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

Recommendations

Info

VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain 2010 Recommendation Location 18 2010 Recommendation Text 19 Module Section Number b. Patients with a significant chronic, or substantiated pain, who develop addiction behaviors in the context of chronic opioid therapy c. Uncontrolled substance use disorder (excluding nicotine) d. Behaviors characteristic of compulsive drug use (addiction) to either opioids or other drugs or alcohol should be referred to an addiction specialty e. Complex conditions who manifest behaviors characteristic of addiction with multiple co- occurring psychiatric disorders f. Need for tapering of opioids or unable to tolerate tapering after discontinuation of OT. 6 O1 2 Consider consultation with a SUD specialist to evaluate the risk of recurrent substance abuse or to assist with ongoing management. 6 O1 3 Refer patient for psychosocial treatments specific to prescription medication addiction/abuse. These can include addiction counselors comfortable with such topics, and self-help organizations (Pills Anonymous/PA, the National Chronic Pain Outreach association, and other similar organizations). 6 O2 1 Consider referral to a Pain Medicine Specialist in the following situations: a. Patient with complex pain conditions or polytrauma b. Patient with significant medical comorbidities that may negatively impact opioid therapy c. Patient who is unable to tolerate increased pain or physical withdrawal symptoms arising from opioid tapering when OT is being discontinued d. Opioid induced hyperalgesia or opioid tolerance is suspected e. High dose of medication (greater than 200 mg/day morphine equivalent) provides no further improvement in function f. Patient requiring management beyond the expertise of the primary provider 6 O2 2 Consider Referral to/consultation with a Behavioral Health Provider for evaluation and treatment in the following conditions: a. Exacerbation of an underlying psychotic disorder b. Uncontrolled, severe psychiatric disorder or those who are emotionally unstable c. Demonstration of high-risk behaviors suggestive of suicide ideation d. Psychosocial problems or comorbidities that may benefit from disease or case management e. Adverse behavioral or cognitive effects of OT f. Co-occurring trauma related conditions (mTBI, TBI, PTSD) 2010 Grade 20 2016 Recommendation (if Category 21 applicable) 22 None Reviewed, New-replaced None Not reviewed, Deleted None Not reviewed, Deleted None Not reviewed, Deleted Recommendation 17 February 2017 Page 154 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain 2010 Recommendation Location 18 2010 Recommendation Text 19 Module Section Number 7 P 1 Schedule follow-up visits at least every 2-4 weeks after any change in medication regimen and at least once every 1-6 months for the duration of the therapy (maintenance). 7 P 2 Assess at each visit: a. Comfort (degree of analgesia) b. Opioid-related adverse effects c. Functional status (physical and psychosocial) d. Adherence to opioid treatment agreement and other aspects of treatment plan e. Obtain laboratory studies (especially liver or kidney function screens), and/or order drug screens as indicated f. Use of self-report instruments (diary, opioid log) may be helpful but should not be required. 7 P 3 Documentation is essential and the medical record for each encounter should specifically address comfort, function, adverse-effects, and treatment plan adherence. 8 Q 1 Opioid therapy should be tapered off and discontinued if any of the following situations occur: a. The medication fails to show partial analgesia with incremental dose titration b. Trials with different agents provide inadequate analgesia c. There is other evidence that the pain may not be opioid responsive d. Real or potential harms outweigh real or potential benefits e. Patient request. 8 Q 2 Consider decreasing the opioid dose when pain level decreases in stable patients. (See Annotation X – Tapering) 8 R 1 Document, and offer referral to addiction specialty for patients demonstrating behaviors suggesting addiction to prescribed opioids or substance use disorders. 8 R 2 Discuss pharmacotherapy options with all patients with opioid and/or alcohol dependence. 8 R 3 If there are clearly unsafe or illegal behaviors, opioid prescribing should stop immediately and withdrawal should be addressed. 8 S 1 Attempt to maintain contact with any patient who withdraws from treatment due to a disagreement. 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 Reviewed, New-replaced None Reviewed, New-replaced None Not reviewed, Deleted None Not reviewed, Deleted Recommendation 17 Recommendation 17 February 2017 Page 155 of 192
Page 1 and 2:
VA/DoD CLINICAL PRACTICE GUIDELINE
Page 3 and 4:
VA/DoD Clinical Practice Guideline
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Appendix D: Drug Tables A. Short-ac
Page 83 and 84:
Short-Acting Opioid Initial Oral Do
Page 85 and 86:
Short-Acting Opioid Initial Oral Do
Page 87 and 88:
Short-Acting Opioid Tramadol (alone
Page 89 and 90:
Long-Acting/ER Opioids 1 Buprenorph
Page 91 and 92:
Long-Acting/ER Opioids 1 Hydrocodon
Page 93 and 94:
Long-Acting/ER Opioids 1 Initial Do
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
3 CYP-3A4 inhibiting agents include
Page 101 and 102:
Page 103 and 104: VA/DoD Clinical Practice Guideline
Page 153: VA/DoD Clinical Practice Guideline
Page 163 and 164: DRAFT 3 - DO NOT DISTRIBUTE VA/DoD
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?