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 />
modification, and/or opioid rotation to minimize the adverse effects as follows:<br />
a. Titrate slowly, temporarily reducing or holding doses if necessary, or modify the<br />
dosage regimen to allow the patient to develop tolerance to the adverse effects<br />
b. If these measures fail to minimize the adverse effects, consider rotating to another<br />
opioid agent<br />
5 N1 3 If adverse effects are unmanageable and therapy is a greater detriment than benefit as<br />
determined by discussion with the patient and family, opioid therapy should be<br />
discontinued.<br />
5 N1 4 Initial bowel regimens should generally consist of a bowel stimulant and a stool softener<br />
as well as general measures, such as increased fluid intake, increased dietary fiber, and<br />
adequate exercise.<br />
5 N1 5 Routinely initiate a stimulant-based bowel regimen at commencement of chronic opioid<br />
therapy.<br />
5 N1 6 If the initial regimen is inadequate, mild hyperosmotic, saline, and emollient laxatives<br />
may be added.<br />
5 N1 7 If possible, reduce or discontinue other drugs that may cause or contribute to<br />
constipation.<br />
5 N1 8 Bulk-producing laxatives, such as psyllium and polycarbophil, are not recommended and<br />
are relatively contraindicated as they may exacerbate constipation and lead to intestinal<br />
obstruction in patients with poor fluid intake.<br />
2010 Grade 20<br />
2016<br />
Recommendation (if<br />
Category 21 applicable) 22<br />
Deleted<br />
None Not reviewed,<br />
Deleted<br />
None Not reviewed,<br />
Deleted<br />
None Not reviewed,<br />
Deleted<br />
None Not reviewed,<br />
Deleted<br />
None Not reviewed,<br />
Deleted<br />
None Not reviewed,<br />
Deleted<br />
5 N1 9 Assess patients for constipation symptoms at every office visit. None Not reviewed,<br />
Deleted<br />
5 N1 10 Consider prophylactic antiemetic therapy at initiation of therapy. None Not reviewed,<br />
Deleted<br />
5 N1 11 Rule out other causes of nausea, and/or treat based on cause including<br />
a. Stimulation of chemoreceptor trigger zone: dopamine or serotonin antagonist<br />
b. Slowed GI motility: metoclopramide<br />
c. Nausea associated with motion: dimenhydrinate or scopolamine.<br />
None Not reviewed,<br />
Deleted<br />
5 N1 12 Rule out an allergic reaction. None Not reviewed,<br />
Deleted<br />
February 2017 Page 150 of 192