VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN
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<strong>VA</strong>/<strong>DoD</strong> Clinical Practice Guideline for Opioid Therapy for Chronic Pain<br />
2010<br />
Recommendation<br />
Location 18 2010 Recommendation Text 19<br />
Module<br />
Section<br />
Number<br />
• Mobility<br />
• Self-care behaviors<br />
• Sexual function<br />
1 C 7 Information from the pain history and physical exam should be reviewed to ensure that<br />
the patient has had an adequate trial of non-opioid therapy.<br />
2 D 1 Opioid therapy trial should NOT be initiated in the following situations (absolute<br />
contraindications):<br />
a. Severe respiratory instability<br />
b. Acute psychiatric instability or uncontrolled suicide risk<br />
c. Diagnosed non-nicotine Substance Use Disorder (DSM-IV criteria) not in remission and<br />
not in treatment<br />
d. True allergy to opioid agents (cannot be resolved by switching agents)<br />
e. Co-administration of drug capable of inducing life-limiting drug-drug interaction<br />
f. QTc interval > 500 millisecond for using methadone<br />
g. Active diversion of controlled substances (providing the medication to someone for<br />
whom it was not intended)<br />
h. Prior adequate trials of specific opioids that were discontinued due to intolerance,<br />
serious adverse effects that cannot be treated, or lack of efficacy<br />
2 D 2 Opioid therapy trial can be initiated with caution in the following situations. Consider<br />
consultation with appropriate specialty care to evaluate if potential benefits outweigh<br />
the risks of therapy.<br />
a. Patient receiving treatment for diagnosed Substance Use Disorder (DSM-IV criteria).<br />
(See<br />
Annotation P1)<br />
b. Medical condition in which OT may cause harm:<br />
• Patient with obstructive sleep apnea not on CPAP<br />
• Patients with central sleep apnea (See Annotation P2)<br />
• Chronic pulmonary disease (mild-moderate asthma, COPD )<br />
• Cardiac condition (QTc interval 450-500 milliseconds) that may increase risk of using<br />
methadone<br />
• Known or suspected paralytic ileus<br />
• Respiratory depression in unmonitored setting<br />
c. Risk for suicide or unstable psychiatric disorder<br />
2010 Grade 20<br />
2016<br />
Recommendation (if<br />
Category 21 applicable) 22<br />
None Not reviewed,<br />
Deleted<br />
None Reviewed,<br />
Amended<br />
None Reviewed,<br />
Deleted<br />
Recommendation 4<br />
February 2017 Page 135 of 192