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i)Opioids with benzodiazepines (compared to patients with no prescription, the odds ratio [OR] and 95% confidence interval [CI] for drug-related death was OR: 14.92, 95% CI: 7.00- 31.77 for patients who filled a prescription for opioids and benzodiazepines; OR: 3.40, 95% CI: 1.60-7.21 for patients who filled only an o... | 236 | What combinations of drugs are dangerous? | Co-administration of a drug capable of inducing fatal drug-drug interactions: Providers should carefully rule out and avoid potential drug interactions prior to initiating LOT. For example, the following combinations are dangerous:[66] i)Opioids with benzodiazepines (compared to patients with no prescription, the odds ... |
PHI’s “Whole Health” approach | 59 | What is an example of Bio-Psycho-Social Model? | 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 Integrative Hea... |
the best information available at the time of publication | 91 | What are the guidelines based upon? | The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should... |
15 mg SR QHS | 974 | When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day eleven of the rapid opioid tapering? | 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 which for... |
the VA via Pharmacy Benefits Management | 1,041 | Who facilitates the distribution of naloxone for the reversal? | 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 events.... |
Risks for overdose and death | 232 | What does significantly increase at a range of 20- 50 mg morphine equivalent daily dose? | 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 morphine equ... |
the individual clinician | 535 | Who must make the ultimate judgement regarding a particular clinical procedure or treatment course? | 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 state reg... |
Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) | 312 | What is critical due to 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. Availabi... |
exacerbation of severe PTSD symptoms | 1,777 | What may gradual benzodiazepine taper result in? | 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 for un... |
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. | 0 | How was an age of 30 years chosen as a clinically reasonable threshold? | 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 of th... |
treatment options, including education on known risks and unknown long-term benefits of OT, risks of SUD and overdose, need for risk mitigation strategies, naloxone rescue | 1,969 | When the patient is willing to engage in a comprehensive pain care plan, what to educate the patient and family about? | 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 pain an... |
physical, psychological, and pain rehabilitation modalities | 18 | To which modalities should the patient have access? | Patient access to physical, psychological, and pain rehabilitation modalities should be considered. In some cases access to care may be limited; all VA and DoD clinics may not have access to multidisciplinary pain services. Still, all avenues for obtaining these treatments (e.g. Internet based CBT) and all appropriat... |
Chronic pain | 0 | What is one of the most disabling chronic medical conditions in the U.S.? | 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 proportion ... |
non-pharmacologic treatments and non-opioid medications | 555 | What are the preferred treatments for chronic non-terminal 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 curre... |
When a decision is made to taper | 0 | When must special attention be given to ensure that the Veteran does not feel abandoned? | 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 telep... |
worsening depressive symptoms | 682 | LOT has been associated with what kinds of symptoms? | Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversio... |
overdose and other adverse events | 993 | Continuing to prescribe the opioid without providing OUD treatment may increase the risk of what? | 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 disord... |
depression, anxiety, poor self-efficacy, poor general emotional functioning | 915 | What are some examples of psychological complaints made by patients with chronic pain? | 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 functional go... |
However, continuing LOT to “prevent suicide” in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases. | 187 | In which cases it is essential to involve behavioral health to assess, monitor, and treat a patient who becomes destabilized as a result of a medically appropriate decision to taper or cease LOT? | 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 suicide r... |
15 mg SR QHS | 974 | When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day eight of the rapid opioid tapering? | 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 which for... |
specific risk factors such as risk for suicide, SUD, and other medical and mental health co-occurring conditions that may complicate the management of pain for these patients | 357 | Throughout the VA/DoD OT CPG, particular attention is paid regarding which factors? | 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 of th... |
Age <30 years | 31 | What is not an absolute contraindication to LOT? | Similar to other risk factors, age <30 years should be weighed heavily in the risk-benefit determination for initiating LOT. Age <30 years is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks of OUD and overdose. Hospitalized patients recoverin... |
Due to the difficulty of tapering or discontinuing benzodiazepines | 919 | Why should particular caution be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain? | 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 for un... |
45 mg SR (15 mg x 3) Q8h | 346 | When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week three of the faster opioid tapering? | 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 SR (1... |
60 mg SR Q8h | 878 | When reducing 5% of morphine SR 90 mg Q8h = 270 MEDD, what dose should be taken on month six of the slowest opioid tapering? | 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 tape... |
patients who are currently prescribed doses over 90 mg morphine equivalent daily dose | 113 | For whom to evaluate for tapering to reduced dose or to discontinuation? | 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 for ac... |
behaviors, age < 30, family history, personal history of SUD | 466 | Which factors can raise concerns related to an increased risk of substance use disorder? | 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 unmanag... |
objective, evidence-based information on the management of chronic pain | 187 | What does the updated CPG include? | 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 aspects... |
the heightened risk for developing OUD | 206 | What is the utmost concern for patients who receive OT beyond 90 days? | 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 Diagnostic a... |
Continuing OT for longer than 90 days | 134 | What is not an absolute contraindication to LOT? | 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 determ... |
Gabapentin | 671 | Which can help reduce withdrawal symptoms and help with pain, anxiety, and sleep? | 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 commonly u... |
the Opioid Therapy Risk Report (OTRR) and the Stratification Tool for Opioid Risk Mitigation (STORM) | 140 | Which electronic tools are currently used in the VA? | 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 pain ... |
Re-evaluate the risks and benefits of continuing opioid therapy | 138 | What to do when dosage indicates high risk of adverse events? | 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 unmanag... |
high prescribed dose, history of SUD, and history of mental health concerns | 160 | Which factors increase overdose risk when opioids are used for acute pain? | In addition, the risk of overdose includes the use of opioids for acute pain. Factors that increase overdose risk when opioids are used for acute pain include high prescribed dose, history of SUD, and history of mental health concerns. While the risk of overdose increases at doses above 20 mg MEDD or greater, this r... |
summarizing advances in pain care research, identifying gaps in research, and developing recommendations regarding ways to minimize duplicative efforts, disseminate pain care information, and expand public/private research partnerships and collaborations | 263 | What was the tasks of Interagency Pain Research Coordinating Committee? | 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, identifying ... |
signs of diversion | 528 | What to be aware of during follow-ups? | 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 lab a... |
do not recommend for or against | 3 | What is the stance regarding the abuse deterrent formulations for LOT? | We do not recommend for or against abuse deterrent formulations for LOT. Our searches identified two RCTs in which the benefits of co-prescribing of naloxone with opioids were examined.[143,144] However, both RCTs were rated as low to very low quality with short-term follow-up. One open-label RCT enrolling 453 patien... |
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 | 247 | The use of the algorithm format as a way to represent patient management was chosen based on what? | 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 diagnosti... |
Because a comprehensive review of the evidence related to LOT was not feasible | 351 | Why only nine key questions (KQs) were prioritized from many possible KQs? | 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 patients o... |
close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering | 239 | What is recommended for patients currently on long-term opioid therapy with evidence of untreated substance use disorder? | 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, and d... |
Frequent requests for early refills or atypically large quantities required to control pain | 139 | What can signal an emerging SUD as well as diversion? | 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 diversio... |
http://opstp.cds.pesgce.com/hub.php | 828 | Where can the DoD Opioid Prescriber Safety Training Program be found? | 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 of th... |
immediately discontinue opioid therapy | 778 | What to do if there is a concern for diversion? | 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 whethe... |
VA and DoD healthcare practitioners including physicians, nurse practitioners, physician assistants, physical and occupational therapists, psychologists, social workers, nurses, clinical pharmacists, chaplains, addiction counselors, and others involved in the care of Service Members and their beneficiaries, retirees... | 209 | For whom is this guideline intended? | 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, physical ... |
Interpretation of a UDT and confirmatory results | 505 | What does require 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. Availabi... |
75 mg (60 mg+15 mg)SR Q8h | 336 | During the first month in the slower taper what does consist of 16% reduction of morphine SR 90 mg Q8h = 270 MEDD? | 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 = 270 M... |
risk for opioid-related adverse events | 200 | What risk is recommended to be evaluated at least every 3 months? | 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 prescribing the... |
Achieving an improved understanding of the factors contributing to prescription opioid-related overdose | 0 | Which step should be taken to address the problem of opioid-related overdose epidemic? | 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, patients ... |
As substance misuse in patients on LOT is more than 30% in some series | 0 | Why is UDT and confirmatory testing used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen? | As substance misuse in patients on LOT is more than 30% in some series,[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. Availabi... |
absolutely safe | 415 | What kind of dose of opioids do not exist? | 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 prescribing the... |
an appropriate response if suicide risk is high or increases | 284 | Why is continuing LOT not recommended 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 suicide r... |
irritability, fatigue, bradycardia, decreased body temperature, craving, insomnia | 839 | What do prolonged symptoms include? | 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 to day... |
Patients with a history of TBI who use chronic short-acting and long-acting opioids | 30 | Who are more likely to attempt suicide? | Traumatic brain injury (TBI): Patients with a history of TBI who use chronic short-acting and long-acting opioids are more likely to attempt suicide.[61] |
a systematic review of both clinical and epidemiological evidence | 46 | What is the clinical practice guideline based on? | This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence ... |
Slower, more gradual tapers | 326 | Which tapers are often the most tolerable? | 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 selected t... |
provide additional education about whole person pain care and LOT and reassurance that the patient will not be abandoned, consider more frequent follow-up using the expanded care team (registered nurse, clinical pharmacist, health coach, mental health provider), consider reduced rate of taper or pause in taper for pati... | 3,040 | What to do if patient is fearful or anxious about taper and ability to function on lower dose or without opioids? | 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 whethe... |
70% | 169 | What is the ratio of opioid prescriptions that 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 tool.[2... |
Individuals with conditions that result in or co-occur with chronic pain | 0 | 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 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 mechanism of... |
Patient values, goals, concerns, and preferences | 652 | What must be factored into clinical decision making on a case-by-case basis? | As outlined in this CPG, there is a rapidly growing understanding of the significant harms of LOT even at doses lower than 50 mg oral morphine equivalent daily dose [MEDD], including but not limited to overdose and OUD. At the same time there is a lack of high quality evidence that LOT improves pain, function, and/o... |
A Veteran with high risk due to a medical condition | 1,087 | Who may require a clinic visit over telephone follow-up? | 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, follow u... |
special attention must be given to ensure that the Veteran does not feel abandoned | 34 | How to make sure that the veteran does not feel abandoned when a decision is made to taper? | 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 telep... |
drug overdose | 216 | What was the leading cause of injury-related death in the U.S. in 2009? | 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 traff... |
Suicide risk is not static, and many factors influence an individual’s risk of suicide at any given point in time, as noted in the VA/DoD Suicide CPG. | 278 | Why is ongoing assessment of suicide risk important whether one is initiating, maintaining, or terminating LOT? | 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 facto... |
1 week to 1 month | 1,657 | When to follow-up after each change in dosage? | 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 whethe... |
14% increase | 660 | What kind of increase has there been in the absolute number of deaths associated with the use of opioids between 2013 and 2014 alone? | 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 traff... |
Pain arising from persistent peripheral stimulation | 39 | Which pain can lead to well-localized nociceptive mechanism pain? | There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain d... |
medication assisted treatment | 199 | What treatment is recommended to offer for opioid use disorder to patients with chronic pain and opioid use disorder? | We recommend interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior. We recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder. Note: See th... |
increase in all-cause mortality, increase risk of unintentional overdose death, increase risk of developing OUD, risk of developing or worsening - depression, falls, fractures, sleep disordered breathing, worsening pain, motor vehicle accidents hypogonadism, prolonged pain, nausea, constipation, dry mouth, sedation, co... | 462 | What are the risks of continuing opioid therapy? | 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 over... |
interdisciplinary | 1,082 | What is the format of the ideal approach to communicate between the SUD and pain management providers when a patient is referred for SUD treatment or is engaged in ongoing treatment? | 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. Availabi... |
patients ≥70 years old | 566 | Who had far less risk of developing OUD or overdose compared to subjects 18-29 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 those ≥... |
loperamide 4 mg orally initially, then 2 mg with each loose stool, not to exceed 16 mg daily; bismuth subsalicylate 524 mg every 0.5 to 1 hour orally, not to exceed 4192 mg/day | 329 | What are the treatment options for diarrhea? | The treatment options for nausea are prochlorperazine 5 to 10 mg every 4 hours as needed, promethazine 25 mg orally or rectally every 6 hours as needed, ondansetron 4 mg every 6 hours as needed. The treatment option for abdominal cramping is dicyclomine 20 mg every 6 to 8 hours as needed. The treatment options for diar... |
in a dose dependent manner | 204 | How do the risks for opioid use disorder increase? | 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 morphine equ... |
assessing suicide risk and intervening when necessary | 13 | What is recommended when considering initiating or continuing long-term opioid therapy? | 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 prescribing the... |
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 | 42 | What is the system-wide goal of the updated CPG guideline? | 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, provide edu... |
registered nurse, clinical pharmacist, health coach, mental health provider | 3,225 | What includes expanded care team? | 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 whethe... |
34% | 806 | As found from a survey of patients prescribed opioids for chronic non-cancer pain and their family members, how many patients reported that they thought they were addicted/dependent on opioid pain medication? | 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 traff... |
When pharmacologic therapies are used | 238 | When should non-opioids be recommended over opioids? | 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. (Str... |
As opioid dosage and risk increase | 0 | When is it recommended more frequent monitoring for adverse events? | 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 morphine equ... |
recommend against | 3 | What is the stance regarding long-term opioid therapy for pain in patients with untreated substance use disorder? | 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, and d... |
a biopsychosocial, multimodal, interdisciplinary model | 575 | Which model was adopted after the biomedical model of pain care? | 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 first... |
treatment with opioid therapy | 18 | What is module B about? | 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), use ... |
Those patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD | 0 | Who may benefit from an alternative management strategy? | 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 close fo... |
Consideration of opioid therapy beyond 90 days | 136 | What does require re-evaluation and discussion with patient of risks and benefits? | 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 recommen... |
cognitive behavioral interventions such as Cognitive Behavioral Therapy [CBT], biofeedback | 31 | What are some examples of psychological therapies? | 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 disability... |
worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships | 516 | What may be experienced by the patients with chronic pain? | 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 functional go... |
non-opioid management, self-management to improve function and quality of life, realistic expectations and limitations of medical treatment | 450 | For patients who are in chronic pain and have not been on daily OT for pain for more than 3 months, which topics to consider for educating or re-educating them? | 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 pain an... |
repeat comprehensive biopsychosocial assessment and see if an SUD is identified | 2,231 | What to do if the patient resists taper? | 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 whethe... |
a four-fold increase | 556 | What kind of increase has there been in the absolute number of deaths associated with the use of opioids since 2000? | 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 traff... |
use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT | 492 | What was the recommendation in the 2010 OT CPG? | 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 (e.g.,... |
a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment | 151 | What are the elements of the biopsychosocial pain interview? | 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 functional go... |
subjects 18-29 years old | 384 | Compared to whom, patients ≥70 years old had far less risk of developing OUD or overdose? | 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 those ≥... |
assessment of the quality of the evidence and consideration of the balance of desirable and undesirable outcomes, patient values and preferences, and other considerations (e.g., resource use, equity) during recommendation development | 792 | What does the GRADE system include? | 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 cancer... |
obtain a biopsychosocial assessment | 431 | What to do if there are no factors requiring immediate attention? | 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 opioi... |
no long-term evidence | 205 | Is there any evidence of the comparative efficacy of tramadol versus another opioid or a non-opioid comparison such as non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen? | Tramadol: There is low quality evidence that tramadol may be more effective than placebo for pain relief. In one short-term study, compared to placebo, tramadol was more effective for pain.[146] There is no long-term evidence of the comparative efficacy of tramadol versus another opioid or a non-opioid comparison suc... |
patients at increased risk of overdose | 977 | Whom to provide opioid overdose education? | 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 selected t... |
1 to 4 weeks after starting taper then monthly before each reduction | 339 | When to follow up with the Veteran during the slowest taper? | 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, follow u... |
time for neurobiological, psychological, and behavioral adaptations | 80 | What does a gradual taper rate allow? | 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 that may... |
prior to initiating or continuing LOT and periodically thereafter | 824 | When should clinicians obtain UDT? | 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. Availabi... |
The VA/DoD PTSD CPG | 1,125 | What does caution against the use of benzodiazepines in treatment of PTSD? | 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 for un... |
1 week to 1 month | 1,657 | When to follow-up after discontinuation? | 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 whethe... |
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