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What may be considered after stopping rapid tapering after day 11? | morphine IR 15 mg ½ tablet (7.5 mg) twice daily | [
"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 | [
"600"
] | 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... |
Why has returning unused opioid medications been explored as a strategy to reduce the amount of opioids in the community? | it has been estimated that 70% of opioid prescriptions are left unused | [
"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 | [
"601"
] | true | [
"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... |
When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day five of the rapid opioid tapering? | 15 mg SR Q12h | [
"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 | [
"602"
] | 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 ... |
Who have an added great risk for OUD and overdose? | younger patients using opioids | [
"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 | [
"603"
] | 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 the simplified linear approach depicted through the algorithm and its format allow? | to assess the critical information needed at the major decision points in the clinical process | [
"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 | [
"604"
] | 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 to do when there is non-adherence to the treatment plan or unsafe behaviors? | Re-evaluate the risks and benefits of continuing opioid therapy | [
"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 | [
"605"
] | 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 state of research on the effectiveness of LOT for non-end-of-life pain? | limited | [
"There has been limited research on the effectiveness of LOT for non-end-of-life pain. At the same time, there is mounting evidence of the ill effects of LOT, including increased mortality, OUD, overdose, sexual dysfunction, fractures, myocardial infarction, constipation, and sleep-disordered breathing. Despite inc... | cpgqa | en | true | [
"606"
] | 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 can be caused by rapid taper? | withdrawal effects | [
"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 | [
"607"
] | true | [
"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... |
What does the OTRR do? | allows VA providers to review clinical data related to opioid pain treatment within the electronic medical record (EMR), providing an efficient way of monitoring the data | [
"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 | [
"608"
] | true | [
"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:... |
What are examples of non-adherence to the treatment plan or unsafe behaviors? | 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 | [
"609"
] | 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... |
In which way the U.S. is in the midst of 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 | [
"610"
] | 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 often the UDT 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 | [
"611"
] | 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... |
Which patients may be at risk? | those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope | [
"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 | [
"612"
] | 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 to do when there is no pain reduction? | Re-evaluate the risks and benefits of continuing opioid therapy | [
"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 | [
"613"
] | 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 is the estimated lifetime prevalence for OUD among patients receiving long-term opioid therapy? | about 41%: approximately 28% for mild symptoms, 10% for moderate symptoms and 3.5% for severe symptoms of OUD | [
"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 | [
"614"
] | 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... |
What to do for patients currently on OT? | look for factors that would require immediate attention and possible discontinuation of OT due to unacceptable risk | [
"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 | [
"615"
] | 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 is recommended when considering initiating or continuing long-term opioid therapy? | assessing suicide risk | [
"We recommend assessing suicide risk when considering initiating or continuing long-term opioid therapy and intervening when necessary. (Strong for | Reviewed, Amended) "
] | cpgqa | en | true | [
"616"
] | 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... |
When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day nine of the rapid opioid tapering? | 15 mg SR QHS | [
"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 | [
"617"
] | 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 ... |
Who may have different needs or respond to treatment differently than individuals with chronic pain alone? | Individuals with conditions that result in or co-occur with chronic pain | [
"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... | cpgqa | en | true | [
"618"
] | true | [
"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... |
Who issued a policy requiring standardized education and signature informed consent for all patients receiving LOT for non-cancer pain? | the VHA | [
"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 | [
"619"
] | 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 there is a clinically meaningful improvement in function in the absence of significant risk factors? | review and optimize comprehensive pain care plan (e.g., 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 | [
"620"
] | 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 to do if there is high risk or dangerous behaviors? | repeat comprehensive biopsychosocial assessment and see if an SUD is identified | [
"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 | [
"621"
] | 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 to do if the patient demonstrates signs or symptoms of SUD? | see whether the patient is willing to engage in SUD 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 | [
"622"
] | 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 conditions significantly increase the risk of adverse outcomes from LOT? | 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, Co-administration of a drug capable of inducing fatal drug-drug interactions, QTc int... | [
"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,... | cpgqa | en | true | [
"623"
] | 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 does the DoD Opioid Prescriber Safety Training Program include? | modules on pain management and opioid prescribing safety, the recent Centers for Disease Control and Prevention (CDC) guideline, and the identification of substance misuse and referral to specialized services | [
"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 | [
"624"
] | 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 ... |
What is the estimation of the lifetime prevalence for severe symptoms of OUD among patients receiving long-term opioid therapy? | 3.5% | [
"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 | [
"625"
] | 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... |
What do psychological therapies help? | effective for pain reduction in multiple pain conditions | [
"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 | [
"626"
] | 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. ",
"Acute psychiatric inst... |
How to determine whether 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 | [
"627"
] | 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 was the purpose of Interagency Pain Research Coordinating Committee? | coordinate pain research efforts throughout federal government agencies | [
"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 | [
"628"
] | 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] ... |
In a study of Veterans with chronic pain who had been on opioids for at least 90 days, how many continued to use opioids after completion of the 3.5 year follow-up period? | nearly 80% | [
"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 | [
"629"
] | 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 do if there is no high risk or dangerous behavior? | develop an individualized tapering treatment plan (including pace of tapering, setting of care) based on patient and treatment characteristics | [
"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 | [
"630"
] | 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 is an ineffective treatment modality for patients with myofascial pain? | LOT | [
"Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such ... | cpgqa | en | true | [
"631"
] | 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 ... |
How was the National Pain Strategy published? | in response to the call from the National Academy of Medicine to increase awareness of pain as a significant public health issue in the U.S. | [
"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 | [
"632"
] | 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] ... |
Why is continuing LOT not recommended to “prevent suicide” in someone with chronic pain? | an appropriate response if suicide risk is high or increases | [
"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 | [
"633"
] | 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... |
When are non-opioids recommended over opioids? | When pharmacologic therapies are used | [
"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 | [
"634"
] | 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.... |
In a study of patients on opioids, who had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder? | those with bipolar 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 | [
"635"
] | 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 are the components of the OEND program? | education and training regarding the following topics: opioid overdose prevention, recognition, and rescue response; risk mitigation strategies; and issuing naloxone kits, which can be used as an antidote to opioid overdose | [
"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 | [
"636"
] | true | [
"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:... |
Why should abrupt discontinuation of benzodiazepines be avoided? | as it can lead to serious adverse effects including seizures and death | [
"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 | [
"637"
] | true | [
"We recommend against the concurrent use of benzodiazepines and opioids. (Strong against | Reviewed, New-added) 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 (see Recommendati... |
If the patients under opioid taper pna resume their original dose, they are at risk of what? | an 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 | [
"638"
] | 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 are some examples of psychological therapies? | cognitive behavioral interventions such as Cognitive Behavioral Therapy [CBT], biofeedback | [
"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 | [
"639"
] | 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. ",
"The components of biop... |
According to CDC, what needs to be checked at least quarterly? | the state database system | [
"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 | [
"640"
] | 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 to do if the patient is not willing to engage in SUD therapy? | address safety and misuse, assess for withdrawal symptoms and offer expedited taper, immediate discontinuation or detox as indicated, continue to monitor for SUD and mental health comorbidities and offer treatment as indicated (see VA/DoD SUD CPG and Academic Detailing Tapering Document), exit algorithm and manage with... | [
"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 | [
"641"
] | 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... |
When to re-evaluate the risks and benefits of continuing opioid therapy? | no pain reduction, no improvement in function or patient requests to discontinue therapy, severe unmanageable adverse effects, dosage indicates high risk of adverse events, concerns related to an increased risk of SUD (Substance use disorder) (e.g., behaviors, age < 30, family history, personal history of SUD), an over... | [
"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 | [
"642"
] | 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) ",
"Factors requiring immediate attention and possible discontinuation are as follows: untreated SUD, unstable mental health disorder, medical... |
If prescribing opioids, what is the recommended dose? | lowest dose of opioids as indicated by patient-specific risks and benefits | [
"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 | [
"643"
] | 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... |
Which opioid/opioid formulation did not have enough evidence to be recommended for or against? | any specific opioid or opioid formulation, specifically the following: Short-acting versus long-acting opioids (for LOT for chronic pain), Route of administration/delivery among alternatives such as transdermal, buccal, sublingual, or pumps, Abuse deterrent formulations of opioids compared to non-abuse deterrent form... | [
"There was insufficient evidence to recommend for or against any specific opioid or opioid formulation, specifically the following: Short-acting versus long-acting opioids (for LOT for chronic pain), Route of administration/delivery among alternatives such as transdermal, buccal, sublingual, or pumps, Abuse deter... | cpgqa | en | true | [
"644"
] | 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... |
Who must follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain? | VHA providers | [
"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 | [
"645"
] | true | [
"Given the recognized risks of opioid therapy, an optimal approach to care should include a robust, signature informed consent process that is patient-centered and provides patients with information about known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for signatu... |
What does the work Group recognize? | not all clinical practices are linear | [
"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 | [
"646"
] | 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 to do if the patient is not willing to engage in a comprehensive pain care plan? | exit algorithm; manage with non-opioid modalities | [
"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 | [
"647"
] | true | [
"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... |
Where to follow up with the Veteran during the slowest taper? | in the clinic and/or over telephone | [
"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 | [
"648"
] | 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... |
When may serious harm occur in patients? | should patients be prescribed additional (or different) opioids if prior administration of opioids led to serious adverse effects or was not tolerated | [
"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... | cpgqa | en | true | [
"649"
] | true | [
"As this guideline is related to LOT, the use of opioids for acute pain is not reviewed in detail. However, because acute OT can be a gateway to LOT, it is part of this CPG. A review of the literature indicates that LOT can result from acute opioid use initially intended for short-term therapy. Further, there is ... |
What does the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommend? | a biopsychosocial approach to pain care that is multimodal and interdisciplinary | [
"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 | [
"650"
] | true | [
"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... |
What is recommended for patients currently on long-term opioid therapy? | ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14) | [
"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 | [
"651"
] | 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 was the dominating period of the biomedical model of pain care? | the 1990s and the first decade of the 2000s | [
"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 | [
"652"
] | 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 assess for patients already on OT? | psychological factors related to continuing vs. tapering OT | [
"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 | [
"653"
] | 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 to do if the patient is not prepared to accept responsibilities or the provider is not prepared to implement risk mitigation strategies? | exit algorithm; manage with non-opioid modalities | [
"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 | [
"654"
] | 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 was the impact of the report on the state of pain research, treatment, and education in the U.S. by the National Academy of Medicine in 2011? | The report called for a cultural transformation in the way pain is viewed and treated. | [
"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 | [
"655"
] | 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 do opioids do to the bowel? | inhibit bowel peristalsis | [
"Impaired bowel motility unresponsive to therapy: Opioids inhibit bowel peristalsis. Their use with patients with impaired bowel motility can increase the risk of severe constipation/impaction or possible obstruction. "
] | cpgqa | en | true | [
"656"
] | true | [
"There has been limited research on the effectiveness of LOT for non-end-of-life pain. At the same time, there is mounting evidence of the ill effects of LOT, including increased mortality, OUD, overdose, sexual dysfunction, fractures, myocardial infarction, constipation, and sleep-disordered breathing. Despite inc... |
Who may disagree with the recommendation to use non-opioid modalities in lieu of LOT to treat their pain? | Some patients with SUD | [
"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 | [
"657"
] | 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 to discuss before starting the treatment? | risks, benefits and responsibilities for managing therapy | [
"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 | [
"658"
] | 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 is OSI? | Opioid Safety Initiative | [
"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 | [
"659"
] | 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 the alternative treatment option for autonomic symptoms using Baclofen? | 5 mg 3 times daily; may increase to 40 mg total daily dose; re-evaluate in 3 to 7 days; average duration 15 days; may continue after acute withdrawal to help decrease cravings; should be tapered when it is discontinued | [
"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 | [
"660"
] | true | [
"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... |
On what to follow-up with the Veteran? | patient function, pain intensity, sleep, physical activity, personal goals, and stress level | [
"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 | [
"661"
] | 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 is recommended for patients who are currently prescribed doses over 90 mg morphine equivalent daily dose? | evaluate for tapering to reduced dose or to discontinuation | [
"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 | [
"662"
] | true | [
"We recommend against opioid doses over 90 mg morphine equivalent daily dose for treating chronic pain. Note: For patients who are currently prescribed doses over 90 mg morphine equivalent daily dose, evaluate for tapering to reduced dose or to discontinuation. We recommend against prescribing long-acting opioids f... |
Which techniques to use to acknowledge the Veteran’s fears about tapering? | Motivational Interviewing (MI) | [
"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 ... | cpgqa | en | true | [
"663"
] | 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... |
Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to what? | the false positive and negative rates associated with UDTs | [
"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 | [
"664"
] | true | [
"The systematic review conducted for the update of this CPG encompassed interventional studies (primarily randomized controlled trials [RCTs]) published between March 2009 and December 2016 and targeted nine key questions (KQs) focusing on the means by which the delivery of healthcare could be optimized for patie... |
What is recommended as opioid dosage and risk increase? | more frequent monitoring for adverse events including opioid use disorder and overdose | [
"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 | [
"665"
] | 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 to document in the Veteran’s medical record? | the rationale for the opioid taper and the opioid taper schedule | [
"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 | [
"666"
] | true | [
"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 ... |
When reducing 5% of morphine SR 90 mg Q8h = 270 MEDD, what dose should be taken on month six of the slowest opioid tapering? | 60 mg SR Q8h | [
"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 | [
"667"
] | 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 = ... |
What is recommended upon initiation of long-term opioid therapy? | implementing risk mitigation strategies | [
"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... | cpgqa | en | true | [
"668"
] | 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 does UDT refer to? | urine drug test | [
"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 | [
"669"
] | 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... |
The use of a CPG must always be considered as what? | a recommendation, within the context of a provider’s clinical judgment and patient values and preferences, in the care for an individual patient. | [
"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... | cpgqa | en | true | [
"670"
] | 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,... |
Who are the target population for the VA/DoD OT CPG? | Service Members, Veterans, and their families—that has unique characteristics and needs related to the military culture and communities to which they return | [
"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 | [
"671"
] | 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,... |
What to monitor for when considering an opioid taper? | conditions that may warrant 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 | [
"672"
] | true | [
"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... |
Where does OT have a limited role? | primarily in the treatment of severe acute pain, post-operative pain, and end-of-life pain | [
"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 | [
"673"
] | 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... |
Who will have other adverse events? | 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 | [
"674"
] | 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... |
Who did carry 11 times the odds of OUD and overdose compared to patients ≥65 years old? | patients 18-30 years old | [
"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 | [
"675"
] | 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... |
For which patients the VA/DoD Suicide CPG recommends restricting the availability of lethal means? | patients considered to be at intermediate or high acute risk of suicide (determined by presence and severity of suicidal ideation, level of intention to act, existence of risk factors, limited or absent protective factors, etc.) | [
"Opioid medications are potentially lethal and an assessment of current suicide risk should be made at every phase of treatment. The VA/DoD Suicide CPG recommends restricting the availability of lethal means for patients considered to be at intermediate or high acute risk of suicide (determined by presence and seve... | cpgqa | en | true | [
"676"
] | true | [
"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 ... |
What should be considered for non-opioid pharmacologic agents? | Potential contraindications and long-term risks of use | [
"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 | [
"677"
] | 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. ",
"There was insufficient... |
In addition to non-pharmacological therapies, what should be tried and optimized before consideration of opioid medications? | appropriate mechanism and condition specific non-opioid pharmacologic agents | [
"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 | [
"678"
] | 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. ",
"We recommend implement... |
During the first week in the faster taper what does consist of 16% reduction of morphine SR 90 mg Q8h = 270 MEDD? | 75 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 | [
"679"
] | 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 = ... |
What are the odds of suicidal ideation within the past 12 months in those with bipolar disorder compared to those with no bipolar disorder? | 2.9 times | [
"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 | [
"680"
] | 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... |
A discussion should occur between the Veteran, family members/caregivers, and the provider prior to what? | any changes being made in opioid prescribing | [
"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 ... | cpgqa | en | true | [
"681"
] | 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 rate of a gradual taper? | 5-10% reduction every 4 weeks | [
"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 | [
"682"
] | 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 influence an individual’s risk of suicide at any given point in time? | many factors | [
"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 | [
"683"
] | 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... |
Who did carry 5 times the odds of OUD and overdose compared to patients ≥65 years old? | Patients 31-40 years | [
"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 | [
"684"
] | 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 could also by itself be a sign of diversion? | A negative UDT for the prescribed opioid | [
"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 | [
"685"
] | 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 opioid/opioid formulation is preferred over the others? | no single | [
"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 | [
"686"
] | true | [
"There was insufficient evidence to recommend for or against any specific opioid or opioid formulation, specifically the following: Short-acting versus long-acting opioids (for LOT for chronic pain), Route of administration/delivery among alternatives such as transdermal, buccal, sublingual, or pumps, Abuse deter... |
What has been associated with worsening depressive symptoms? | LOT | [
"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 | [
"687"
] | 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 is the stance regarding the initiation of long-term opioid therapy for chronic pain? | strongly recommend against | [
"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 | [
"688"
] | 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.... |
When reducing 5% of morphine SR 90 mg Q8h = 270 MEDD, what dose should be taken on month two of the slowest opioid tapering? | 75 mg SR qam, 75 mg noon, 90 mg qpm | [
"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 | [
"689"
] | 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 = ... |
Due to the difficulty of tapering or discontinuing benzodiazepines, what should be done when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain? | particular caution should be used | [
"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 | [
"690"
] | 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... |
Which tapers may be required in certain instances like situations where the risks of continuing the opioid outweigh the risks of a rapid taper? | 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 | [
"691"
] | 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... |
What is needed when there is unexplained weight loss? | 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 | [
"692"
] | 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 the veteran is actively suicidal? | consult with mental health provider before beginning taper | [
"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 | [
"693"
] | true | [
"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... |
When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day seven of the rapid opioid tapering? | 15 mg SR Q12h | [
"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 | [
"694"
] | 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 to do if a patient is taking more than their prescribed dosage of opioids? | before deciding to change therapy, look for “red flags”. The red flags are 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 | [
"695"
] | true | [
"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... |
What is critical due to the false positive and negative rates associated with UDTs? | Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) | [
"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 | [
"696"
] | 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 does the OSI use to identify providers whose prescribing practices do not reflect best evidence so that patient care can be improved? | Veterans Health Administration (VHA’s) electronic health record | [
"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 | [
"697"
] | 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... |
When to consider tapering opioids to taper and discontinue? | If benefits do not outweigh harms | [
"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... | cpgqa | en | true | [
"698"
] | 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 does assess the critical information needed at the major decision points in the clinical process? | the provider | [
"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 | [
"699"
] | true | [
"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... |
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