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 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
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Appendix D: Drug Tables A. Short-ac
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Short-Acting Opioid Initial Oral Do
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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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Long-Acting/ER Opioids 1 Initial Do
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3 CYP-3A4 inhibiting agents include
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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