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a short duration | 75 | What timeframe is recommended if prescribing opioid therapy for patients with chronic pain? | 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... |
fentanyl analogs, potent opioid receptor agonists | 26 | What are some examples of synthetic opioids? | Synthetic opioids such as fentanyl analogs, potent opioid receptor agonists, are responsible for a recent rise in death rates. Fentanyl analogs that may be used to create counterfeit opioid analgesic pills can cause a toxidrome characterized by significant CNS and profound respiratory depression requiring multiple n... |
certain chronic pain conditions | 28 | Which represent an independent risk factor for suicide? | 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... |
see whether referral/consultation for evaluation and treatment is indicated (e.g., mental health, SUD, more intensive interdisciplinary care) | 1,141 | What to do if patient risk outweighs benefits? | 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... |
many factors | 310 | What influence an individual’s risk of suicide at any given point in time? | 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... |
LOT | 653 | What has been associated with worsening depressive symptoms? | Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversio... |
90 mg SR qam, 75 mg for noon, 90 mg qpm | 384 | 5% opioid reduction of morphine SR 90 mg Q8h = 270 MEDD during the first month in the slowest taper consists of what? | 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... |
above 20-50 mg MEDD | 787 | How much dose escalation has not been shown to improve function and increase risk? | 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 ... |
provide clinicians with materials to inform clinical decision-making regarding opioid therapy and safe opioid prescribing | 292 | What was the purpose of the OSI toolkit? | 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... |
at least every three months or more frequently | 291 | When to follow up? | Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months o... |
LOT | 60 | What treatment modality may result in worsening of the underlying headache condition in patients with migraine headaches, tension-type headaches, occipital neuralgia, or myofascial pain? | Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as ce... |
More rapid tapers | 622 | Which tapers may be required in certain instances like illegal activities? | 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... |
increased risk of abnormalities and addiction | 365 | What are the risks of substance use early in life? | Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD and overdose. Studies in other areas (e.g., use of different substances) indicate t... |
proceed to module C | 947 | What to do if risks outweigh benefits of continuing OT? | 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... |
patient function, pain intensity, sleep, physical activity, personal goals, and stress level | 1,467 | On what to follow-up with the Veteran? | 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... |
to ensure that the patient understands the associated risks and benefits of LOT | 289 | Why should the providers discuss with patients 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? | 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... |
the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave | 166 | What is QTc interval? | 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 ... |
notice in the Federal Register for a public review and comment period as well as peer review | 1,218 | What did the CDC guideline development process include? | There were also some differences in the methodology used between the development of the VA/DoD OT CPG and the CDC guideline. Along with a clinical evidence review, during which the evidence was evaluated using GRADE, the CDC guideline developers also considered the findings of a contextual evidence review. Further, th... |
long-term opioid therapy | 1,091 | What is LOT? | 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 ... |
a daily dosage range of 20 to <50 mg MEDD | 303 | At what dosage there is a significant risk? | 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... |
fixing or numbing pain with medications, interventions, or surgery | 219 | What is the aim of the pain treatment in 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... |
the recommendation to use non-opioid modalities in lieu of LOT to treat their pain | 41 | Some patients with SUD may disagree with what? | Some patients with SUD may disagree with the recommendation to use non-opioid modalities in lieu of LOT to treat their pain. However, the lack of evidence of efficacy of LOT and considerable evidence of significant harms of overdose, death from overdose, and increased risk of suicide outweigh any potential modest be... |
the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) | 328 | Who does recommend a biopsychosocial approach to pain care that is multimodal and interdisciplinary? | In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accor... |
involve behavioral health to assess, monitor, and treat | 380 | What is essential to do when a patient 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... |
identify the followings: use of opioids to modulate emotions (i.e., “chemical coping”), untreated or undertreated psychiatric disorder | 2,437 | What to do if an SUD is not identified? | Module C is on tapering or discontinuation of opioid therapy. If there is indication to taper to reduced dose or taper to discontinuation, repeat comprehensive biopsychosocial assessment. Then see if the patient demonstrates signs or symptoms of SUD. If the patient demonstrates signs or symptoms of SUD, then see whethe... |
patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses | 883 | Among patients on OT, a prevalence of self inflicted injuries was significantly higher among which patients? | 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... |
the late 1990s and early 2000s | 273 | Since when has there been a significant increment of opioid-related morbidity, mortality, overdose death, and SUD treatment admissions? | 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 ... |
over weeks | 21 | How long does the faster taper take? | 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... |
central nervous system | 106 | What is CNS? | Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with... |
evidence available by December 2016 | 594 | This CPG is based on what? | As with other CPGs, there are limitations, including significant evidence gaps. Further, there is a need to develop effective strategies for guideline implementation and evaluation of the effect of guideline adherence on clinical outcomes. Thus, as stated in the qualifying statements at the beginning of the CPG, thi... |
Unique pharmacokinetic profile, Continuous delivery, even after the patch is removed due to depot effect, Increased rate of delivery, Unpredictable variation in rate of delivery - Due to alterations in temperature due to external heat, skin integrity, and amount of adipose tissue, Among patients with fever, skin dama... | 421 | What are the risks associated with a fentanyl transdermal delivery system (or patch)? | 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... |
patients currently on long-term opioid therapy | 261 | For whom ongoing risk mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits are recommended? | 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... |
15% | 410 | In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, how many reported using opioids? | 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... |
addressing the epidemic of overdoses from prescription opioids and other prescription drugs and heroin | 98 | What is the aim of CARA? | On July 22, 2016, the Comprehensive Addiction and Recovery Act (CARA) was enacted with the aim of addressing the epidemic of overdoses from prescription opioids and other prescription drugs and heroin. While this act was primarily focused on opioid abuse treatment and prevention, it also gave specific instruction to th... |
a discussion should occur between the Veteran, family members/caregivers, and the provider either during a face-to-face appointment or on the telephone | 173 | What should be done prior to any changes being made in opioid prescribing? | When a decision is made to taper, special attention must be given to ensure that the Veteran does not feel abandoned. Prior to any changes being made in opioid prescribing, a discussion should occur between the Veteran, family members/caregivers, and the provider either during a face-to-face appointment or on the telep... |
risks of OT outweigh benefits, patient preference, diversion | 177 | What are the indications for tapering and discontinuation? | 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... |
March 2016 | 576 | When was the National Pain Strategy published? | 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 ... |
decreasing the prevalence of all types of pain (acute and chronic) in the U.S., as well as the disability and morbidity associated with pain | 900 | What was the aim of the National Pain Strategy? | 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 ... |
to educate themselves and better understand their care | 703 | How can patients examine the guideline? | This guideline can be used in a variety of ways. This guideline can be used by general clinicians or specialists to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice. It can be used to provide specific information ... |
UDT results | 702 | What can identify active SUD or possible diversion? | As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availabi... |
age, marital status, race, geography, mental health comorbidity, and dosage | 1,151 | Based on the study, which factors influence the rates of opioid-use continuation in Veterans? | 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 emerging SUD as well as diversion | 242 | What can be signalled by frequent requests for atypically large quantities required to control pain? | 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... |
providing follow-up in a clinic visit may be more optimal than a telephone visit | 1,372 | What to do when patients are displaying other aberrant behaviors during the 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... |
family members or other supporters | 661 | Who to include in the discussion? | 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... |
potential drug interactions prior to initiating LOT | 124 | What should providers carefully rule out and avoid? | 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 ... |
the addition of other psychoactive medications to LOT | 32 | In addition to benzodiazepines, what to do with caution? | 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... |
consider one or more of the following: shortening prescribing interval, intensifying risk mitigation strategies, increasing intensity of monitoring, referring to interdisciplinary care and consulting with or referring to specialty care | 2,274 | What to do if the factors that increase risks of OT are present? | 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 ... |
follow-up 1 week to 1 month after each change in dosage and after discontinuation considering patient and treatment characteristics | 1,647 | What to do if there is no 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... |
anaphylaxis | 196 | What is an example of true allergy to opioid agents? | True allergy to opioid agents: Morphine causes a release of histamine that frequently results in itching, but this does not constitute an allergic reaction. True allergy to opioid agents (e.g., anaphylaxis) is not common, but does occur. Generally, allergy to one opioid does not mean the patient is allergic to other... |
If suicidal, then activate suicide prevention plan. If high suicide risk or actively suicidal, consult with mental health provider before beginning taper. | 379 | What to do if the veteran is suicidal, have high suicide risk or 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... |
concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder) | 283 | When should risk mitigation for LOT occur? | 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.,... |
patients with CNCP on long-acting OT | 358 | Who has a significantly increased risk of all-cause mortality compared to patients with CNCP who are taking an analgesic anticonvulsants or a low-dose antidepressant? | There is concern for additional overdose risk associated with long-acting versus short-acting opioids. A study (not included in the evidence review due to its design) suggests increased risk for non-fatal overdose in VA patients with initiation of a long-acting opioid compared with immediate-release opioids.[137] Als... |
the harms due to the potential for severe adverse events associated with opioids, particularly overdose and OUD | 385 | What often far outweighs the potential benefits? | Given the relevance of all four domains in grading recommendations, the Work Group encountered multiple instances in which confidence in the quality of the evidence was low or very low, while there was marked imbalance of benefits and harms, as well as certain other important considerations arising from the domains of ... |
comprehensive pain care plan | 162 | What to review and optimize during a follow-up? | 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 ... |
One identified study was a systematic review of 11 studies | 834 | Is there any study looking at opioid treatment agreements (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.,... |
Complementary and Integrative Health | 287 | What is CIH? | 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... |
Im et al. (2015) found moderate quality evidence | 128 | Is there any evidence that, at the facility level, patients on LOT within facilities ordering more drug screens than the comparison group were associated with decreased risk of suicide attempt? | 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... |
review the patient’s history including previous treatment approaches, their results, and any other outcomes with the patient | 65 | What should the clinicians do as part of the patient-centered care approach? | As part of the patient-centered care approach, clinicians should review the patient’s history including previous treatment approaches, their results, and any other outcomes with the patient. They should ask the patient about his or her willingness to accept a referral to an addiction or other behavioral health speciali... |
subjects 18-29 years old | 384 | Compared to whom, patients 30-39 years old had roughly half the 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 ≥... |
Slower Taper | 0 | Which one is the most common taper? | 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... |
only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate | 533 | When may LOT be appropriate? | 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... |
Tapering benzodiazepines | 768 | What should be performed with caution and within a team environment when possible? | 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... |
Younger patients | 0 | Who are at a higher risk of opioid misuse? | 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... |
before deciding to change therapy, look for “red flags”. The red flags are progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection. | 271 | What to do if a patient is showing signs of aberrant behavior? | 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 ... |
within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed | 1,042 | How frequently should the harms versus benefits be re-evaluated according to the CDC guideline? | Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months o... |
A paradigm shift in the use of OT for chronic non-terminal pain | 0 | What happened concurrently with the transformation in pain care? | 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... |
history, physical exam, comorbidities, previous treatment and medications, duration of symptoms, onset and triggers | 758 | What does pain assessment include? | 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 ... |
general clinicians or specialists | 79 | Who can use this guideline? | This guideline can be used in a variety of ways. This guideline can be used by general clinicians or specialists to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice. It can be used to provide specific information ... |
skills training and/or have a comprehensive pain care plan | 928 | The veteran undergoing slow tapering should be involved in what? | Follow up in the first 1 to 4 weeks of taper. If Veteran feels supported and is adjusting to the dose reduction, continue the strategy of reducing to morphine SR 30 mg every 8 hours, follow up in 1 to 4 weeks to determine the next step in the taper. If Veteran strongly resists reduction, then request mental health supp... |
drowsiness, constipation, and cognitive impairment | 675 | What are some examples of severe unmanageable adverse effects? | 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... |
at least annually | 206 | How often the UDT needs to be performed? | Offer risk mitigation strategies, including naloxone for patients at risk for overdose. Review PDMP (Prescription Drug Monitoring Program) data at least every 3 months and perform UDT (Urine Drug Testing) at least annually. Avoid prescribing opioid and benzodiazepines concurrently when possible. Clinicians should offe... |
fever, recent skin or urinary infection, immunosuppression, IV drug use | 816 | What are the signs of/risk factors for infection? | When considering an opioid taper, monitor for conditions that may warrant evaluation and arrange primary care and/or emergency department follow-up when indicated. If a patient is taking more than their prescribed dosage of opioids or showing signs of aberrant behavior, before deciding to change therapy, look for “red ... |
when patients have a history of previous opioid or non-opioid SUD | 66 | When is the relationship between OUD and duration of therapy magnified? | The relationship between OUD and duration of therapy is magnified when patients have a history of previous opioid or non-opioid SUD. A cross-sectional cohort study found that provision of LOT (four prescriptions within a 12 month period) to CNCP patients who had a history of severe OUD resulted in increased odds of ... |
as prescribing an exclusive course of management | 341 | How should the guideline not be interpreted as? | 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... |
recent overdose, current sedation, recent motor vehicle accident | 309 | What other factors can acutely increase risk of overdose? | 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... |
30 mg SR (15 mg x 2) Q8h | 383 | When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week four 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... |
gradual benzodiazepine taper | 1,733 | Exacerbation of severe PTSD symptoms may result from what? | 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... |
continue the strategy of reducing to morphine SR 30 mg every 8 hours, follow up in 1 to 4 weeks to determine the next step in the taper | 113 | What to do when Veteran feels supported and is adjusting to the dose reduction? | Follow up in the first 1 to 4 weeks of taper. If Veteran feels supported and is adjusting to the dose reduction, continue the strategy of reducing to morphine SR 30 mg every 8 hours, follow up in 1 to 4 weeks to determine the next step in the taper. If Veteran strongly resists reduction, then request mental health supp... |
educate on self-management and risks of OT, optimize whole person approach to pain care, optimize treatment of co-occurring mental health conditions, optimize non-opioid pain treatment modalities, reassess for OUD and readiness for OUD treatment as indicated | 1,839 | What to consider at each interaction with patient during the follow-ups? | 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... |
45 mg SR (15 mg x 3) Q8h | 851 | When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day two 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... |
in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care | 756 | Why is frequent follow-up needed? | Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months o... |
betrayal, disproportionate violence, incidents involving civilians, within-rank violence | 879 | What can cause moral injury? | 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... |
long-acting opioids such as methadone or exceptionally potent opioids | 1,182 | On which kind of opioids the use of the distribution of naloxone does not have established clinical efficacy? | 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.... |
methadone and transdermal fentanyl | 491 | Alternatives should be considered for which opioid pain medications? | 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 ... |
patients who decline MAT for OUD | 732 | For whom should clinicians consider educating the patient regarding sterile injection techniques and community-based needle exchange programs, if programs are available? | Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. ... |
3 tablets = 45 mg in the morning, 3 tablets = 45 mg in the afternoon, 3 tablets = 45 mg in the evening | 601 | How much to take from days 21 to 30, when using morphine SR 15 mg tablets? | Here is an example of an opioid taper plan for a Veteran. Veteran is currently taking morphine SR 60 mg, 1 tablet every 8 hours. Goal is to reduce the dose of morphine to SR 30 mg every 8 hours using a slow taper. Dose will be reduced by 15 mg every 10 days. Using morphine SR 15 mg tablets, follow the schedule below. F... |
in the clinic and/or over telephone | 819 | Where to follow up with the Veteran during the slower 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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