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assist Primary Care providers in determining if an opioid taper is necessary for a specific patient, in performing the taper, and in providing follow-up and support during the taper
46
227
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Establish treatment goals
64
89
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257
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risks, benefits and responsibilities for managing therapy
257
314
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immediate-release
4
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lowest
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benefits and risks
198
216
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benefits and risks
198
216
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If benefits do not outweigh harms
253
286
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If benefits do not outweigh harms
253
286
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Offer risk mitigation strategies, including naloxone
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at least annually
206
223
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at least annually
206
223
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Offer risk mitigation strategies, including naloxone
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opioid and benzodiazepines
243
269
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patients with OUD (Opioid Use Disorder)
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patients with OUD (Opioid Use Disorder)
373
412
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no pain reduction, no improvement in function or patient requests to discontinue therapy, severe unmanageable adverse effects, dosage indicates high risk of adverse events, concerns related to an increased risk of SUD (Substance use disorder) (e.g., behaviors, age < 30, family history, personal history of SUD), an overdose event involving opioids, non-adherence to the treatment plan or unsafe behaviors
216
621
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drowsiness, constipation, and cognitive impairment
675
725
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doses of 90 MEDD (Morphine equivalent daily dose) and higher
792
852
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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drowsiness, constipation, and cognitive impairment
675
725
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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doses of 90 MEDD (Morphine equivalent daily dose) and higher
792
852
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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early refills, lost/stolen prescription, buying or borrowing opioids, failure to obtain or aberrant UDT
887
990
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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early refills, lost/stolen prescription, buying or borrowing opioids, failure to obtain or aberrant UDT
887
990
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Re-evaluate the risks and benefits of continuing opioid therapy
138
201
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conditions that may warrant evaluation
46
84
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before deciding to change therapy, look for “red flags”. The red flags are progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection.
271
551
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before deciding to change therapy, look for “red flags”. The red flags are progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection.
271
551
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progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection
346
550
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when there is progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, a history of internal malignancy that has not been re-staged, signs of/risk factors for infection such as fever, recent skin or urinary infection, immunosuppression, IV drug use
587
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An urgent evaluation
552
572
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An urgent evaluation
552
572
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An urgent evaluation
552
572
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An urgent evaluation
552
572
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An urgent evaluation
552
572
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816
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screening and treatment is offered for conditions that can complicate pain management
7
92
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mental health disorders, OUD and other SUD, moral injury, central sensitization, medical complications, sleep disorders
179
298
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PTSD, anxiety disorders, depressive disorders
332
377
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If suicidal, then activate suicide prevention plan. If high suicide risk or actively suicidal, consult with mental health provider before beginning taper.
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activate suicide prevention plan
397
429
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consult with mental health provider before beginning taper
474
532
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consult with mental health provider before beginning taper
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about 41%: approximately 28% for mild symptoms, 10% for moderate symptoms and 3.5% for severe symptoms of OUD
635
744
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approximately 28%
646
663
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746
818
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BOTH pain and OUD
832
849
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Either tapering the opioid analgesic or continuing to prescribe the opioid without providing OUD treatment
861
967
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993
1,026
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overdose and other adverse events
993
1,026
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shared decision-making
6
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Medication-Assisted Therapy (MAT)
76
109
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Opioid Agonist Therapy (OAT)
178
206
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buprenorphine/naloxone (Suboxone) or methadone
284
330
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through a federally regulated opioid treatment program for OUD therapy
359
429
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extended-release (ER) injectable naltrexone (Vivitrol)
464
518
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585
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an act of transgression that leads to serious inner conflict typically brought on by betrayal, disproportionate violence, incidents involving civilians, within-rank violence
794
967
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betrayal, disproportionate violence, incidents involving civilians, within-rank violence
879
967
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Bio-Psycho-Social Model e.g., PHI’s “Whole Health” approach
29
88
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PHI’s “Whole Health” approach
59
88
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Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT) for Pain
139
225
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Complementary and Integrative Health
287
323
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slow tapering of opioids to reduce opioid risks while not “cutting off” the Veteran
407
490
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dose reduction or complete discontinuation
74
116
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subsequent regular reassessment
176
207
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Slower, more gradual tapers
326
353
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Slower, more gradual tapers
326
353
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several months to years
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432
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the opioid dose
442
457
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5% to 20%
597
606
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5% to 20% every 4 weeks
597
620
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drug diversion, illegal activities, or situations where the risks of continuing the opioid outweigh the risks of a rapid taper
682
808
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More rapid tapers
622
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More rapid tapers
622
639
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More rapid tapers
622
639
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More rapid tapers
622
639