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 Appendix C: Diagnostic and Statistical Manual of Mental Disorders for Opioid Use Disorders DSM-5 diagnostic criteria for OUD: A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least 2 of the symptoms in the table above, occurring within a 12-month period.[197] Table C-1: DSM-5 Diagnostic Criteria for OUD [197] Normal Characteristics of a Urine Sample 1. Craving or strong desire or urge to use opioids 2. Recurrent use in situations that are physically hazardous 3. Tolerance 4. Withdrawal (or opioids are taken to relieve or avoid withdrawal) 5. Using larger amounts of opioids or over a longer period than initially intended 6. Persisting desire or unable to cut down on or control opioid use 7. Spending a lot of tie to obtain, use, or recover from opioids 8. Continued opioid use despite persistent or recurrent social or interpersonal problems related to opioids 9. Continued use despite physical or psychological problems related to opioids 10. Failure to fulfill obligations at work, school, or home due to use 11. Activities are given up or reduced because of us Table C-2: DSM-5 Diagnostic Criteria for Severity of OUD [197] Mild Moderate Severe Severity of OUD Number of Symptoms Presence of 2-3 symptoms Presence of 4-5 symptoms Presence of 6 or more symptoms February 2017 Page 80 of 192
Appendix D: Drug Tables A. Short-acting, Orally Administered Opioids Table D-1: Use of Short-acting, Orally Administered Opioids in Adults [198] Short-Acting Opioid Initial Oral Dosage (in opioid-naïve) Additional Dosage Information • Maximum APAP dose: 4000 mg/d (2000 mg/d in chronic alcoholics or in hepatic impairment) • Analgesic ceiling effect occurs with codeine at doses >60 mg/dose • Codeine alone is a weak analgesic; more effective alternatives are available (including codeine in combination with APAP or ASA) Analgesic Onset (min) Peak (min) Duration (hr) 15 to 30 30 to 60 4 to 6 Dosing In Special Populations Other Considerations • Codeine may be less effective in patients with decreased CYP- 2D6 activity (due to poor CYP- 2D6 metabolism or CYP-2D6 inhibiting drugs 2 ) because of decreased conversion to the active metabolite, morphine • CYP-2D6 ultra-rapid metabolizers 3 can have extensive conversion to morphine with increase in opioid-mediated effects Codeine (alone or in combination with acetaminophen [APAP] or acetylsalicylic acid [ASA]) • Codeine available as 15, 30 and 60 mg tablets • Combination products vary in codeine content from 15 to 60 mg/dose unit • 15 to 30 mg every 4 to 6 hr • Initial dose based upon codeine component, maximum dose based upon nonopioid component • Elderly or debilitated: Use with caution • Hepatic dysfunction: Conversion to active metabolite (morphine) may be reduced in patients with cirrhosis; avoid use in patients with liver disease • Renal dysfunction: Use lower dosage or an alternative analgesic February 2017 Page 81 of 192
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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN

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