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The use of the algorithm format as a way to represent patient management was chosen based on what? | the understanding that such a format may promote more efficient diagnostic and therapeutic decision making and has the potential to change patterns of resource use | [
"This CPG follows an algorithm that is designed to facilitate understanding of the clinical pathway and decision making process used in management of LOT. The use of the algorithm format as a way to represent patient management was chosen based on the understanding that such a format may promote more efficient diag... | cpgqa | en | true | [
"500"
] | 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 should be the duration and dosage when initiatiing opioid thrapy? | 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 | [
"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 | [
"501"
] | true | [
"Use immediate-release (IR) opioids when starting therapy. Prescribe the lowest effective dose. When using opioids for acute pain, provide no more than needed for the condition. Follow up and review benefits and risks before starting and during therapy. If benefits do not outweigh harms, consider tapering opioids t... |
If patients are prescribed both long-acting and short-acting opioids, the decision about which formulation to be tapered first should be individualized based on what? | medical history, mental health diagnoses, and patient preference | [
"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 | [
"502"
] | 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... |
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 benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to whom? | patients in the 20-44 age group | [
"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 ... | cpgqa | en | true | [
"503"
] | 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... |
Why is future research needed to optimize care for chronic-pain patients with and without cannabis use? | Given the increasing use of cannabis among patients with chronic pain and the lack of RCTs comparing outcomes of prescribing LOT versus other therapies for patients with and without cannabis use and cannabis use disorder | [
"Given the increasing use of cannabis among patients with chronic pain and the lack of RCTs comparing outcomes of prescribing LOT versus other therapies for patients with and without cannabis use and cannabis use disorder, future research is needed to optimize care for these patients. Research is also needed to ... | cpgqa | en | true | [
"504"
] | 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 does VA/DoD Suicide CPG refer to? | VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide | [
"The components of biopsychosocial assessment are pain assessment, patient functional goals, impact of pain on family, work, life, review of previous diagnostic studies, additional consultations and referrals, coexisting illness and treatments and effect on pain, significant psychological, social, or behavioral fac... | cpgqa | en | true | [
"505"
] | 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 is recommended for patients less than 30 years of age currently on long-term opioid therapy? | close monitoring and consideration for tapering when risks exceed benefits | [
"a) We recommend against long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose. (Strong against) b) For patients less than 30 years of age currently on long-term opioid therapy, we recommend close monitoring and consideration for tapering when... | cpgqa | en | true | [
"506"
] | true | [
"We recommend against the concurrent use of benzodiazepines and opioids. Note: For patients currently on long-term opioid therapy and benzodiazepines, consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate. We recommend against long-term opioid therapy for patie... |
How much to take from days 1 to 10, when using morphine SR 15 mg tablets? | 4 tablets = 60 mg in the morning, 3 tablets = 45 mg in the afternoon, 4 tablets = 60 mg in the evening | [
"Here is an example of an opioid taper plan for a Veteran. Veteran is currently taking morphine SR 60 mg, 1 tablet every 8 hours. Goal is to reduce the dose of morphine to SR 30 mg every 8 hours using a slow taper. Dose will be reduced by 15 mg every 10 days. Using morphine SR 15 mg tablets, follow the schedule bel... | cpgqa | en | true | [
"507"
] | 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 ... |
When was the 2015 National Drug Control strategy released? | October 2015 | [
"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 | [
"508"
] | true | [
"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 ... |
What is recommended when risks of long-term opioid therapy outweigh benefits? | tapering to reduced dose or to discontinuation of long-term opioid therapy | [
"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... | cpgqa | en | true | [
"509"
] | true | [
"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... |
What to do if a patient is not medically or psychiatrically unstable? | see if there is a clinically meaningful improvement in function in the absence of significant risk factors | [
"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 | [
"510"
] | 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. ",
"While these guidelines... |
When did a more cautious approach to OT for chronic non-terminal pain emerge? | in the decade of the 2010s | [
"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 | [
"511"
] | true | [
"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 ... |
What to do if patient risk outweighs benefits? | see whether referral/consultation for evaluation and treatment is indicated (e.g., mental health, SUD, more intensive interdisciplinary care) | [
"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 | [
"512"
] | true | [
"Patients may decline offered treatments (e.g., OT) and may also decline risk mitigation strategies (e.g., UDT, pill counts) that are recommended in the course of clinical care. However, providers should discuss this decision with the patient, including the likelihood that their decision may result in the risks o... |
What are the limitation of this CPG? | As with other CPGs, there are limitations, including significant evidence gaps. Further, there is a need to develop effective strategies for guideline implementation and evaluation of the effect of guideline adherence on clinical outcomes. | [
"As with other CPGs, there are limitations, including significant evidence gaps. Further, there is a need to develop effective strategies for guideline implementation and evaluation of the effect of guideline adherence on clinical outcomes. Thus, as stated in the qualifying statements at the beginning of the CPG,... | cpgqa | en | true | [
"513"
] | true | [
"This OT CPG is designed to assist healthcare providers in managing or co-managing patients on or being considered for LOT. Specifically, this CPG is intended for adults, including Veterans as well as deployed and non-deployed Active Duty Service Members, their beneficiaries, and retirees and their beneficiaries,... |
Consideration of opioid therapy beyond 90 days requires what? | reevaluation and discussion with patient of risks and benefits | [
"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 | [
"514"
] | true | [
"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... |
Community-based needle exchange programs have been shown to do what? | be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users | [
"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 | [
"515"
] | 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... |
Further research is needed for what? | to identify strategies for safely managing patients at elevated risk of suicide who demand opioid medications or become further destabilized during tapering | [
"Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However, continuing LOT to “prevent suicide” in someone with chronic pain is not recommended as an appropriate response if suic... | cpgqa | en | true | [
"516"
] | true | [
"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... |
What has been an effective risk mitigation strategy for reducing high-risk behaviors and infectious disease transmission among injection drug users? | Community-based needle exchange programs | [
"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 | [
"517"
] | 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... |
Who developed the guidelines? | a panel of multidisciplinary experts | [
" 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 evid... | cpgqa | en | true | [
"518"
] | 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 are some examples of severe unmanageable adverse effects? | drowsiness, constipation, and cognitive impairment | [
"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 | [
"519"
] | true | [
"Intolerance, serious adverse effects, or a history of inadequate beneficial response to opioids: Serious harm may occur should patients be prescribed additional (or different) opioids if prior administration of opioids led to serious adverse effects or was not tolerated. It is also inadvisable to prescribe opioids... |
What can be utilized to assist with managing the withdrawal symptoms? | Short-term oral medications | [
"Short-term oral medications can be utilized to assist with managing the withdrawal symptoms, especially when prescribing fast tapers. Do not treat withdrawal symptoms with an opioid or benzodiazepine. Withdrawal symptoms are not life-threatening and may not be seen with a gradual taper. Early symptoms take hours t... | cpgqa | en | true | [
"520"
] | true | [
"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... |
What to do if there are factors that would require immediate attention? | admit/provide treatment to stabilize, including opioid tapering or SUD treatment as indicated | [
"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 | [
"521"
] | 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 ... |
Which system is used by the CDC guideline to assign a grade for the strength for each recommendation? | GRADE system | [
"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 | [
"522"
] | true | [
"There were also some differences in the methodology used between the development of the VA/DoD OT CPG and the CDC guideline. Along with a clinical evidence review, during which the evidence was evaluated using GRADE, the CDC guideline developers also considered the findings of a contextual evidence review. Furthe... |
What was the outcome of the survey of patients prescribed opioids for chronic non-cancer pain and their family members? | 34% of patients reported that they thought they were “addicted” or “dependent” on opioid pain medication, 34% said that they used the medication for “fun” or to “get high,” while 22% used the medication to relieve day-to-day stress | [
"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 | [
"523"
] | 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 to keep in mind for patients with OUD? | sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17) | [
"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... | cpgqa | en | true | [
"524"
] | 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 is recommended for patients currently on long-term opioid therapy with evidence of untreated substance use disorder? | close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering | [
"For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits. We recommend against long-term opioid therapy for pain in patients with untreated substance use disorder. For patients ... | cpgqa | en | true | [
"525"
] | true | [
"We recommend against long-term opioid therapy for pain in patients with untreated substance use disorder. (Strong against) For patients currently on long-term opioid therapy with evidence of untreated substance use disorder, we recommend close monitoring, including engagement in substance use disorder treatment, ... |
Which can help with pain, anxiety, and sleep? | Gabapentin | [
"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 | [
"526"
] | true | [
"The treatment options for anxiety, dysphoria, lacrimation, and rhinorrhea are hydroxyzine 25 to 50 mg three times a day as needed, diphenhydramine 25 mg every 6 hours as needed. Avoid diphenhydramine for Veterans older than 65 years. The treatment options for myalgias are NSAIDs (e.g., naproxen 375 to 500 mg twice... |
With whom to follow up during opioid taper? | PACT Team | [
"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 | [
"527"
] | true | [
"When a decision is made to taper, special attention must be given to ensure that the Veteran does not feel abandoned. Prior to any changes being made in opioid prescribing, a discussion should occur between the Veteran, family members/caregivers, and the provider either during a face-to-face appointment or on the ... |
What to do if a patient is with chronic pain and has been on daily OT for pain for more than 3 months? | proceed to module D | [
"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 | [
"528"
] | 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 is the clinical practice guideline based on? | a systematic review of both clinical and epidemiological evidence | [
" 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 evid... | cpgqa | en | true | [
"529"
] | true | [
"This guideline is not intended as a standard of care and should not be used as such. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advances and patterns evolve. Today there is variation among stat... |
What is not static? | Suicide risk | [
"A number of studies suggest certain chronic pain conditions represent an independent risk factor for suicide.[123-130] A recent large retrospective cohort study also suggests an association with prescribed opioid dose and suicide risk among Veterans receiving OT for CNCP.[131] Suicide risk is not static, and many ... | cpgqa | en | true | [
"530"
] | true | [
"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 ... |
Where can more information on bipolar disorder be found? | the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) | [
"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 | [
"531"
] | 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 should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents? | Concurrent benzodiazepine and LOT use | [
"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 | [
"532"
] | 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... |
Who are at a higher risk of opioid misuse? | Younger patients | [
"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 ... | cpgqa | en | true | [
"533"
] | true | [
"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... |
Which conditions can complicate pain management? | mental health disorders, OUD and other SUD, moral injury, central sensitization, medical complications, sleep disorders | [
"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... | cpgqa | en | true | [
"534"
] | 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... |
What was coupled with the newly cautious approach to LOT? | the evidence of both the safety and efficacy for non-pharmacologic and non-opioid pharmacologic pain therapies | [
"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 | [
"535"
] | 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... |
Which taper can cause withdrawal effects? | Rapid tapers | [
"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 | [
"536"
] | true | [
"Short-term oral medications can be utilized to assist with managing the withdrawal symptoms, especially when prescribing fast tapers. Do not treat withdrawal symptoms with an opioid or benzodiazepine. Withdrawal symptoms are not life-threatening and may not be seen with a gradual taper. Early symptoms take hours t... |
What are significantly less likely in patients in the 45-64 and ≥65 age groups than 20-44 year olds? | to have non-detection of a prescribed opioid as well (indicating possible diversion) | [
"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 ... | cpgqa | en | true | [
"537"
] | true | [
"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... |
What do autonomic symptoms include? | sweating, tachycardia, myoclonus | [
"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 | [
"538"
] | true | [
"Short-term oral medications can be utilized to assist with managing the withdrawal symptoms, especially when prescribing fast tapers. Do not treat withdrawal symptoms with an opioid or benzodiazepine. Withdrawal symptoms are not life-threatening and may not be seen with a gradual taper. Early symptoms take hours t... |
What is needed when there are signs of/risk factors for infection? | An urgent evaluation | [
"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 | [
"539"
] | 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... |
How much to take from days 21 to 30, when using morphine SR 15 mg tablets? | 3 tablets = 45 mg in the morning, 3 tablets = 45 mg in the afternoon, 3 tablets = 45 mg in the evening | [
"Here is an example of an opioid taper plan for a Veteran. Veteran is currently taking morphine SR 60 mg, 1 tablet every 8 hours. Goal is to reduce the dose of morphine to SR 30 mg every 8 hours using a slow taper. Dose will be reduced by 15 mg every 10 days. Using morphine SR 15 mg tablets, follow the schedule bel... | cpgqa | en | true | [
"540"
] | 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 is recommended to be a team function? | Follow-up for tapering | [
"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 | [
"541"
] | true | [
"This CPG follows an algorithm that is designed to facilitate understanding of the clinical pathway and decision making process used in management of LOT. The use of the algorithm format as a way to represent patient management was chosen based on the understanding that such a format may promote more efficient diag... |
Which factors increase the risk of opioid overdose? | certain concomitant demographic factors, co-occurring medical or psychiatric conditions, or interacting medications or substances | [
"Achieving an improved understanding of the factors contributing to prescription opioid-related overdose is an essential step toward addressing this epidemic problem. Although it is widely accepted that progressively higher doses of prescribed opioids result in correspondingly higher risks of opioid overdose, pati... | cpgqa | en | true | [
"542"
] | true | [
"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... |
What is the relationship between patient values and preferences? | There may be some variation | [
"There may be some variation in patient values and preferences. Certain patients may appreciate the use of risk mitigation strategies and others may not. Participants in the patient focus group expressed an understanding of why various risk mitigation strategies were used (see Patient Focus Group Methods and Fin... | cpgqa | en | true | [
"543"
] | true | [
"VA/DoD CPGs encourage clinicians to use a patient-centered care approach that is tailored to the patient’s capabilities, needs, goals, prior treatment experience, and preferences. Regardless of setting, all patients in the healthcare system should be offered access to evidence-based interventions appropriate to ... |
There may be some variation in what? | patient values and preferences | [
"There may be some variation in patient values and preferences. Certain patients may appreciate the use of risk mitigation strategies and others may not. Participants in the patient focus group expressed an understanding of why various risk mitigation strategies were used (see Patient Focus Group Methods and Fin... | cpgqa | en | true | [
"544"
] | true | [
"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 approp... |
Which model was adopted after the biomedical model of pain care? | a biopsychosocial, multimodal, interdisciplinary model | [
"The U.S. is in the midst of a cultural transformation in the way pain is viewed and treated. The biomedical model of pain care, in which the pain experience is reduced to a pain generator and pain treatment is aimed at fixing or numbing pain with medications, interventions, or surgery, dominated the 1990s and the ... | cpgqa | en | true | [
"545"
] | 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 behaviors can be characterized as unsafe? | early refills, lost/stolen prescription, buying or borrowing opioids, failure to obtain or aberrant UDT | [
"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 | [
"546"
] | 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... |
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 for fun or to get high? | 34% | [
"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 | [
"547"
] | 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... |
In a 2013 medication take back event in a Michigan community, how many containers were collected in four hours? | 3,633 containers containing 345 different prescription medications | [
"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... | cpgqa | en | true | [
"548"
] | true | [
"Naloxone administration has been identified as a life saving measure following opioid overdose. A systematic review of 22 observational studies provided moderate quality evidence that take home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse ev... |
What is OT? | opioid therapy | [
"The components of biopsychosocial assessment are pain assessment, patient functional goals, impact of pain on family, work, life, review of previous diagnostic studies, additional consultations and referrals, coexisting illness and treatments and effect on pain, significant psychological, social, or behavioral fac... | cpgqa | en | true | [
"549"
] | 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... |
Depending on age, marital status, race, and living conditions, who were more likely to continue using opioids? | those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting | [
"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 | [
"550"
] | 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... |
The recommendation against LOT for patients with SUD does not refer to which patients? | patients whose sole SUD relates to tobacco misuse | [
"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 | [
"551"
] | 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 highest for individuals on LOT for chronic pain (without anxiety or PTSD) who also received concurrent long-term benzodiazepine therapy? | the adjusted odds ratio (AOR) for drug overdose | [
"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... | cpgqa | en | true | [
"552"
] | 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 is one of the most disabling chronic medical conditions in the U.S.? | Chronic pain | [
"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... | cpgqa | en | true | [
"553"
] | 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... |
Why did VHA issue a policy requiring standardized education and signature informed consent for all patients receiving LOT for non-cancer pain? | To further promote safety and patient centered care | [
"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 | [
"554"
] | 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... |
How did the 2015 National Drug Control strategy and an accompanying presidential memorandum encourage the improvement of health and safety using evidence-based methods regarding SUD treatments? | by calling for change in a number of key areas including preventing drug use in communities, seeking early intervention opportunities, and integrating SUD treatment and supporting recovery | [
"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 | [
"555"
] | true | [
"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 ... |
Self-management strategies are recommended as alternatives to what? | opioid therapy | [
"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 | [
"556"
] | true | [
"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.... |
Among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with what? | opioid-related toxicity/overdose | [
"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 | [
"557"
] | 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... |
What was the considerations behind the recommendations made in the CPG? | the implications they would have within the VA/DoD healthcare settings, particularly regarding considerations such as resource use, accessibility, and equity related to each recommendation and the urgent need for rigorous attention to the balance of risks and benefits for patients within the VA/DoD specifically | [
"The VA/DoD OT CPG was developed with a specific patient population in mind—Service Members, Veterans, and their families—that has unique characteristics and needs related to the military culture and communities to which they return. Throughout the VA/DoD OT CPG, attention is paid to the characteristics and needs ... | cpgqa | en | true | [
"558"
] | 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 is required by the interpretation of a UDT and confirmatory results? | education and knowledge of the local procedures and clinical scenario | [
"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 | [
"559"
] | 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 to do if there is evidence of diversion? | immediately discontinue 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 | [
"560"
] | 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 did the 2010 OT CPG reflect? | prior practice of using opioid treatment (or pain care) agreements | [
"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... | cpgqa | en | true | [
"561"
] | 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... |
How does the updated CPG guideline fulfil its system-wide goal 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 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... | cpgqa | en | true | [
"562"
] | true | [
"As with other CPGs, there are limitations, including significant evidence gaps. Further, there is a need to develop effective strategies for guideline implementation and evaluation of the effect of guideline adherence on clinical outcomes. Thus, as stated in the qualifying statements at the beginning of the CPG,... |
What does this CPG intend to do? | provide healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with chronic pain who are on or being considered for long-term opioid therapy (LOT) | [
"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 | [
"563"
] | true | [
"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... |
Exacerbation of severe PTSD symptoms may result from what? | gradual benzodiazepine taper | [
"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 | [
"564"
] | true | [
"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... |
What should be approached with extreme caution and warrants specialty consultation? | The concomitant use of oral and transdermal opioids or oral and intrathecal pumps | [
"Route of Administration/Delivery: The systematic evidence review for this CPG did not find any studies that compared alternative delivery systems (e.g., fentanyl transdermal, fentanyl buccal) to other delivery systems (e.g., oral, intravenous) (information on transdermal and sublingual buprenorphine is included ... | cpgqa | en | true | [
"565"
] | true | [
"We recommend assessing suicide risk when considering initiating or continuing long-term opioid therapy and intervening when necessary. (Strong for | Reviewed, Amended) ",
"Given the potential serious risks with starting fentanyl and challenges with tapering, clinicians intent on prescribing transdermal fentanyl... |
What should be weighed heavily in the risk benefit calculus for LOT? | continuing OT beyond 90 days’ duration | [
"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... | cpgqa | en | true | [
"566"
] | 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... |
How often the urine drug testing needs to be performed? | at least annually | [
"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 | [
"567"
] | true | [
"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... |
What is a red flag in the presence of which providers should proceed with utmost caution when considering LOT for these patients? | A history of overdose | [
"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 | [
"568"
] | true | [
"The support for these recommendations is two-fold: a paucity of research showing benefit for LOT and the strength of the evidence demonstrating the potential for life-threatening harm. Of utmost concern is the heightened risk for developing OUD in patients who receive OT beyond 90 days (see Appendix C for Diagnos... |
What does significantly increase at a range of 20- 50 mg morphine equivalent daily dose? | Risks for overdose and death | [
"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... | cpgqa | en | true | [
"569"
] | true | [
"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... |
What can allow the patient time to acquire new skills for management of pain and emotional distress while allowing for neurobiological equilibration? | Pauses in the taper | [
"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... | cpgqa | en | true | [
"570"
] | true | [
"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... |
What can be used to study and consider the latest information on opioid therapy (OT) by general clinicians or specialists? | This guideline | [
"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 | [
"571"
] | 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... |
In a study of civilian patients who had been on opioids for at least 90 days, how many remained on opioids through the 4.8 year follow-up period? | approximately 65% | [
"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 | [
"572"
] | true | [
"Moderate quality evidence demonstrates that the prevalence of OUD in patients with CNCP is related to duration of opioid use as well as dose (see Recommendations 7-9).[86-88] There are two studies of patients with CNCP which support the current recommendations. Edlund et al. (2014) conducted a large retrospectiv... |
When we may not see withdrawal symptoms? | with a gradual taper | [
"Short-term oral medications can be utilized to assist with managing the withdrawal symptoms, especially when prescribing fast tapers. Do not treat withdrawal symptoms with an opioid or benzodiazepine. Withdrawal symptoms are not life-threatening and may not be seen with a gradual taper. Early symptoms take hours t... | cpgqa | en | true | [
"573"
] | true | [
"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... |
Every healthcare professional making use of these guidelines is responsible for what? | evaluating the appropriateness of applying them in the setting of any particular clinical situation | [
"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 approp... | cpgqa | en | true | [
"574"
] | true | [
"This guideline is not intended as a standard of care and should not be used as such. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advances and patterns evolve. Today there is variation among stat... |
Is there any evidence that, at the facility level, patients on LOT within facilities ordering more drug screens than the comparison group were associated with decreased risk of suicide attempt? | Im et al. (2015) found moderate quality evidence | [
"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 | [
"575"
] | true | [
"Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (... |
What is the utmost concern for patients who receive OT beyond 90 days? | the heightened risk for developing OUD | [
"The support for these recommendations is two-fold: a paucity of research showing benefit for LOT and the strength of the evidence demonstrating the potential for life-threatening harm. Of utmost concern is the heightened risk for developing OUD in patients who receive OT beyond 90 days (see Appendix C for Diagnos... | cpgqa | en | true | [
"576"
] | 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... |
The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of what? | the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy | [
"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 | [
"577"
] | true | [
"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 ... |
Whom to prescribe naloxone? | patients at increased risk of overdose | [
"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 | [
"578"
] | true | [
"Naloxone administration has been identified as a life saving measure following opioid overdose. A systematic review of 22 observational studies provided moderate quality evidence that take home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse ev... |
Which represent an independent risk factor for suicide? | certain chronic pain conditions | [
"A number of studies suggest certain chronic pain conditions represent an independent risk factor for suicide.[123-130] A recent large retrospective cohort study also suggests an association with prescribed opioid dose and suicide risk among Veterans receiving OT for CNCP.[131] Suicide risk is not static, and many ... | cpgqa | en | true | [
"579"
] | 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... |
What to do if there are no indications to discontinue or taper? | reassess in 1-3 months or more frequently as determined by patient risk factors | [
"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 | [
"580"
] | true | [
"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... |
Under which circumstances risks of opioid therapy outweigh benefits? | lack of clinically meaningful improvement in function, concomitant use of medications that increase risk of overdose, co-occurring medical or mental health conditions that increase risk, concerns about OUD or other SUD, patient non-compliance with opioid safety measures and opioid risk mitigation strategies, patient no... | [
"Necessary risk mitigation strategies are OEND, UDT, PDMP, face-to-face follow-up with frequency determined by risk. Indications for tapering and discontinuation are as follows: risks of OT outweigh benefits, patient preference, diversion. Risks of opioid therapy outweigh benefits under the following circumstances:... | cpgqa | en | true | [
"581"
] | 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... |
What should be offered to patients? | Patient education about opioid risks and alternatives to opioid therapy | [
"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 | [
"582"
] | 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... |
How many Americans were affected by an OUD related to non-medical use of prescription pain relievers in 2014? | 1.9 million | [
"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 | [
"583"
] | 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 can be caused by fentanyl analogs that may be used to create counterfeit opioid analgesic pills? | a toxidrome characterized by significant CNS and profound respiratory depression requiring multiple naloxone doses for reversal | [
"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... | cpgqa | en | true | [
"584"
] | true | [
"Although some patients may prefer either transdermal or buccal opioid delivery for opioids, there is significant potential for harm from OT with these delivery mechanisms, with no evidence of benefit over traditional opioid delivery systems in patients with chronic pain. Clinicians need to be especially aware of... |
When did VHA issue a policy requiring standardized education and signature informed consent for all patients receiving LOT for non-cancer pain? | in 2014 | [
"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 | [
"585"
] | 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... |
What percentage of people entering SUD treatment for heroin use started using prescription opioids as their first opioid in the 2000s? | 75% | [
"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... | cpgqa | en | true | [
"586"
] | 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... |
Where can the guidance on management of SUD be found? | the VA/DoD SUD CPG | [
"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... | cpgqa | en | true | [
"587"
] | 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... |
Why may primary care providers require more time with patients? | to allow for shared decision making and treatment planning | [
"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... | cpgqa | en | true | [
"588"
] | true | [
"VA/DoD CPGs encourage clinicians to use a patient-centered care approach that is tailored to the patient’s capabilities, needs, goals, prior treatment experience, and preferences. Regardless of setting, all patients in the healthcare system should be offered access to evidence-based interventions appropriate to ... |
What is the trend in pain management and care in the U.S.? | The U.S. is in the midst of a cultural transformation in the way pain is viewed and treated | [
"The U.S. is in the midst of a cultural transformation in the way pain is viewed and treated. The biomedical model of pain care, in which the pain experience is reduced to a pain generator and pain treatment is aimed at fixing or numbing pain with medications, interventions, or surgery, dominated the 1990s and the ... | cpgqa | en | true | [
"589"
] | 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 does the OSI requirements include? | specific indicators (e.g., the number of unique pharmacy patients dispensed an opioid, the unique patients on LOT who have received UDT) | [
"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 | [
"590"
] | true | [
"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... |
What is not recommended as an appropriate response if suicide risk is high or increases? | continuing LOT to “prevent suicide” in someone with chronic pain | [
"Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However, continuing LOT to “prevent suicide” in someone with chronic pain is not recommended as an appropriate response if suic... | cpgqa | en | true | [
"591"
] | true | [
"We recommend assessing suicide risk when considering initiating or continuing long-term opioid therapy and intervening when necessary. (Strong for | Reviewed, Amended) ",
"Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstabl... |
What should the clinicians do as part of the patient-centered care approach? | review the patient’s history including previous treatment approaches, their results, and any other outcomes with the patient | [
"As part of the patient-centered care approach, clinicians should review the patient’s history including previous treatment approaches, their results, and any other outcomes with the patient. They should ask the patient about his or her willingness to accept a referral to an addiction or other behavioral health spe... | cpgqa | en | true | [
"592"
] | true | [
"VA/DoD CPGs encourage clinicians to use a patient-centered care approach that is tailored to the patient’s capabilities, needs, goals, prior treatment experience, and preferences. Regardless of setting, all patients in the healthcare system should be offered access to evidence-based interventions appropriate to ... |
What should the guidelines not be construed as? | a standard of care | [
"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 s... | cpgqa | en | true | [
"593"
] | true | [
"This guideline is not intended as a standard of care and should not be used as such. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advances and patterns evolve. Today there is variation among stat... |
What should not be used for treatment of acute pain? | Long-acting opioids | [
"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... | cpgqa | en | true | [
"594"
] | true | [
"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... |
What is multidisciplinary biopsychosocial rehabilitation? | described as a combination of a physical intervention such as graded exercise and a psychological, social, or occupational intervention | [
"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 | [
"595"
] | 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 should be done when a patient is referred for SUD treatment or is engaged in on-going treatment? | close communication between the SUD and pain management providers | [
"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 | [
"596"
] | true | [
"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... |
Continuing to prescribe the opioid without providing OUD treatment may increase the risk of what? | overdose and other adverse events | [
"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... | cpgqa | en | true | [
"597"
] | 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 is an example of opioid medications? | gabapentin in neuropathic pain states | [
"In addition to non-pharmacological therapies (e.g., exercise, CBT), appropriate mechanism and condition specific non-opioid pharmacologic agents should be tried and optimized before consideration of opioid medications (e.g., gabapentin in neuropathic pain states).[83] Potential contraindications and long-term ri... | cpgqa | en | true | [
"598"
] | 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 sugested when opioids are used for acute pain? | use of multimodal pain care including non-opioid medications as 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 | [
"599"
] | 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... |
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