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 nonadherence 4 M3 1 Inform patients that drug testing is a routine procedure for all patients starting or on opioid therapy, and is an important tool for monitoring the safety of their treatment. 2010 Grade 20 2016 Recommendation (if Category 21 applicable) 22 None Reviewed, New-replaced 4 M3 2 With patient consent, obtain a UDT in all patients prior to initiation of OT. [B] B Reviewed, New-replaced 4 M3 3 With patient consent monitor all patients on OT with periodic random UDTs to confirm adherence to the treatment plan. Increase the frequency of UDTs based on risk level for aberrant drug-related behaviors and following each dose increase. [B] 4 M3 4 Take into consideration a patient’s refusal to take a UDT as part of the ongoing assessment of the patient’s ability to adhere to the treatment plan and the level of risk for adverse outcomes (see Annotation F). 4 M3 5 When interpreting UDT results take into account other clinical information (e.g., past SUD, other risk factors, aberrant drug-related behaviors, and other conditions indicating risk.) 4 M3 6 Understanding of lab methods for drug testing and reporting are necessary to interpret UDT results (i.e., screen versus confirmatory test, substances tested, cut-off levels for tests). Maintain a close working relationship with the clinical laboratory to answer any questions about the UDT or for confirming the results. 4 M4 1 Evaluate and assess the patient for the following problems or other indications for consultation or referral: a. Patient with complex pain conditions b. Patient with significant medical comorbidities that may negatively impact opioid therapy c. Patient with significant concurrent psychiatric illnesses d. Patient who is unable to tolerate increased pain or physical withdrawal symptoms arising from opioid tapering when OT is being discontinued e. Opioid induced hyperalgesia or opioid tolerance suspected (i.e., pain increases or changes while on chronic stable opioid dosing and with an unchanged underlying medical condition causing the pain) f. Patient with conditions requiring management beyond the expertise level of the primary provider B Reviewed, New-replaced None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted Recommendation 7 Recommendation 7 Recommendation 7 February 2017 Page 148 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain 2010 Recommendation Location 18 2010 Recommendation Text 19 Module Section Number 4 M5 1 Evaluate pain intensity at each visit. a. Intensity of pain should be measured in the following manner using a Numeric Rating Scale (NSR) (0 to 10) and include the following: • Current pain • Least pain in last week • “Usual” or “Average” pain in the last week b. The patient’s response to current pain medications should be assessed each visit using questions such as: • “What is your intensity of pain after taking your current treatment/medication?” • “How long does your pain relief last after taking your medication?” 4 M5 2 Evaluate pain-related function using objective documentation whenever possible, such as physical therapy progress notes, employment records, exercise diaries, family reports, clinician observations (e.g., walking distance), or validated instruments or NRS rating scales on a monthly basis during the titration phase and every six months after the patient is on stable opioids. Assessment of function may include: • Employment • Enjoyment of life • Emotional distress (depression and anxiety) • Housework, chores, hobbies, and other day to day activities • Sleep • Mobility • Self-care behaviors • Sexual function 2010 Grade 20 2016 Recommendation (if Category 21 applicable) 22 None Not reviewed, Deleted None Not reviewed, Deleted 4 M5 3 Assess overall patient satisfaction with pain therapy at each visit None Not reviewed, Deleted 4 M5 4 Emphasis should be given to capitalizing on improved analgesia by gains in physical and social function; opioid therapy should be considered complementary to other analgesic and rehabilitative approaches. 5 N1 1 Adverse effects can usually be minimized through the use of low starting doses, slow titration rates, prophylactic and symptomatic treatments, and specific patient education provided at initiation of therapy. None Not reviewed, Deleted None Not reviewed, Deleted 5 N1 2 Symptomatic treatment should be augmented with slow dosage titration, dose None Not reviewed, February 2017 Page 149 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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Long-Acting/ER Opioids 1 Hydrocodon
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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