risk that younger patients using opioids face for OUD and overdose is great. Edlund et al. (2014) found that, compared to patients ≥65 years old, patients 18-30 years old carried 11 times the odds of OUD and overdose. Patients 31-40 years old carried 5 times the odds of OUD and overdose compared to tho... | cpgqa | en | true | [
"1048"
] | true | [
"All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are younger than 30 years of age. Seven studies were identified that examined age as a predictor of OUD, respiratory/CNS depression, and/or overdose. Four of the seven studies were rated as fair quality evidence... |
What does the updated CPG include? | objective, evidence-based information on the management of chronic pain | [
"Consequently, a recommendation to update the 2010 OT CPG was initiated in 2015. The updated CPG, titled Clinical Practice Guideline for Opioid Therapy for Chronic Pain (OT CPG), includes objective, evidence-based information on the management of chronic pain. It is intended to assist healthcare providers in all as... | cpgqa | en | true | [
"1049"
] | true | [
"The 2017 version of the VA/DoD OT CPG is the second update to the original CPG. It provides practice recommendations for the care of populations with chronic pain already on or being considered for LOT. Although there are many other approaches to the treatment of chronic pain, the scope of this CPG is to focus ... |
What does a gradual taper rate allow? | time for neurobiological, psychological, and behavioral adaptations | [
"When safety allows, a gradual taper rate (5-10% reduction every 4 weeks) allows time for neurobiological, psychological, and behavioral adaptations. When there are concerns regarding risks of tapering (e.g., unmasked OUD, exacerbation of underlying mental health conditions), consider interdisciplinary services tha... | cpgqa | en | true | [
"1050"
] | true | [
"When formulating an opioid taper plan, determine if the initial goal is a dose reduction or complete discontinuation. If the initial goal is determined to be a dose reduction, subsequent regular reassessment may indicate that complete discontinuation is more suitable. Several factors go into the speed of the selec... |
Which factors increase overdose risk when opioids are used for acute pain? | high prescribed dose, history of SUD, and history of mental health concerns | [
"In addition, the risk of overdose includes the use of opioids for acute pain. Factors that increase overdose risk when opioids are used for acute pain include high prescribed dose, history of SUD, and history of mental health concerns. While the risk of overdose increases at doses above 20 mg MEDD or greater, th... | cpgqa | en | true | [
"1051"
] | true | [
"Factors requiring immediate attention and possible discontinuation are as follows: untreated SUD, unstable mental health disorder, medical condition that acutely increases opioid risks (e.g., compromised or worsening cognitive or cardiopulmonary status), other factors that acutely increase risk of overdose (recent... |
In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, how many reported using opioids? | 15% | [
"From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were... | cpgqa | en | true | [
"1052"
] | true | [
"Take Back Programs: Returning unused opioid medications has been explored as a strategy to reduce the amount of opioids in the community, as it has been estimated that 70% of opioid prescriptions are left unused.[115] Accordingly, the National Drug Control Strategy advocates take back programs as an effective to... |
Tapering will involve dose reduction of how much? | 5% to 20% every 4 weeks | [
"When formulating an opioid taper plan, determine if the initial goal is a dose reduction or complete discontinuation. If the initial goal is determined to be a dose reduction, subsequent regular reassessment may indicate that complete discontinuation is more suitable. Several factors go into the speed of the selec... | cpgqa | en | true | [
"1053"
] | true | [
"Rapid Taper is done over days. Rapid tapers can cause withdrawal effects and patients should be treated with adjunctive medications to minimize these effects; may need to consider admitting the patient for inpatient care. If patients are prescribed both long-acting and short-acting opioids, the decision about whic... |
What to do if adding OT to comprehensive pain therapy is indicated at this time? | see if the patient is prepared to accept responsibilities and the provider is prepared to implement risk mitigation strategies | [
"Module A is about determination of appropriateness for opioid therapy. Note: Non-pharmacologic and non-opioid pharmacologic therapies are preferred for chronic pain. If a patient is with chronic pain and has been on daily OT for pain for more than 3 months, then proceed to module D. If a patient is with chronic pa... | cpgqa | en | true | [
"1054"
] | true | [
"Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three mon... |
Where can the DoD Opioid Prescriber Safety Training Program be found? | http://opstp.cds.pesgce.com/hub.php | [
"The presidential memorandum of October 2015 mandated that executive departments and agencies shall, to the extent permitted by law, provide training on the appropriate and effective prescribing of opioid medications to all employees who are health care professionals and who prescribe controlled substances as part ... | cpgqa | en | true | [
"1055"
] | true | [
"The current document is an update to the 2010 VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. The methodology used in developing the 2017 CPG follows the VA/DoD Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG. The VA/DoD Guideline for Guideline... |
What were the goals of President’s National Drug Control strategy in 2010? | curtailing illicit drug consumption in America and improving the health and safety of the American people by reducing the consequences of drug abuse | [
"The increasing use of opioids, as well as the accompanying rise in morbidity and mortality associated with opioid use, has garnered increasing attention from federal and local officials as well as other policy makers. This public health issue, which has been labeled an epidemic, became a focus of the President’s ... | cpgqa | en | true | [
"1056"
] | true | [
"Take Back Programs: Returning unused opioid medications has been explored as a strategy to reduce the amount of opioids in the community, as it has been estimated that 70% of opioid prescriptions are left unused.[115] Accordingly, the National Drug Control Strategy advocates take back programs as an effective to... |
When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month six of the slower opioid tapering? | 15 mg SR Q12h | [
"Slower Taper is done over months or years. In the slower taper, reduce opioid by 5 to 20% every 4 weeks with pauses in taper as needed. Slower taper is the most common taper. An example of the slower taper is given below. During the first month in the slower taper, 16% opioid reduction of morphine SR 90 mg Q8h = ... | cpgqa | en | true | [
"1057"
] | true | [
"Slowest taper is done over years. In the slowest taper, reduce opioid by 2 to 10% every 4 to 8 weeks with pauses in taper as needed. Consider the slowest taper for patients taking high doses of long-acting opioids for many years. An example of the slowest taper is given below. During the first month in the slowest... |
What is Module C about? | tapering or discontinuation of opioid therapy | [
"Module C is on tapering or discontinuation of opioid therapy. If there is indication to taper to reduced dose or taper to discontinuation, repeat comprehensive biopsychosocial assessment. Then see if the patient demonstrates signs or symptoms of SUD. If the patient demonstrates signs or symptoms of SUD, then see w... | cpgqa | en | true | [
"1058"
] | true | [
"Module A is about determination of appropriateness for opioid therapy. Note: Non-pharmacologic and non-opioid pharmacologic therapies are preferred for chronic pain. If a patient is with chronic pain and has been on daily OT for pain for more than 3 months, then proceed to module D. If a patient is with chronic pa... |
What is the basis of the shared decision making process for chronic pain treatment planning? | the foundation of a patient-centered assessment of risks and benefits and a clinical synthesis performed by the provider | [
"The shared decision making process for chronic pain treatment planning is based on the foundation of a patient-centered assessment of risks and benefits and a clinical synthesis performed by the provider (Figure 1). The patient-centered assessment incorporates a patient-centered interview, and exploration of pa... | cpgqa | en | true | [
"1059"
] | true | [
"With the passage of the Patient Protection and Affordable Care Act (PPACA) in March 2010, the Interagency Pain Research Coordinating Committee was created to coordinate pain research efforts throughout federal government agencies. The Committee was tasked with summarizing advances in pain care research, identif... |
What to do if the treatments are not effective in managing pain and optimizing function? | complete opioid risk assessment and see if patient risks outweigh benefits by considering strength and number of risk factors and patient preference | [
"Module A is about determination of appropriateness for opioid therapy. Note: Non-pharmacologic and non-opioid pharmacologic therapies are preferred for chronic pain. If a patient is with chronic pain and has been on daily OT for pain for more than 3 months, then proceed to module D. If a patient is with chronic pa... | cpgqa | en | true | [
"1060"
] | true | [
"Opioids are not first-line or routine therapy for chronic pain. Establish treatment goals before starting opioid therapy and a plan if therapy is discontinued. Only continue opioid if there is clinically meaningful improvement in pain and function. Discuss risks, benefits and responsibilities for managing therapy ... |
Opioids carry a significant risk for what? | OUD, overdose, and death, especially among patients with untreated SUD | [
"Opioids carry a significant risk for OUD, overdose, and death, especially among patients with untreated SUD. The recommendation against LOT for patients with SUD is supported by five large studies (four retrospective case cohort studies and one case cohort study).[59,61,66,86,87] Individually, these studies are... | cpgqa | en | true | [
"1061"
] | true | [
"Opioids are associated with many risks and it may be determined that they are not indicated for pain management for a particular Veteran. Re-evaluate the risks and benefits of continuing opioid therapy when there is no pain reduction, no improvement in function or patient requests to discontinue therapy, severe un... |
What is recommended at least every 3 months? | evaluating benefits of continued opioid therapy and risk for opioid-related adverse events | [
"We recommend assessing suicide risk and intervening when necessary when considering initiating or continuing long-term opioid therapy. We recommend evaluating benefits of continued opioid therapy and risk for opioid-related adverse events at least every three months. If prescribing opioids, we recommend prescribin... | cpgqa | en | true | [
"1062"
] | true | [
"We recommend evaluating benefits of continued opioid therapy and risk for opioid-related adverse events at least every three months. (Strong for | Reviewed, New-replaced) ",
"Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be compl... |
How much dosage indicates high risk of adverse events? | doses of 90 MEDD (Morphine equivalent daily dose) and higher | [
"Opioids are associated with many risks and it may be determined that they are not indicated for pain management for a particular Veteran. Re-evaluate the risks and benefits of continuing opioid therapy when there is no pain reduction, no improvement in function or patient requests to discontinue therapy, severe un... | cpgqa | en | true | [
"1063"
] | true | [
"As opioid dosage and risk increase, we recommend more frequent monitoring for adverse events including opioid use disorder and overdose. Note: Risks for opioid use disorder start at any dose and increase in a dose dependent manner. Risks for overdose and death significantly increase at a range of 20- 50 mg morphin... |
As found from a survey of patients prescribed opioids for chronic non-cancer pain and their family members, how many patients reported that they used the medication to relieve day-to-day stress? | 22% | [
"The increase in opioid prescribing is matched by a parallel increase in morbidity, mortality, opioid-related overdose death rates, and substance use disorders (SUD) treatment admissions from 1999 to 2008. In 2009, drug overdose became the leading cause of injury-related death in the U.S., surpassing deaths from ... | cpgqa | en | true | [
"1064"
] | true | [
"Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the propor... |
What is QTc interval? | the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave | [
"QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or f... | cpgqa | en | true | [
"1065"
] | true | [
"The relationship between OUD and duration of therapy is magnified when patients have a history of previous opioid or non-opioid SUD. A cross-sectional cohort study found that provision of LOT (four prescriptions within a 12 month period) to CNCP patients who had a history of severe OUD resulted in increased odd... |
What was the National Academy of Medicine formerly known as? | the Institute of Medicine [IOM] | [
"Chronic pain is a national public health problem as outlined in the 2011 study by the National Academy of Medicine (previously the Institute of Medicine [IOM]). At least 100 million Americans suffer from some form of chronic pain. Until recently, the treatment of chronic pain with opioids was increasing at an alar... | cpgqa | en | true | [
"1066"
] | true | [
"In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] ... |
What is recommended if take-home opioids are prescribed? | immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated | [
"We recommend alternatives to opioids for mild-to-moderate acute pain. (Strong for). We suggest use of multimodal pain care including non-opioid medications as indicated when opioids are used for acute pain. (Weak for). If take-home opioids are prescribed, we recommend that immediate-release opioids are used at the... | cpgqa | en | true | [
"1067"
] | true | [
"We recommend alternatives to opioids for mild-to-moderate acute pain. We suggest use of multimodal pain care including non-opioid medications as indicated when opioids are used for acute pain. If take-home opioids are prescribed, we recommend that immediate-release opioids are used at the lowest effective dose wit... |
What to do if the factors that increase risks of OT are present? | consider one or more of the following: shortening prescribing interval, intensifying risk mitigation strategies, increasing intensity of monitoring, referring to interdisciplinary care and consulting with or referring to specialty care | [
"Module B is about treatment with opioid therapy. The treatment of opioid therapy is provided to the candidate for trial of OT with consent (in conjunction with a comprehensive pain care plan). Initiate OT using the following approach: short duration (e.g., 1 week initial prescription; no more than 3 months total),... | cpgqa | en | true | [
"1068"
] | true | [
"The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insuffic... |
What is an example of Bio-Psycho-Social Model? | PHI’s “Whole Health” approach | [
"Educate the Veteran by using Bio-Psycho-Social Model e.g., PHI’s “Whole Health” approach. Offer Veterans pain education groups [especially Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT) for Pain, if available]. Clinicians should offer physical therapy and Complementary and Integrativ... | cpgqa | en | true | [
"1069"
] | true | [
"In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] ... |
What is the role of OT in the treatment of severe acute pain, post-operative pain, and end-of-life pain? | limited | [
"The accumulation of evidence of harms and the absence of evidence of long-term benefits has warranted a newly cautious approach to LOT that prioritizes safety. This approach coupled with the evidence of both the safety and efficacy for non-pharmacologic and non-opioid pharmacologic pain therapies has led to the ... | cpgqa | en | true | [
"1070"
] | true | [
"A paradigm shift in the use of OT for chronic non-terminal pain has paralleled this transformation in pain care. Prior to the 1980s, OT was rarely used outside of severe acute injury or post-surgical pain, primarily due to concern for tolerance, physical dependence, and addiction. As the hospice and palliative ca... |
From 1999 to 2008, what is increasing in parallel with the increment of opioid prescribing? | morbidity, mortality, opioid-related overdose death rates, and substance use disorders (SUD) treatment admissions | [
"The increase in opioid prescribing is matched by a parallel increase in morbidity, mortality, opioid-related overdose death rates, and substance use disorders (SUD) treatment admissions from 1999 to 2008. In 2009, drug overdose became the leading cause of injury-related death in the U.S., surpassing deaths from ... | cpgqa | en | true | [
"1071"
] | true | [
"Concurrent with the increase in prescription opioid use, the rate of heroin overdose deaths increased nearly four-fold between 2000 and 2013. According to a survey of patients entering SUD treatment for heroin use, the prescription opioid epidemic has resulted in a marked shift in how and which opioids are abus... |
What are the red flags in a patient who is taking more than their prescribed dose or showing signs of aberrant behavior? | progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection | [
"When considering an opioid taper, monitor for conditions that may warrant evaluation and arrange primary care and/or emergency department follow-up when indicated. If a patient is taking more than their prescribed dosage of opioids or showing signs of aberrant behavior, before deciding to change therapy, look for ... | cpgqa | en | true | [
"1072"
] | true | [
"Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of div... |
How to implement the risk mitigation strategies upon initiation of long-term opioid therapy? | starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies | [
"We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and includ... | cpgqa | en | true | [
"1073"
] | true | [
"We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and inc... |
What does require reevaluation and discussion of risks and benefits with patients? | Consideration of opioid therapy beyond 90 days | [
"We strongly recommend against initiation of long-term opioid therapy for chronic pain. We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. When pharmacologic therapies are used, we recommend non-opioids over opioids. If prescribing opioid therapy... | cpgqa | en | true | [
"1074"
] | true | [
"At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and ... |
What does the STORM tool do? | incorporates co-occurring medical and mental health conditions, SUD, opioid dose, co-prescribed sedatives, and information about prior adverse events and generates estimates of patients’ risk or hypothetical risk when considering initiation of opioid therapy. It quantifies risk for poisoning or suicide-related event... | [
"There are electronic tools to facilitate clinical risk assessment and adherence to risk mitigation. Two tools currently used in the VA are the Opioid Therapy Risk Report (OTRR) and the Stratification Tool for Opioid Risk Mitigation (STORM). The OTRR allows VA providers to review clinical data related to opioid ... | cpgqa | en | true | [
"1075"
] | true | [
"The Opioid Taper Decision Tool is designed to assist Primary Care providers in determining if an opioid taper is necessary for a specific patient, in performing the taper, and in providing follow-up and support during the taper.",
"As substance misuse in patients on LOT is more than 30% in some series,[107] UDT ... |
Why is UDT and confirmatory testing used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen? | As substance misuse in patients on LOT is more than 30% in some series | [
"As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Ava... | cpgqa | en | true | [
"1076"
] | true | [
"Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is im... |
What is SAMHSA? | Substance Abuse and Mental Health Services Administration | [
"Government agencies, including the VA, DoD, and Substance Abuse and Mental Health Services Administration (SAMHSA), have also launched initiatives to improve the study and treatment of pain and adverse events associated with opioid analgesics such as OUD and overdose. By August 2013, the VA deployed the Opioid ... | cpgqa | en | true | [
"1077"
] | true | [
"In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] ... |
Which factors require immediate attention and possible discontinuation? | untreated SUD, unstable mental health disorder, medical condition that acutely increases opioid risks (e.g., compromised or worsening cognitive or cardiopulmonary status), other factors that acutely increase risk of overdose (recent overdose, current sedation, recent motor vehicle accident), acutely elevated suicide ri... | [
"Factors requiring immediate attention and possible discontinuation are as follows: untreated SUD, unstable mental health disorder, medical condition that acutely increases opioid risks (e.g., compromised or worsening cognitive or cardiopulmonary status), other factors that acutely increase risk of overdose (recent... | cpgqa | en | true | [
"1078"
] | true | [
"When considering an opioid taper, monitor for conditions that may warrant evaluation and arrange primary care and/or emergency department follow-up when indicated. If a patient is taking more than their prescribed dosage of opioids or showing signs of aberrant behavior, before deciding to change therapy, look for ... |
Who will have co-occurring medical conditions? | patients who require higher doses of opioids, even in those who benefit from such therapy | [
"Recognizing the lack of evidence of long-term benefit associated with LOT used alone and the risks of harms with use of opioids without risk mitigation, dosing determinations should be individualized based upon patient characteristics and preferences, with the goal of using the lowest dose of opioids for the sh... | cpgqa | en | true | [
"1079"
] | true | [
"Individuals with conditions that result in or co-occur with chronic pain may have different needs or respond to treatment differently than individuals with chronic pain alone. Many different physical and psychological conditions have a pain component that can be difficult to distinguish from the underlying mechani... |
How to choose between psychological and physical therapies as a first-try? | the choice of which to try first should be individualized based on patient assessment and a shared decision making process | [
"Psychological therapies (e.g., cognitive behavioral interventions such as Cognitive Behavioral Therapy [CBT], biofeedback) have been found to be effective for pain reduction in multiple pain conditions.[80-82] Exercise treatments, including yoga, also have evidence of benefit for reducing pain intensity and disab... | cpgqa | en | true | [
"1080"
] | true | [
"Further studies may help determine earlier in the course of treatment which patients are most likely to benefit from a specific non-pharmacologic therapy (physical, psychological, and pain rehabilitation) or non opioid pharmacologic therapies alone or as part of a multimodal approach. ",
"Module A is about dete... |
What is Module A about? | determination of appropriateness for opioid therapy | [
"Module A is about determination of appropriateness for opioid therapy. Note: Non-pharmacologic and non-opioid pharmacologic therapies are preferred for chronic pain. If a patient is with chronic pain and has been on daily OT for pain for more than 3 months, then proceed to module D. If a patient is with chronic pa... | cpgqa | en | true | [
"1081"
] | true | [
"Module B is about treatment with opioid therapy. The treatment of opioid therapy is provided to the candidate for trial of OT with consent (in conjunction with a comprehensive pain care plan). Initiate OT using the following approach: short duration (e.g., 1 week initial prescription; no more than 3 months total),... |
What to review at each step in the taper? | review the risk of the taper vs. the benefit of remaining at the current dose | [
"Follow up in the first 1 to 4 weeks of taper. If Veteran feels supported and is adjusting to the dose reduction, continue the strategy of reducing to morphine SR 30 mg every 8 hours, follow up in 1 to 4 weeks to determine the next step in the taper. If Veteran strongly resists reduction, then request mental health... | cpgqa | en | true | [
"1082"
] | true | [
"Follow-up for tapering should be done with PACT Team. Follow-up for tapering is recommended to be a team function with various team members taking on roles in which they have demonstrated specific competencies. Mental health practitioners may need to be included in the follow-up plan. During the slowest taper, fol... |
What does risk of overdose include? | the use of opioids for acute pain | [
"In addition, the risk of overdose includes the use of opioids for acute pain. Factors that increase overdose risk when opioids are used for acute pain include high prescribed dose, history of SUD, and history of mental health concerns. While the risk of overdose increases at doses above 20 mg MEDD or greater, th... | cpgqa | en | true | [
"1083"
] | true | [
"There is moderate quality evidence from retrospective cohort and retrospective case-control studies indicating that risk of prescription opioid overdose and overdose death exists even at low opioid dosage levels and increases with increasing doses. Significant risk (approximately 1.5 times) exists at a daily dosa... |
What is not first-line or routine therapy for chronic pain management? | Opioids | [
"Opioids are not first-line or routine therapy for chronic pain. Establish treatment goals before starting opioid therapy and a plan if therapy is discontinued. Only continue opioid if there is clinically meaningful improvement in pain and function. Discuss risks, benefits and responsibilities for managing therapy ... | cpgqa | en | true | [
"1084"
] | true | [
"A paradigm shift in the use of OT for chronic non-terminal pain has paralleled this transformation in pain care. Prior to the 1980s, OT was rarely used outside of severe acute injury or post-surgical pain, primarily due to concern for tolerance, physical dependence, and addiction. As the hospice and palliative ca... |
What to do if risks do not outweigh benefits of continuing OT? | educate/re-educate on the following: non-opioid management, self-management to improve function and quality of life, realistic expectations and limitations of medical treatment options, preferred treatment methods being non-pharmacotherapy and non-opioid pharmacotherapy, new information on risks and lack of benefits of... | [
"Module D is for patients currently on opioid therapy. For patients currently on OT, look for factors that would require immediate attention and possible discontinuation of OT due to unacceptable risk. If there are factors that would require immediate attention, then admit/provide treatment to stabilize, including ... | cpgqa | en | true | [
"1085"
] | true | [
"Similar to other risk factors, continuing OT beyond 90 days’ duration should be weighed heavily in the risk benefit calculus for LOT. Continuing OT for longer than 90 days is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks. That must be d... |
Which topics are covered in the CDC Guideline for Prescribing Opioids for Chronic Pain? | initiation and continuation of OT, management of OT, and risk assessment and use of risk mitigation strategies | [
"The CDC released its Guideline for Prescribing Opioids for Chronic Pain, directed toward primary care physicians, on March 15, 2016. The aim of the guideline is to assist primary care providers in offering safe and effective treatment for patients with chronic pain in the outpatient setting (not including active c... | cpgqa | en | true | [
"1086"
] | true | [
"Consequently, a recommendation to update the 2010 OT CPG was initiated in 2015. The updated CPG, titled Clinical Practice Guideline for Opioid Therapy for Chronic Pain (OT CPG), includes objective, evidence-based information on the management of chronic pain. It is intended to assist healthcare providers in all as... |
What is not an absolute contraindication to LOT? | Age <30 years | [
"Similar to other risk factors, age <30 years should be weighed heavily in the risk-benefit determination for initiating LOT. Age <30 years is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks of OUD and overdose. Hospitalized patients reco... | cpgqa | en | true | [
"1087"
] | true | [
"Similar to other risk factors, continuing OT beyond 90 days’ duration should be weighed heavily in the risk benefit calculus for LOT. Continuing OT for longer than 90 days is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks. That must be d... |
In 2010, what was the focus of National Drug Control Strategy? | The increasing use of opioids | [
"The increasing use of opioids, as well as the accompanying rise in morbidity and mortality associated with opioid use, has garnered increasing attention from federal and local officials as well as other policy makers. This public health issue, which has been labeled an epidemic, became a focus of the President’s ... | cpgqa | en | true | [
"1088"
] | true | [
"Take Back Programs: Returning unused opioid medications has been explored as a strategy to reduce the amount of opioids in the community, as it has been estimated that 70% of opioid prescriptions are left unused.[115] Accordingly, the National Drug Control Strategy advocates take back programs as an effective to... |
Who are at an increased risks of acute OT extending into LOT? | patients with mood disorders, those who refill the initial prescription, higher prescribed dose (greater than 120 mg MEDD), and initiation using long acting opioids | [
"The risks of acute OT extending into LOT are increased in patients with mood disorders, those who refill the initial prescription, higher prescribed dose (greater than 120 mg MEDD), and initiation using long acting opioids.[183-185] The risk of acute post-operative OT progressing into LOT is increased with a his... | cpgqa | en | true | [
"1089"
] | true | [
"Conditions that significantly increase the risk of adverse outcomes from LOT are Duration and dose of OT, Severe respiratory instability or sleep disordered breathing, Acute psychiatric instability or intermediate to high acute suicide risk, Mental health disorders, History of drug overdose, Under 30 years of age,... |
What to do at follow-up visits? | a clinician should re-examine the rationale for continuing the patient on OT | [
"At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and ... | cpgqa | en | true | [
"1090"
] | true | [
"Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three mon... |
What methodology was used in developing the 2017 CPG? | the VA/DoD Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG | [
"The current document is an update to the 2010 VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. The methodology used in developing the 2017 CPG follows the VA/DoD Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG. The VA/DoD Guideline for Guideline... | cpgqa | en | true | [
"1091"
] | true | [
"The 2017 version of the VA/DoD OT CPG is the second update to the original CPG. It provides practice recommendations for the care of populations with chronic pain already on or being considered for LOT. Although there are many other approaches to the treatment of chronic pain, the scope of this CPG is to focus ... |
LOT has been associated with what kinds of symptoms? | worsening depressive symptoms | [
"Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of div... | cpgqa | en | true | [
"1092"
] | true | [
"Conditions that significantly increase the risk of adverse outcomes from LOT are Duration and dose of OT, Severe respiratory instability or sleep disordered breathing, Acute psychiatric instability or intermediate to high acute suicide risk, Mental health disorders, History of drug overdose, Under 30 years of age,... |
What should be arranged for patients with OUD? | MAT (Medication-Assisted Treatment) | [
"Offer risk mitigation strategies, including naloxone for patients at risk for overdose. Review PDMP (Prescription Drug Monitoring Program) data at least every 3 months and perform UDT (Urine Drug Testing) at least annually. Avoid prescribing opioid and benzodiazepines concurrently when possible. Clinicians should... | cpgqa | en | true | [
"1093"
] | true | [
"Ensure screening and treatment is offered for conditions that can complicate pain management before initiating an opioid taper. Conditions that can complicate pain management are mental health disorders, OUD and other SUD, moral injury, central sensitization, medical complications, sleep disorders. Mental health d... |
What does interdisciplinary care do? | addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior | [
"We recommend interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior. We recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder. Note: S... | cpgqa | en | true | [
"1094"
] | true | [
"While these guidelines are broadly recommended, their implementation is intended to be patient centered. Thus, treatment and care should take into account a patient’s needs and preferences. Good communication between healthcare professionals and the patient about the patient’s pain experience, treatment goals, a... |
Intensification of monitoring helps with what? | mitigate the risk of suicide among patients on LOT | [
"There is moderate quality evidence that intensification of monitoring helps mitigate the risk of suicide among patients on LOT. Im et al. (2015) found moderate quality evidence that, at the facility level, patients on LOT within facilities ordering more drug screens than the comparison group were associated with d... | cpgqa | en | true | [
"1095"
] | true | [
"Those patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD may benefit from an alternative management strategy: close follow-up and CBT. Jamison et al. (2010) randomized patients at high-risk for OUD (as measured by standard rating scales) to receive either standard pain management or clo... |
What is the ratio of new users of injectable opioids who had previously used prescription oral opioid pain medication? | 80% | [
"Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infect... | cpgqa | en | true | [
"1096"
] | true | [
"Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the propor... |
How long is the Gasene gas pipeline? | 1400km | [
"Petrobras has postponed until the end of the first half of 2006 the start of production at the offshore Peroa-Cangoa gasfields in the Espirito Santo basin because of lack of transport capacity for the fuel. The development project includes a fixed unmanned platform on Peroa and a 50-km subsea pipeline from the pla... | pira | en | true | [
"A643"
] | false | [
"Petrobras has launched the 38-in., 179-km Cabiunas-Reduc III (Gasduc III) gas pipeline, which is capable of carrying 40 million cu m/day. Gasduc III enhances regional transportation capacity to 40 million from 16 million cu m/day. The line can transport gas produced in the Campos and Espirito Santo basins, as well... |
What makes vortex-induced movements more complex? | aspects such as asymmetric lashing restoring the stiffness and the probable three-dimensionality of the flow. | [
"The vortex-induced vibrations - VIV have been studied for several fields of engineering due to its occurrence in different structures, such as electrical cables, industries chimneys and offshore risers. Although available an extensive literature describing its fundamental issues, these vortex-induced phenomena sti... | pira | en | true | [
"A1009"
] | false | [
"Circular to elliptical topographic depressions, isolated or organized in trails, have been observed on the modern seabed in different contexts and water depths. Such features have been alternatively interpreted as pockmarks generated by fluid flow, as sediment waves generated by turbidity currents, or as a combina... |
What is the peak production that the PDET project will achieve? | 600,000 bbl/day. | [
"Considering demands for internal Brazilian market and international crude oil trade, PETROBRAS has taken the decision to concentrate a significantly part of the future of crude oil production from three deep-water fields; Roncador, Marlim Sul and Marlim Leste, all of which are in Campos Basin, with one off-shore t... | pira | en | true | [
"A1010"
] | false | [
"A discussion covers the South American activities of about a dozen companies in brief. Enventure Global Technology has installed the first solid expansible tubular system (SET) in a well in Campeche sound for Pemex. Enventure Global Technology and Halliburton Energy Services have installed a 270 ft 4.5 in. FlexCla... |
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