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lung disease, sleep apnea, liver disease, renal disease, fall risk, advanced age | 49 | Which medical comorbidities can increase risk during opioid therapy? | 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 PTSD, ... |
37.6 | 284 | In 2012, how many benzodiazepine prescriptions were written by healthcare providers for every 100 persons in the U.S.? | From 2000 through 2010, the proportion of pain visits during which opioid and non-opioid pharmacologic therapies were prescribed increased from 11.3% to 19.6% and from 26% to 29%, respectively. In 2012, for every 100 persons in the United States (U.S.), 82.5 opioid prescriptions and 37.6 benzodiazepine prescriptions we... |
5% to 20% | 597 | Most commonly, tapering involves dose reduction of how much every 4 weeks? | When formulating an opioid taper plan, determine if the initial goal is a dose reduction or complete discontinuation. If the initial goal is determined to be a dose reduction, subsequent regular reassessment may indicate that complete discontinuation is more suitable. Several factors go into the speed of the selected t... |
close monitoring and consideration for tapering when risks exceed benefits | 498 | What to recommend for patients less than 30 years of age currently on long-term opioid therapy? | We recommend against the concurrent use of benzodiazepines and opioids. Note: For patients currently on long-term opioid therapy and benzodiazepines, consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate. We recommend against long-term opioid therapy for patients l... |
take back programs | 0 | What does the National Drug Control Strategy advocate? | 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... |
a panel of multidisciplinary experts | 126 | Who developed the guidelines? | 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 ... |
Overdose Education and Naloxone Distribution | 1,581 | What does OEND refer to? | 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: lack... |
the treatment of chronic pain with opioids | 247 | What was increasing at an alarming rate until recently? | 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 alarming ... |
immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated | 248 | What is recommended if take-home opioids are prescribed? | 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 with opi... |
any co-occurring condition that significantly affects respiratory rate or function such as chronic obstructive pulmonary disease (COPD), asthma, pneumonia, sleep apnea, or a neuromuscular condition (e.g., amyotrophic lateral sclerosis) | 224 | What does include severe respiratory instability or sleep disordered breathing? | Duration and dose of OT: See Recommendation 2 for more guidance on duration of OT and Recommendations 10-12 for more guidance on dosing of OT. Severe respiratory instability or sleep disordered breathing: This would include any co-occurring condition that significantly affects respiratory rate or function such as chron... |
Alcohol use, pregnancy, nursing of infants, and lab abnormalities | 267 | What may change the risk/benefit calculus for LOT? | 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... |
screening and treatment is offered for conditions that can complicate pain management | 7 | What to ensure before initiating an opioid 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 disord... |
an ordered sequence of steps of care, recommended observations and examinations, decisions to be considered, actions to be taken | 696 | What does the algorithm include? | 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... |
progression from acute to long-term OT is associated with little evidence for sustained analgesic efficacy but a substantial increase in risk for OUD | 33 | What information should be discussed with patients at initiation of OT and continuously thereafter? | Patients should be informed that progression from acute to long-term OT is associated with little evidence for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient und... |
non-inferior | 9 | What was the efficacy of long-acting opioids used once-daily compared to twice-daily use? | A second non-inferiority RCT compared once-daily hydromorphone ER to twice-daily oxycodone controlled-release in patients with moderate-to-severe cancer pain. The primary efficacy endpoint was patient assessment of “Brief Pain Inventory (BPI) worst pain in the past 24 hr.” Results demonstrated similar improvements i... |
from 26% to 29% | 163 | From 2000 through 2010, what was the increment of the proportion of pain visits during which non-opioid pharmacologic therapies were prescribed? | From 2000 through 2010, the proportion of pain visits during which opioid and non-opioid pharmacologic therapies were prescribed increased from 11.3% to 19.6% and from 26% to 29%, respectively. In 2012, for every 100 persons in the United States (U.S.), 82.5 opioid prescriptions and 37.6 benzodiazepine prescriptions we... |
to advise the “…Health Executive Council on the use of clinical and epidemiological evidence to improve the health of the population across the Veterans Health Administration and Military Health System,” by facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations | 175 | What was the mission of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG)? | 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 the V... |
Re-evaluate the risks and benefits of continuing opioid therapy | 138 | What to do when there is no pain reduction? | 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... |
to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice | 113 | When can this guideline be used? | This guideline can be used in a variety of ways. This guideline can be used by general clinicians or specialists to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice. It can be used to provide specific information ... |
those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope | 376 | Which patients may be at risk? | 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 fatal ... |
patients who already have had an adequate opioid trial (of sufficient dose and duration to determine whether or not it will optimize benefit) without a positive response | 319 | It is inadvisable to prescribe opioids to which patients? | 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 to p... |
effective for pain reduction in multiple pain conditions | 146 | What do psychological therapies help? | 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... |
Veterans with PTSD who have co-occurring chronic pain | 1,070 | For whom particular caution should be used when considering initiating benzodiazepines due to the difficulty of tapering or discontinuing benzodiazepines? | 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... |
to assess the critical information needed at the major decision points in the clinical process | 588 | What does the simplified linear approach depicted through the algorithm and its format allow? | 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... |
Mechanical or inflammatory pain with a visceral origin | 211 | Which pain may produce a less localized 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... |
patients who require higher doses of opioids, even in those who benefit from such therapy | 500 | Who will have greater mortality? | 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 shortes... |
Prescribed opioid dosage | 295 | What is a good predictor of overdose death? | In a nested case-control study of U.S. Veterans (not included in our evidence review as it was published after the end of the search date range), Bohnert et al. (2016) examined the association between prescribed opioid dose as a continuous measure (in 10 mg MEDD increments) and overdose.[134] Prescribed opioid dosage ... |
exit algorithm; manage with non-opioid modalities | 816 | What to do if the treatments are effective in managing pain and optimizing function? | 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... |
consult with mental health provider before beginning taper | 474 | What to do if the veteran is actively suicidal? | 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... |
an overdose | 1,130 | If the patients under opioid taper pna resume their original dose, they are at risk of what? | 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... |
help to address safety, fairness, and trust with OT | 258 | What do UDTs do when used appropriately? | 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... |
more frequent monitoring for adverse events including opioid use disorder and overdose | 49 | What is recommended as opioid dosage and risk 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... |
5 to 10 days following opioid dose reduction/cessation but may take longer depending on the half-life of the opioid (e.g., methadone) | 955 | How long does it take to resolve early symptoms? | 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... |
Research | 482 | What is necessary to more accurately determine how long it takes for OUD to occur and whether the nature of the pain is one of the factors that can influence either of this phenomena? | Patients should be informed that progression from acute to long-term OT is associated with little evidence for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient und... |
implemented as a risk mitigation strategy aimed at reducing deaths from opioid overdose | 1,270 | What was the purpose of the OEND program? | 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 Safet... |
education and knowledge of the local procedures and clinical scenario | 564 | What is required by the interpretation of a UDT and confirmatory results? | 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 Suicide CPG | 128 | Who recommends restricting the availability of lethal means for patients considered to be at intermediate or high acute risk of suicide? | 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 severity ... |
from 18.9% to 33.4%, an increase of 76.7% | 96 | What was the increment of the prevalence of opioid prescriptions among Veterans from fiscal years 2004 to 2012? | 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 inte... |
An urgent evaluation | 552 | What is needed when there is a history of internal malignancy that has not been re-staged? | 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 “red ... |
11 | 190 | Compared to patients ≥65 years old, patients 18-30 years old carried how many times the odds of OUD and 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 ≥... |
continuing OT beyond 90 days’ duration | 31 | What should be weighed heavily in the risk benefit calculus for 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... |
patients at increased risk of overdose | 977 | Whom to prescribe naloxone? | 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... |
either transdermal or buccal | 34 | Which delivery mechanism has no evidence of benefit ove traditional opioid delivery systems in patients with chronic pain? | Although some patients may prefer either transdermal or buccal opioid delivery for opioids, there is significant potential for harm from OT with these delivery mechanisms, with no evidence of benefit over traditional opioid delivery systems in patients with chronic pain. Clinicians need to be especially aware of the... |
Efforts to destigmatize the use of prescription opioids for chronic non-terminal pain | 504 | Which efforts led to an unprecedented increase in opioid prescribing for chronic non-terminal pain? | 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 care m... |
The increasing use of opioids, as well as the accompanying rise in morbidity and mortality associated with opioid use | 0 | What has accumulated growing attention from federal and local officials as well as other policymakers? | The increasing use of opioids, as well as the accompanying rise in morbidity and mortality associated with opioid use, has garnered increasing attention from federal and local officials as well as other policy makers. This public health issue, which has been labeled an epidemic, became a focus of the President’s Nati... |
recommend against | 3 | What is the stance regarding prescribing long-acting opioids for acute pain? | 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... |
ensuring opioids are used in a safe, effective, and judicious manner. | 421 | What was the aim of the 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 Safet... |
the VHA | 1,017 | Who issued a policy requiring standardized education and signature informed consent for all patients receiving LOT for non-cancer pain? | Other initiatives are aimed at improving the safe use of opioids, including the OSI Toolkit and the patient guide “Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain”. The OSI Toolkit was developed to provide clinicians with mat... |
shared decision-making | 6 | What kind of approach should be used to discuss options for OUD treatment? | Use a shared decision-making approach to discuss options for OUD treatment. Medication-Assisted Therapy (MAT) is the first-line treatment for OUD. The preferred OUD treatment is Opioid Agonist Therapy (OAT). Opioid agonist treatment involves taking opioid agonist medications such as buprenorphine/naloxone (Suboxone) or... |
tramadol and tapentadol | 228 | What are the examples of dual-mechanism opioids? | Dual-Mechanism Opioids: Dual-mechanism opioids include formulations of an opioid medication with a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI). Two common examples are tramadol and tapentadol. While both are dual-mechanism opioids, they differ in their affinit... |
There is moderate quality evidence from retrospective cohort and retrospective case-control studies | 0 | Is there any evidence that risk of prescription opioid overdose and overdose death exists even at low opioid dosage levels and increases with increasing doses? | There is moderate quality evidence from retrospective cohort and retrospective case-control studies indicating that risk of prescription opioid overdose and overdose death exists even at low opioid dosage levels and increases with increasing doses. Significant risk (approximately 1.5 times) exists at a daily dosage ra... |
intensification of monitoring | 40 | What does help mitigate the risk of suicide among patients on LOT? | There is moderate quality evidence that intensification of monitoring helps mitigate the risk of suicide among patients on LOT. Im et al. (2015) found moderate quality evidence that, at the facility level, patients on LOT within facilities ordering more drug screens than the comparison group were associated with decrea... |
recommend against | 3 | What is the stance regarding long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose? | We recommend against the concurrent use of benzodiazepines and opioids. Note: For patients currently on long-term opioid therapy and benzodiazepines, consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate. We recommend against long-term opioid therapy for patients l... |
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 | 781 | What is the alternative treatment option for autonomic symptoms using Baclofen? | 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... |
VHA policy regarding education and signature informed consent | 340 | What must VHA providers follow when providing LOT for patients with non-cancer pain? | 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 provide... |
to acknowledge the Veteran’s fears about tapering | 602 | What are Motivational Interviewing (MI) techniques used for? | 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... |
psychological factors related to continuing vs. tapering OT | 612 | What to assess for patients already on 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 factors ... |
at every phase of treatment | 99 | When should an assessment of current suicide risk be made? | 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 severity ... |
patients in the 20-44 age group | 394 | Patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to whom? | Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benz... |
when considering initiating or continuing long-term opioid therapy | 67 | When is assessing suicide risk and intervening recommended? | 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... |
balancing desired outcomes with potential harms of treatment, equity of resource availability, the potential for variation in patient values and preferences, and other considerations | 113 | Which factors were considered for the framework for recommendations in this CPG? | 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 more ... |
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... | 216 | When to 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 unmanag... |
15 mg SR Q12h | 947 | 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? | 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... |
younger patients using opioids | 20 | Who have an added great risk for OUD and 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 ≥... |
the AOR of overdose | 496 | The combination of zolpidem and opioids increases what? | In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and be... |
potential adverse outcomes (e.g., risk of overdose) | 560 | What can happen with the combined use of antidepressants and opioids in patients who do not have depression? | In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and be... |
SAMHSA, the American Medical Association (AMA), and other medical societies | 936 | Who supports 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.... |
Every healthcare professional making use of these guidelines | 214 | Who is responsible for evaluating the appropriateness of applying the guidelines? | Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriate... |
continuing LOT to “prevent suicide” in someone with chronic pain | 197 | What is not recommended as 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 suicide r... |
2.9 times | 583 | What are the odds of suicidal ideation within the past 12 months in those with bipolar disorder compared to those with no 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 disorder was... |
consider whether LOT will result in clinically meaningful improvements in function such as readiness to return to work/duty and/or measurable improvement in other areas of function, such that the benefits outweigh the potential harms | 850 | What needs to be considered when considering the initiation or continuation of LOT? | 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... |
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 | 252 | What does the OTRR do? | 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 ... |
BOTH pain and OUD | 832 | What needs to be addressed for patients with chronic pain who develop OUD from opioid analgesic therapy? | 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... |
continue OT using the following approach: shortest duration, using lowest effective dose (recognizing that no dose is completely safe and overdose risk increases at doses > 20-50 mg MEDD), continual assessment of improvement in pain and functional status and adverse effects | 2,056 | What to do if the patient is experiencing clear functional improvement with minimal 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 opioi... |
The concomitant use of oral and transdermal opioids or oral and intrathecal pumps | 369 | What should be approached with extreme caution and warrants specialty consultation? | Route of Administration/Delivery: The systematic evidence review for this CPG did not find any studies that compared alternative delivery systems (e.g., fentanyl transdermal, fentanyl buccal) to other delivery systems (e.g., oral, intravenous) (information on transdermal and sublingual buprenorphine is included in th... |
when there is progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, a history of internal malignancy that has not been re-staged, signs of/risk factors for infection such as fever, recent skin or urinary infection, immunosuppression, IV drug use | 587 | What warrants an urgent evaluation during opioid therapy? | 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 “red ... |
opioid treatment agreements | 904 | What is OTAs? | 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.,... |
allow the patient time to acquire new skills for management of pain and emotional distress while allowing for neurobiological equilibration | 495 | How may pauses in the slowest opioid taper help the patient? | 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... |
in 2014 | 1,041 | When did VHA issue a policy requiring standardized education and signature informed consent for all patients receiving LOT for non-cancer pain? | Other initiatives are aimed at improving the safe use of opioids, including the OSI Toolkit and the patient guide “Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain”. The OSI Toolkit was developed to provide clinicians with mat... |
recommend against | 199 | What is the stance regarding the long-term opioid therapy for pain in patients with untreated substance use disorder? | For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits. We recommend against long-term opioid therapy for pain in patients with untreated substance use disorder. For patients curre... |
in the decade of the 2010s | 1,187 | When did a more cautious approach to OT for chronic non-terminal pain emerge? | 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 care m... |
clinical practice guidelines | 414 | What are CPGs? | 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 the V... |
Patients with chronic pain who develop OUD from opioid analgesic therapy | 746 | Who needs to have both pain and OUD addressed? | 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... |
drug diversion, illegal activities, or situations where the risks of continuing the opioid outweigh the risks of a rapid taper | 682 | In which instances more rapid tapers may be required? | 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... |
opioid therapy | 54 | Self-management strategies are recommended as alternatives to what? | 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 for ... |
naloxone | 965 | What to prescribe to patients at increased risk of overdose? | When formulating an opioid taper plan, determine if the initial goal is a dose reduction or complete discontinuation. If the initial goal is determined to be a dose reduction, subsequent regular reassessment may indicate that complete discontinuation is more suitable. Several factors go into the speed of the selected t... |
patients should be treated with adjunctive medications | 77 | How to minimize withdrawal effects in patients caused by rapid tapers? | Rapid Taper is done over days. Rapid tapers can cause withdrawal effects and patients should be treated with adjunctive medications to minimize these effects; may need to consider admitting the patient for inpatient care. If patients are prescribed both long-acting and short-acting opioids, the decision about which for... |
acupuncture, meditation, yoga | 352 | What are some examples of Complementary and Integrative Health (CIH) interventions? | 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... |
develop an individualized tapering treatment plan (including pace of tapering, setting of care) based on patient and treatment characteristics | 1,503 | What to do if there is no high risk or dangerous behavior? | 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... |
There is moderate quality evidence | 0 | Is there any evidence that intensification of monitoring helps mitigate the risk of suicide among patients on LOT? | There is moderate quality evidence that intensification of monitoring helps mitigate the risk of suicide among patients on LOT. Im et al. (2015) found moderate quality evidence that, at the facility level, patients on LOT within facilities ordering more drug screens than the comparison group were associated with decrea... |
Concomitant use of benzodiazepines | 1,815 | What is considered a contraindication to initiation of OT? | 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... |
current prescriber, prior and current UDT, PDMP | 503 | What includes prior medical records? | 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... |
lowest effective | 290 | If take-home opioids are prescribed, what is the recommended dose of immediate-release opioids? | 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 with opi... |
multimodal pain care including non-opioid medications as indicated | 88 | What is suggested to be used when opioids are used for acute pain? | 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 with opi... |
when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice | 63 | When will the variations in practice inevitably and appropriately occur? | Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriate... |
checking the PDMP, performing a UDT, placement in an inpatient setting or monitored environment, and/or providing OEND | 178 | Which strategies may be helpful for those at higher risk of adverse events related to opioid therapy? | For those at higher risk of adverse events related to opioid therapy, the following strategies may help to decrease opioid-related overdose events and unintended long-term use: checking the PDMP, performing a UDT, placement in an inpatient setting or monitored environment, and/or providing OEND. |
consult with mental health provider before beginning taper | 474 | What to do if suicide risk is high in patients? | 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... |
primary care physicians | 89 | Who are the targeted individuals for the CDC Guideline for Prescribing Opioids for Chronic Pain? | 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... |
refer/consult with appropriate interdisciplinary treatments. Then after referral/consultation with appropriate interdisciplinary treatments, see if the patient is willing to engage in a comprehensive pain care plan. | 1,357 | What to do if referral/consultation for evaluation and treatment is indicated? | 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... |
weekly before each dose reduction | 583 | When to follow up with the Veteran during the faster 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... |
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