question stringlengths 11 325 | title stringclasses 5
values | id int64 0 1.1k | context stringlengths 156 3.7k | answers dict |
|---|---|---|---|---|
What is needed when there is progressive numbness or weakness? | Features and overview | 53 | 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 ... | {
"answer_start": [
552
],
"text": [
"An urgent evaluation"
]
} |
How are the standards of care determined? | Introductory information | 289 | 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... | {
"answer_start": [
118
],
"text": [
"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"
]
} |
The presence of a lifetime history of SUD for patients with CNCP was associated with what? | Recommendations | 793 | The Edlund et al. (2014) study of 568,640 commercial health plan patients (see Recommendation 2 and 3) found that those diagnosed with CNCP and an alcohol use or non-opioid drug use disorder had higher rates of OUD (OR: 3.22, 95% CI: 1.79-5.80 for patients with pre-index alcohol use disorder compared to no alcohol u... | {
"answer_start": [
601
],
"text": [
"28 times increased odds of therapeutic opioid addiction compared to patients with CNCP without a lifetime history of SUD"
]
} |
Who facilitates the distribution of naloxone for the reversal? | Recommendations | 924 | 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.... | {
"answer_start": [
1041
],
"text": [
"the VA via Pharmacy Benefits Management"
]
} |
When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month five of the slower opioid tapering? | Features and overview | 149 | 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... | {
"answer_start": [
495
],
"text": [
"15 mg SR Q8h"
]
} |
What was the aim of the Opioid Safety Initiative? | Background information | 564 | 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... | {
"answer_start": [
421
],
"text": [
"ensuring opioids are used in a safe, effective, and judicious manner."
]
} |
In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, how many reported chronic pain? | Background information | 642 | 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... | {
"answer_start": [
379
],
"text": [
"44%"
]
} |
What to assess during a follow-up with a patient? | Algorithm | 411 | 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 ... | {
"answer_start": [
1806
],
"text": [
"function, risks, and benefits of OT, progress toward functional treatment goals, adverse effects, adherence to treatment plan, complications or co-occurring conditions (e.g., medical, mental health, and/or SUD)"
]
} |
What evidence is there to recommend psychological over physical therapies or vice versa? | Recommendations | 752 | 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... | {
"answer_start": [
1250
],
"text": [
"insufficient"
]
} |
What should be offered for patients with OUD? | Features and overview | 20 | 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... | {
"answer_start": [
333
],
"text": [
"MAT (Medication-Assisted Treatment)"
]
} |
What can have potential adverse outcomes in patients who do not have depression? | Recommendations | 836 | 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... | {
"answer_start": [
618
],
"text": [
"the combined use of antidepressants and opioids"
]
} |
What are some examples of severe unmanageable adverse effects? | Features and overview | 32 | 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... | {
"answer_start": [
675
],
"text": [
"drowsiness, constipation, and cognitive impairment"
]
} |
What is Module A about? | Algorithm | 365 | 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... | {
"answer_start": [
18
],
"text": [
"determination of appropriateness for opioid therapy"
]
} |
In which topics the goals of the OSI is related to? | Background information | 567 | 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... | {
"answer_start": [
539
],
"text": [
"increased education, monitoring, use of safe and effective prescribing and management methods, tool development, collaboration, and use of alternative pain treatment"
]
} |
What contributed to strong recommendations in multiple instances? | Recommendations | 299 | 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 ... | {
"answer_start": [
586
],
"text": [
"these factors"
]
} |
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? | Recommendations | 781 | 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... | {
"answer_start": [
289
],
"text": [
"to ensure that the patient understands the associated risks and benefits of LOT"
]
} |
Why follow up at least every three months or more frequently? | Recommendations | 993 | 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... | {
"answer_start": [
384
],
"text": [
"due to the balance of benefits and harms"
]
} |
In comparison to patients in the 20-44 age group, patients in the 45-64 year age group were significantly less likely to have what? | Recommendations | 864 | 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... | {
"answer_start": [
245
],
"text": [
"an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC])"
]
} |
What is essential to do when a patient becomes destabilized as a result of a medically appropriate decision to taper or cease LOT? | Recommendations | 986 | 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... | {
"answer_start": [
380
],
"text": [
"involve behavioral health to assess, monitor, and treat"
]
} |
When may LOT be appropriate? | Recommendations | 847 | 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... | {
"answer_start": [
533
],
"text": [
"only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate"
]
} |
What are examples of non-adherence to the treatment plan or unsafe behaviors? | Features and overview | 36 | 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... | {
"answer_start": [
887
],
"text": [
"early refills, lost/stolen prescription, buying or borrowing opioids, failure to obtain or aberrant UDT"
]
} |
What to do when patients are displaying other aberrant behaviors during the taper? | Features and overview | 215 | 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... | {
"answer_start": [
1372
],
"text": [
"providing follow-up in a clinic visit may be more optimal than a telephone visit"
]
} |
What should be commensurate with risk factors? | Recommendations | 318 | We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include ong... | {
"answer_start": [
229
],
"text": [
"The strategies and their frequency"
]
} |
When did a more cautious approach to OT for chronic non-terminal pain emerge? | Background information | 537 | 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... | {
"answer_start": [
1187
],
"text": [
"in the decade of the 2010s"
]
} |
What is the most common method of abuse? | Recommendations | 1,047 | Abuse Deterrent Formulations of Opioids: The aim of most abuse deterrent formulations is to present a physical barrier to prevent chewing, crushing, cutting, grating, or grinding of the dosage form, or present a chemical barrier, such as a gelling agent, that will resist extraction of the opioid with use of a common ... | {
"answer_start": [
652
],
"text": [
"consumption of a large number of intact capsules or tablets"
]
} |
What not to use to treat withdrawal symptoms? | Features and overview | 218 | 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... | {
"answer_start": [
172
],
"text": [
"an opioid or benzodiazepine"
]
} |
What is the stance regarding the long-term opioid therapy for pain in patients with untreated substance use disorder? | Recommendations | 310 | 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... | {
"answer_start": [
199
],
"text": [
"recommend against"
]
} |
How much does the risk increase at a range of 50 to <100 mg MEDD compared to risk at <20 mg MEDD? | Recommendations | 1,015 | 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... | {
"answer_start": [
368
],
"text": [
"approximately 2.6 times"
]
} |
From 2000 through 2010, what was the increment of the proportion of pain visits during which opioid was prescribed? | Background information | 493 | 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... | {
"answer_start": [
139
],
"text": [
"from 11.3% to 19.6%"
]
} |
What is the alternative treatment option for autonomic symptoms using Tizanidine? | Features and overview | 241 | 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... | {
"answer_start": [
1382
],
"text": [
"4 mg three times daily, can increase to 8 mg three times daily"
]
} |
What warrants an urgent evaluation during opioid therapy? | Features and overview | 52 | 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 ... | {
"answer_start": [
587
],
"text": [
"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... |
Which one is the strongest predictor of developing OUD among opioid dose and duration of OT? | Recommendations | 775 | Moderate quality evidence demonstrates that the prevalence of OUD in patients with CNCP is related to duration of opioid use as well as dose (see Recommendations 7-9).[86-88] There are two studies of patients with CNCP which support the current recommendations. Edlund et al. (2014) conducted a large retrospective coh... | {
"answer_start": [
1097
],
"text": [
"duration of OT"
]
} |
How much opioid to reduce in the slowest taper? | Features and overview | 127 | 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... | {
"answer_start": [
73
],
"text": [
"2 to 10% every 4 to 8 weeks with pauses in taper as needed"
]
} |
When was the Interagency Pain Research Coordinating Committee created? | Background information | 554 | 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 ... | {
"answer_start": [
78
],
"text": [
"March 2010"
]
} |
It is inadvisable to prescribe opioids to which patients? | Background information | 705 | 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... | {
"answer_start": [
319
],
"text": [
"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"
]
} |
What is a crime and constitutes an absolute contraindication to prescribing additional medications? | Background information | 692 | Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is importa... | {
"answer_start": [
113
],
"text": [
"drug diversion"
]
} |
What maybe included in interdisciplinary services? | Algorithm | 462 | 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... | {
"answer_start": [
329
],
"text": [
"mental health, SUD, primary care, and specialty pain care"
]
} |
Who does assess the critical information needed at the major decision points in the clinical process? | Algorithm | 363 | 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... | {
"answer_start": [
575
],
"text": [
"the provider"
]
} |
What should be done when a patient is referred for SUD treatment or is engaged in on-going treatment? | Recommendations | 917 | 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... | {
"answer_start": [
989
],
"text": [
"close communication between the SUD and pain management providers"
]
} |
What is the state of research on the effectiveness of LOT for non-end-of-life pain? | Background information | 498 | There has been limited research on the effectiveness of LOT for non-end-of-life pain. At the same time, there is mounting evidence of the ill effects of LOT, including increased mortality, OUD, overdose, sexual dysfunction, fractures, myocardial infarction, constipation, and sleep-disordered breathing. Despite increasi... | {
"answer_start": [
15
],
"text": [
"limited"
]
} |
What do UDTs do when used appropriately? | Recommendations | 908 | 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... | {
"answer_start": [
258
],
"text": [
"help to address safety, fairness, and trust with OT"
]
} |
What is multidisciplinary biopsychosocial rehabilitation? | Recommendations | 746 | 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... | {
"answer_start": [
681
],
"text": [
"described as a combination of a physical intervention such as graded exercise and a psychological, social, or occupational intervention"
]
} |
Compared to whom, patients 31-40 years old carried 5 times the odds of OUD and overdose? | Recommendations | 853 | 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 ≥... | {
"answer_start": [
312
],
"text": [
"those ≥65 years old"
]
} |
When is a short duration recommended? | Recommendations | 306 | 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 ... | {
"answer_start": [
286
],
"text": [
"If prescribing opioid therapy for patients with chronic pain"
]
} |
What methodology was used in developing the 2017 CPG? | Features and overview | 1,083 | The current document is an update to the 2010 VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. The methodology used in developing the 2017 CPG follows the VA/DoD Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG. The VA/DoD Guideline for Guidelines can... | {
"answer_start": [
193
],
"text": [
"the VA/DoD Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG"
]
} |
What may not reliably detect synthetic or semi-synthetic opioids? | Background information | 697 | Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is importa... | {
"answer_start": [
815
],
"text": [
"Routine UDT"
]
} |
When can this guideline be used? | Introductory information | 282 | 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 ... | {
"answer_start": [
113
],
"text": [
"to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice"
]
} |
Which factor can help identify non-adherence to a comprehensive pain care plan? | Algorithm | 422 | 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... | {
"answer_start": [
1108
],
"text": [
"attendance at appointment"
]
} |
What should providers carefully rule out and avoid? | Background information | 682 | 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 ... | {
"answer_start": [
124
],
"text": [
"potential drug interactions prior to initiating LOT"
]
} |
Which strategies may be helpful for those at higher risk of adverse events related to opioid therapy? | Recommendations | 1,065 | 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. | {
"answer_start": [
178
],
"text": [
"checking the PDMP, performing a UDT, placement in an inpatient setting or monitored environment, and/or providing OEND"
]
} |
What is the strength of this CPG? | Features and overview | 1,081 | The 2017 version of the VA/DoD OT CPG is the second update to the original CPG. It provides practice recommendations for the care of populations with chronic pain already on or being considered for LOT. Although there are many other approaches to the treatment of chronic pain, the scope of this CPG is to focus on th... | {
"answer_start": [
453
],
"text": [
"the multidisciplinary stakeholder involvement from its inception, ensuring representation from the broad spectrum of clinicians engaged in the treatment and management of patients with chronic pain on or being considered for LOT"
]
} |
Why should an optimal approach to care should include a robust, signature informed consent process? | Recommendations | 897 | Given the recognized risks of opioid therapy, an optimal approach to care should include a robust, signature informed consent process that is patient-centered and provides patients with information about known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for signature in... | {
"answer_start": [
0
],
"text": [
"Given the recognized risks of opioid therapy"
]
} |
When reducing 5% of morphine SR 90 mg Q8h = 270 MEDD, what dose should be taken on month seven of the slowest opioid tapering? | Features and overview | 138 | 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... | {
"answer_start": [
904
],
"text": [
"60 mg SR qam, 45 mg noon, 60 mg qpm"
]
} |
On which basis the frequency of follow-ups with a patient on OT should be considered? | Algorithm | 409 | 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 ... | {
"answer_start": [
1638
],
"text": [
"patient risk factors (e.g., 1-4 weeks with any dose change; up to every 3 months without dose change if clinically and functionally stable)"
]
} |
What to do if an SUD is not identified and there is use of opioids to modulate emotions or an untreated or undertreated psychiatric disorder? | Algorithm | 448 | 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... | {
"answer_start": [
2709
],
"text": [
"engage the patient in appropriate behavioral and/or psychiatric treatment, ideally in an interdisciplinary setting, consider reduced rate of taper or pause in taper for patients actively engaged in skills training"
]
} |
How frequently should the harms versus benefits be re-evaluated according to the CDC guideline? | Recommendations | 996 | 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... | {
"answer_start": [
1042
],
"text": [
"within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed"
]
} |
What warranted a cautious approach to LOT prioritizing safety? | Background information | 539 | 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... | {
"answer_start": [
0
],
"text": [
"The accumulation of evidence of harms and the absence of evidence of long-term benefits"
]
} |
What are some examples of synthetic opioids? | Background information | 698 | Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is importa... | {
"answer_start": [
886
],
"text": [
"methadone, fentanyl, tramadol"
]
} |
What is necessary to more accurately determine how long it takes for OUD to occur? | Recommendations | 783 | 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... | {
"answer_start": [
482
],
"text": [
"Research"
]
} |
What to do when there is evidence that the patient is diverting opioids? | Background information | 700 | Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is importa... | {
"answer_start": [
1052
],
"text": [
"discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities"
]
} |
How much opioid to reduce in the faster taper? | Features and overview | 155 | 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... | {
"answer_start": [
67
],
"text": [
"10 to 20% every week"
]
} |
All patients who take opioids chronically are at risk for what? | Recommendations | 842 | All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are younger than 30 years of age. Seven studies were identified that examined age as a predictor of OUD, respiratory/CNS depression, and/or overdose. Four of the seven studies were rated as fair quality evidence,[59,... | {
"answer_start": [
58
],
"text": [
"OUD and overdose"
]
} |
When reducing 33% of morphine SR 90 mg Q8h = 270 MEDD on day 1, what dose should be taken on day four of the rapid opioid tapering? | Features and overview | 170 | 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... | {
"answer_start": [
923
],
"text": [
"15 mg SR Q8h"
]
} |
What other factors can acutely increase risk of overdose? | Algorithm | 484 | 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... | {
"answer_start": [
309
],
"text": [
"recent overdose, current sedation, recent motor vehicle accident"
]
} |
During the first month in the slower taper what does consist of 16% reduction of morphine SR 90 mg Q8h = 270 MEDD? | Features and overview | 145 | 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... | {
"answer_start": [
336
],
"text": [
"75 mg (60 mg+15 mg)SR Q8h"
]
} |
A discussion should occur between the Veteran, family members/caregivers, and the provider prior to what? | Features and overview | 91 | 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... | {
"answer_start": [
127
],
"text": [
"any changes being made in opioid prescribing"
]
} |
Why is it important to consider patients’ values and concerns, address misconceptions, express empathy, and fully explain to patients with one or more risk factors that they may not benefit from, and may even be harmed by, treatment with OT? | Background information | 656 | The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insufficient ... | {
"answer_start": [
505
],
"text": [
"As patient values and preferences may be impacted by other clinical considerations, some patients with one or more risk factors for adverse outcomes may differ with the clinician’s assessment that the risks of OT outweigh the potential for modest short-term benefits.... |
What are the characteristics of higher risk medication? | Algorithm | 424 | 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... | {
"answer_start": [
1313
],
"text": [
"high-dose opioids, combination of opioids and benzodiazepines"
]
} |
Who will have greater mortality? | Recommendations | 1,023 | 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... | {
"answer_start": [
500
],
"text": [
"patients who require higher doses of opioids, even in those who benefit from such therapy"
]
} |
Who does recommend a biopsychosocial approach to pain care that is multimodal and interdisciplinary? | Recommendations | 738 | 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... | {
"answer_start": [
328
],
"text": [
"the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016)"
]
} |
What can be the reasons for the reluctance in further dose reductions? | Features and overview | 193 | 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... | {
"answer_start": [
491
],
"text": [
"medical (increased pain), mental health (worsening depression, anxiety, etc.), and substance use disorder (SUD)/opioid use disorder (OUD)"
]
} |
The use of a CPG must always be considered as what? | Introductory information | 293 | 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... | {
"answer_start": [
795
],
"text": [
"a recommendation, within the context of a provider’s clinical judgment and patient values and preferences, in the care for an individual patient."
]
} |
When will the variations in practice inevitably and appropriately occur? | Introductory information | 258 | 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... | {
"answer_start": [
63
],
"text": [
"when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice"
]
} |
What is the alternative OUD treatment? | Features and overview | 81 | 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... | {
"answer_start": [
464
],
"text": [
"extended-release (ER) injectable naltrexone (Vivitrol)"
]
} |
What specific information can this guideline provide to guide a patient encounter? | Introductory information | 285 | 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 ... | {
"answer_start": [
358
],
"text": [
"looking up the dosing of a medication used less frequently or the meaning of the urine drug testing (UDT) result"
]
} |
Why did the National Academy of Medicine issue a call for the transformation of pain care to a biopsychosocial, multimodal, interdisciplinary model? | Background information | 527 | 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... | {
"answer_start": [
342
],
"text": [
"As the cost, potential harm, and limited effectiveness of the approach in the biomedical model of pain care to chronic pain was becoming apparent"
]
} |
What are some examples of psychological complaints made by patients with chronic pain? | Background information | 627 | 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... | {
"answer_start": [
915
],
"text": [
"depression, anxiety, poor self-efficacy, poor general emotional functioning"
]
} |
What can be caused by rapid taper? | Features and overview | 181 | 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... | {
"answer_start": [
54
],
"text": [
"withdrawal effects"
]
} |
When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week two of the faster opioid tapering? | Features and overview | 157 | 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... | {
"answer_start": [
309
],
"text": [
"60 mg SR (15 mg x 4) Q8h"
]
} |
When to consider tapering opioids to lower doses? | Features and overview | 11 | Use immediate-release (IR) opioids when starting therapy. Prescribe the lowest effective dose. When using opioids for acute pain, provide no more than needed for the condition. Follow up and review benefits and risks before starting and during therapy. If benefits do not outweigh harms, consider tapering opioids to low... | {
"answer_start": [
253
],
"text": [
"If benefits do not outweigh harms"
]
} |
What is OT? | Algorithm | 390 | 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 ... | {
"answer_start": [
928
],
"text": [
"opioid therapy"
]
} |
Who should not be prescribed long-acting opioids? | Algorithm | 401 | 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 ... | {
"answer_start": [
440
],
"text": [
"opioid-naive individuals"
]
} |
What increases the risk of overdose and overdose death? | Recommendations | 803 | Harms may outweigh benefits for the concurrent use of benzodiazepines and LOT. There is moderate quality evidence that concurrent use of benzodiazepines with prescription opioids increases the risk of overdose and overdose death.[66] In a retrospective cohort study, the adjusted odds ratio (AOR) for drug overdose was... | {
"answer_start": [
119
],
"text": [
"concurrent use of benzodiazepines with prescription opioids"
]
} |
How are the standards of care determined? | Features and overview | 1,069 | 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... | {
"answer_start": [
407
],
"text": [
"on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and patterns evolve"
]
} |
What does the National Drug Control Strategy advocate? | Recommendations | 939 | 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... | {
"answer_start": [
0
],
"text": [
"take back programs"
]
} |
What can be caused by fentanyl analogs that may be used to create counterfeit opioid analgesic pills? | Recommendations | 930 | 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... | {
"answer_start": [
218
],
"text": [
"a toxidrome characterized by significant CNS and profound respiratory depression requiring multiple naloxone doses for reversal"
]
} |
What is the updated CPG intended for? | Introductory information | 277 | 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... | {
"answer_start": [
275
],
"text": [
"to assist healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, and follow-up"
]
} |
Veterans receiving both opioids and benzodiazepines were at an increased risk of what? | Recommendations | 808 | Harms may outweigh benefits for the concurrent use of benzodiazepines and LOT. There is moderate quality evidence that concurrent use of benzodiazepines with prescription opioids increases the risk of overdose and overdose death.[66] In a retrospective cohort study, the adjusted odds ratio (AOR) for drug overdose was... | {
"answer_start": [
656
],
"text": [
"death from drug overdose"
]
} |
What is needed when there are progressive changes in bowel or bladder function? | Features and overview | 54 | 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 ... | {
"answer_start": [
552
],
"text": [
"An urgent evaluation"
]
} |
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? | Features and overview | 177 | 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... | {
"answer_start": [
974
],
"text": [
"15 mg SR QHS"
]
} |
What kind of risk is associated with concurrent benzodiazepine and LOT use? | Recommendations | 810 | 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... | {
"answer_start": [
318
],
"text": [
"unintentional overdose death"
]
} |
What does pain assessment include? | Algorithm | 386 | 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 ... | {
"answer_start": [
758
],
"text": [
"history, physical exam, comorbidities, previous treatment and medications, duration of symptoms, onset and triggers"
]
} |
What is the aim of most abuse deterrent formulations? | Recommendations | 1,045 | Abuse Deterrent Formulations of Opioids: The aim of most abuse deterrent formulations is to present a physical barrier to prevent chewing, crushing, cutting, grating, or grinding of the dosage form, or present a chemical barrier, such as a gelling agent, that will resist extraction of the opioid with use of a common ... | {
"answer_start": [
89
],
"text": [
"to present a physical barrier to prevent chewing, crushing, cutting, grating, or grinding of the dosage form, or present a chemical barrier, such as a gelling agent, that will resist extraction of the opioid with use of a common solvent"
]
} |
From 1999 to 2008, what is increasing in parallel with the increment of opioid prescribing? | Background information | 501 | 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... | {
"answer_start": [
72
],
"text": [
"morbidity, mortality, opioid-related overdose death rates, and substance use disorders (SUD) treatment admissions"
]
} |
Among patients being treated by the VHA system that received opioids, what was significantly associated with opioid-related toxicity/overdose compared to no history of depression? | Background information | 674 | 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... | {
"answer_start": [
518
],
"text": [
"a history of depression"
]
} |
Further research is needed for what? | Recommendations | 988 | 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... | {
"answer_start": [
569
],
"text": [
"to identify strategies for safely managing patients at elevated risk of suicide who demand opioid medications or become further destabilized during tapering"
]
} |
When should non-opioids be recommended over opioids? | Recommendations | 723 | 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... | {
"answer_start": [
238
],
"text": [
"When pharmacologic therapies are used"
]
} |
What to do if referral/consultation for evaluation and treatment is not indicated? | Algorithm | 376 | 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... | {
"answer_start": [
1498
],
"text": [
"see if the patient is willing to engage in a comprehensive pain care plan"
]
} |
How may LOT affect patients with migraine headaches, tension-type headaches, occipital neuralgia, or myofascial pain? | Background information | 714 | 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... | {
"answer_start": [
232
],
"text": [
"may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal"
]
} |
What risk is recommended to be evaluated at least every 3 months? | Recommendations | 324 | 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... | {
"answer_start": [
200
],
"text": [
"risk for opioid-related adverse events"
]
} |
End of preview. Expand in Data Studio
No dataset card yet
- Downloads last month
- 4