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 B. Risk Mitigation ................................................................................................................................... 46 C. Type, Dose, Duration, Follow-up, and Taper of Opioids .................................................................. 51 Appendix A: VA Signature Informed Consent ......................................................................................... 71 Appendix B: Urine Drug Testing ............................................................................................................. 75 A. Benefits of Urine Drug Testing .......................................................................................................... 75 B. Types of Urine Drug Testing .............................................................................................................. 75 Appendix C: Diagnostic and Statistical Manual of Mental Disorders for Opioid Use Disorders ................ 80 Appendix D: Drug Tables ....................................................................................................................... 81 A. Short-acting, Orally Administered Opioids ....................................................................................... 81 B. Long-acting/Extended-release Opioids ............................................................................................. 88 C. Morphine Milligram Equivalent Doses ............................................................................................. 99 D. Methadone Dosing Guidance .......................................................................................................... 101 Appendix E: Evidence Review Methodology ........................................................................................ 106 A. Developing the Scope and Key Questions ...................................................................................... 106 B. Conducting the Systematic Review ................................................................................................. 111 C. Convening the Face-to-face Meeting .............................................................................................. 116 D. Grading Recommendations ............................................................................................................. 117 E. Recommendation Categorization ................................................................................................... 120 F. Drafting and Submitting the Final Clinical Practice Guideline........................................................ 122 Appendix F: Patient Focus Group Methods and Findings ...................................................................... 123 A. Methods ........................................................................................................................................... 123 B. Patient Focus Group Findings .......................................................................................................... 124 Appendix G: Evidence Table ................................................................................................................ 127 Appendix H: 2010 Recommendation Categorization Table ................................................................... 132 Appendix I: Participant List .................................................................................................................. 160 Appendix J: Literature Review Search Terms and Strategy ................................................................... 162 A. Topic-specific Search Terms ............................................................................................................ 162 B. Search Strategies ............................................................................................................................. 168 Appendix K: Abbreviation List .............................................................................................................. 176 References .......................................................................................................................................... 179 February 2017 Page 4 of 192
VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain I. Introduction The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the “…Health Executive Council on the use of clinical and epidemiological evidence to improve the health of the population across the Veterans Health Administration and Military Health System,” by facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations.[1] This CPG is intended to provide healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with chronic pain who are on or being considered for long-term opioid therapy (LOT). In 2010, the VA and DoD published the Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain (2010 OT CPG), which was based on evidence reviewed through March 2009. Since the release of that guideline, there has been growing recognition of an epidemic of opioid misuse and opioid use disorder (OUD) in America, including among America’s Veterans, as documented in the Background section. At the same time, there is a mounting body of research expanding detailing the lack of benefit and severe harms of LOT. Consequently, a recommendation to update the 2010 OT CPG was initiated in 2015. The updated CPG, titled Clinical Practice Guideline for Opioid Therapy for Chronic Pain (OT CPG), includes objective, evidencebased information on the management of chronic pain. It is intended to assist healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, and follow-up. The system-wide goal of this guideline is to improve the patient’s health and well-being by providing evidence-based guidance to providers who are taking care of patients on or being considered for LOT. The expected outcome of successful implementation of this guideline is to: • Assess the patient’s condition, provide education, and determine the best treatment methods in collaboration with the patient and a multidisciplinary care team • Optimize the patient’s health outcomes and function and improve quality of life • Minimize preventable complications and morbidity • Emphasize the use of patient-centered care February 2017 Page 5 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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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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