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 Prepared by: The Opioid Therapy for Chronic Pain Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 3.0 – 2017 Based on evidence reviewed through December 2016 February 2017 Page 2 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Table of Contents I. Introduction ..................................................................................................................................... 5 II. How to Use This Clinical Practice Guideline ...................................................................................... 6 III. Recommendations ........................................................................................................................... 7 IV. Algorithm ...................................................................................................................................... 10 A. Module A: Determination of Appropriateness for Opioid Therapy ................................................. 11 B. Module B: Treatment with Opioid Therapy ...................................................................................... 12 C. Module C: Tapering or Discontinuation of Opioid Therapy ............................................................. 13 D. Module D: Patients Currently on Opioid Therapy ............................................................................ 14 V. Background.................................................................................................................................... 15 A. Opioid Epidemic ................................................................................................................................. 15 B. Paradigm Shift in Pain and Its Treatment ......................................................................................... 16 C. Prioritizing Safe Opioid Prescribing Practices and Use ..................................................................... 16 D. Taxonomy ........................................................................................................................................... 19 E. Epidemiology and Impact .................................................................................................................. 20 F. Chronic Pain and Co-occurring Conditions ....................................................................................... 21 G. Risk Factors for Adverse Outcomes of Opioid Therapy .................................................................... 21 VI. About this Clinical Practice Guideline ............................................................................................. 26 A. Scope of this Clinical Practice Guideline ........................................................................................... 26 B. Highlighted Features of this Clinical Practice Guideline ................................................................... 27 C. Methods ............................................................................................................................................. 27 D. Implementation ................................................................................................................................. 31 E. Summary of Patient Focus Group Methods and Findings ................................................................ 31 F. Conflict of Interest ............................................................................................................................. 32 G. Patient-centered Care ....................................................................................................................... 33 H. Shared Decision Making .................................................................................................................... 34 I. Stepped Care Model for Pain Management ..................................................................................... 34 J. Transfer of Care ................................................................................................................................. 35 K. Clinical Decision Support Tools ......................................................................................................... 37 VII. Guideline Work Group ................................................................................................................... 38 VIII. Discussion of Recommendations .................................................................................................... 39 A. Initiation and Continuation of Opioids ............................................................................................. 39 February 2017 Page 3 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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DRAFT 3 - DO NOT DISTRIBUTE VA/DoD
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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