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

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VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain 2010 Recommendation Location 18 2010 Recommendation Text 19 Module Section Number pain or likely high level of opioid tolerance. If the new dose is well tolerated but ineffective, additional increases in dose can be considered. 3 K2 8 To ensure that the full effect from a dosage change has been manifested, and to avoid potential toxicity due to rapid accumulation of a drug, do not increase the dose more frequently than every five half-lives. In the case of methadone, upward dosage titration should not occur more frequently than every 7 days and perhaps longer (e.g., every 1 to 2 months), and only if there is no problem with daytime sedation, taking into consideration that there is wide interpatient variability in half-lives and responsiveness. (See Appendices E1 and F) 3 K2 9 If possible, titrate only one drug at a time while observing the patient for additive effects. Maintain patients on as few medications as possible to minimize drug interactions and adverse events. Discontinue medications, especially adjuvant medications, which do not add substantially to patient function or comfort. Continue close assessment of patients prescribed multiple centrally acting/psychoactive medications. 3 K2 10 If a medication provides less than satisfactory pain reduction despite increasing the dose as tolerated to a reasonable level (less than 200 mg/day morphine equivalent), evaluate for potential causes such as nonadherence and drug interactions (see Appendix E, Table E6– Drug Interactions), and consider changing to an alternate opioid medication. 3 K2 11 Medication may be increased until limited by adverse effects or clear evidence of lack of efficacy. If a high dose of medication (greater than 200 mg/day morphine equivalent) provides no further improvement in function, consider consultation rather than further increasing the dose. 3 K2 12 During the titration phase, reasonable supplemental (rescue) doses of a short acting opioid may be considered. (See Annotation K-4-Supplemental Dosing) 3 K2 13 Consider one or more of the following adjustments in therapy when there is an apparent loss of analgesic effect a. Further optimize adjuvant therapies b. Re-titrate the dose • Increase dose by 25-100%. • Do not increase the dose more frequently than every 5 half lives (for methadone or fentanyl no more than once a week), to ensure that the full effect from a dosage change 2010 Grade 20 2016 Recommendation (if Category 21 applicable) 22 None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted February 2017 Page 142 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain 2010 Recommendation Location 18 2010 Recommendation Text 19 Module Section Number has been manifested and to avoid potential toxicity due to rapid accumulation of a drug • If possible, titrate only one drug at a time, while observing the patient for additive effects. Inappropriate or ineffective medications should be tapered while titrating an appropriate pharmacologic regimen • Medication may be increased until treatment goals are met, intolerable adverse effects occur, or there is clear evidence of lack of efficacy c. Rotate to another opioid • Rotation between opioids may help to improve efficacy, reduce side effects and reduce dose escalation in some patients who are receiving long-term opioid therapy • Rotate to another agent based on equianalgesic table and titrate (see Appendix E, Table E6 for conversion factors) d. Refer or consult with advanced pain care (pain or palliative care specialist/pharmacist) • If the dose of opioid is large (more than 200mg/day morphine equivalent) • If opioid induced hyperalgesia or opioid tolerance is suspected e. Discontinue Opioid Therapy (See Annotation X). 3 K2 14 For a patient with continuous pain, an agent with a long duration of action, such as controlled-release morphine or methadone, is recommended. 3 K2 15 If short-acting opioids are effective and well tolerated, it may be possible to achieve equivalent pain relief with fewer daily doses of the medication by substituting an equivalent dose of long-acting opioid medication (such as methadone, morphine CR, oxycodone CR, or transdermal fentanyl). These long- acting medications may provide steadier serum levels and smoother pain control. They can be supplemented with doses of short-acting medication to control pain exacerbation. 3 K2 16 The conversion to a long-acting opioid should be based on an equianalgesic conversion (see Appendix E, Table E3 for conversion factors) and consideration of the incomplete cross-tolerance between opioids. To allow for incomplete cross-tolerance, in most cases, the starting conversion dose should be 50% to 67% of the calculated equianalgesic dose. 2010 Grade 20 2016 Recommendation (if Category 21 applicable) 22 None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted A notable exception to this general rule is methadone, which has relatively little crosstolerance with other opioids and should be started at a conversion dose that is based on the previous morphine- equivalent dose. Inexperienced clinicians should consult with an expert before initiating methadone; even in an opioid tolerant patient (see Appendix E, February 2017 Page 143 of 192
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Appendix D: Drug Tables A. Short-ac
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Short-Acting Opioid Tramadol (alone
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Long-Acting/ER Opioids 1 Buprenorph
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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