VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

Recommendations

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VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain # Recommendation 12. We recommend against opioid doses over 90 mg morphine equivalent daily dose for treating chronic pain. Note: For patients who are currently prescribed doses over 90 mg morphine equivalent daily dose, evaluate for tapering to reduced dose or to discontinuation (see Recommendations 15 and 16). 13. We recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of long-term opioid therapy. 14. We recommend tapering to reduced dose or to discontinuation of long-term opioid therapy when risks of long-term opioid therapy outweigh benefits. Note: Abrupt discontinuation should be avoided unless required for immediate safety concerns. 15. We recommend individualizing opioid tapering based on risk assessment and patient needs and characteristics. 2010 Grade 14 Evidence 15 Strength of Recommendation 16 None [58,59,66,87,133,136] Strong against Additional References: [134,135] None [140,141,143,144,146,149- 159,163,165] Additional References: [10,137- 139,142,145,160,162,164,166- 169] N/A [259] Additional References: [132,170-175](2010) N/A Additional References: [10,79,137,170-175] Strong against Strong for Strong for Recommendation Category 17 Reviewed, Newreplaced Reviewed, Newreplaced Reviewed, Newadded Reviewed, Newadded Note: There is insufficient evidence to recommend for or against specific tapering strategies and schedules. 16. We recommend interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior. 17. We recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder. Note: See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. None None None None None None None None [114,176] Strong for Reviewed, Newreplaced [114] Additional References: [177-182] Strong for Reviewed, Newreplaced February 2017 Page 130 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain # Recommendation 18. a) We recommend alternatives to opioids for mild-tomoderate acute pain. b) We suggest use of multimodal pain care including nonopioid medications as indicated when opioids are used for acute pain. c) If take-home opioids are prescribed, we recommend that immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated. Note: Patient education about opioid risks and alternatives to opioid therapy should be offered. 2010 Grade 14 Evidence 15 Strength of Recommendation 16 N/A [58,59,183-188] a) Strong for b) Weak for c) Strong for Recommendation Category 17 Reviewed, Newadded February 2017 Page 131 of 192
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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