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to assist healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, and follow-up
275
404
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to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice
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This guideline
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looking up the dosing of a medication used less frequently or the meaning of the urine drug testing (UDT) result
358
470
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section on tapering and its accompanying appendix
476
525
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703
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to assure that its clinicians and patients have the resources available to compassionately, effectively, and safely evaluate and deliver LOT in a timely, culturally sensitive manner
796
977
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on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advances and patterns evolve
118
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the variety of ever-changing state regulations that may be pertinent
364
432
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535
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the patient’s clinical presentation, patient preferences, and the available diagnostic and treatment options
573
681
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a recommendation, within the context of a provider’s clinical judgment and patient values and preferences, in the care for an individual patient.
795
940
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a systematic approach considering four domains as per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach
46
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Grading of Recommendations Assessment, Development and Evaluation
104
169
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confidence in the quality of the evidence, balance of desirable and undesirable outcomes (i.e., benefits and harms), patient or provider values and preferences, and other implications, as appropriate (e.g., resource use, equity, acceptability)
211
454
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multiple instances in which confidence in the quality of the evidence was low or very low, while there was marked imbalance of benefits and harms, as well as certain other important considerations arising from the domains of values and preferences and/or other implications
95
368
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the harms due to the potential for severe adverse events associated with opioids, particularly overdose and OUD
385
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these factors
586
599
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self-management strategies and other non-pharmacological treatments
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opioid therapy
54
68
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When pharmacologic therapies are used
208
245
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non-opioids over opioids
260
284
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a short duration
361
377
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If prescribing opioid therapy for patients with chronic pain
286
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Consideration of opioid therapy beyond 90 days
385
431
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ongoing risk mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits
65
194
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close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering
417
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consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate
150
258
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recommend against
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20
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close monitoring and consideration for tapering when risks exceed benefits
498
572
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implementing risk mitigation strategies
13
52
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starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies
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The strategies and their frequency
229
263
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ongoing, random urine drug testing (including appropriate confirmatory testing), checking state prescription drug monitoring programs, monitoring for overdose potential and suicidality, providing overdose education, prescribing of naloxone rescue and accompanying education
317
590
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assessing suicide risk and intervening when necessary
13
66
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when considering initiating or continuing long-term opioid therapy
67
133
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evaluating benefits of continued opioid therapy and risk for opioid-related adverse events
148
238
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risk for opioid-related adverse events
200
238
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benefits of continued opioid therapy
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lowest dose of opioids as indicated by patient-specific risks and benefits
321
395
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patient-specific risks and benefits
360
395
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absolutely safe
415
430
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more frequent monitoring for adverse events including opioid use disorder and overdose
49
135
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As opioid dosage and risk increase
0
34
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at any dose
179
190
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in a dose dependent manner
204
230
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20- 50 mg morphine equivalent daily dose
298
338
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Risks for overdose and death
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recommend against
3
20
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evaluate for tapering to reduced dose or to discontinuation
200
259
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113
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recommend against
3
20
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tapering to reduced dose or to discontinuation of long-term opioid therapy
13
87
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when risks of long-term opioid therapy outweigh benefits
88
144
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Abrupt discontinuation
152
174
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risk assessment and patient needs and characteristics
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addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior
41
175
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opioid use disorder
233
252
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VA/DoD Clinical Practice Guideline
322
356
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alternatives to opioids
13
36
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when opioids are used for acute pain
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multimodal pain care including non-opioid medications as indicated
88
154
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immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated
248
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lowest effective
290
306
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345
367
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to determine if adjustments or continuing opioid therapy is indicated
368
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determination of appropriateness for opioid therapy
18
69
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77
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proceed to module D
263
282
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obtain biopsychosocial assessment. Then educate or re-educate on non-opioid management, self-management to improve function and quality of life, realistic expectations and limitations of medical treatment. Then implement and optimize non-opioid treatments for chronic pain (e.g., physical, psychological, and complementary and integrative treatments).
385
736
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exit algorithm; manage with non-opioid modalities
816
865
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complete opioid risk assessment and see if patient risks outweigh benefits by considering strength and number of risk factors and patient preference
950
1,098
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see whether referral/consultation for evaluation and treatment is indicated (e.g., mental health, SUD, more intensive interdisciplinary care)
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refer/consult with appropriate interdisciplinary treatments. Then after referral/consultation with appropriate interdisciplinary treatments, see if the patient is willing to engage in a comprehensive pain care plan.
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see if the patient is willing to engage in a comprehensive pain care plan
1,498
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exit algorithm; manage with non-opioid modalities
816
865
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educate the patient and family about treatment options, including education on known risks and unknown long-term benefits of OT, risks of SUD and overdose, need for risk mitigation strategies, naloxone rescue. Then see if adding OT to comprehensive pain therapy is indicated at this time.
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treatment options, including education on known risks and unknown long-term benefits of OT, risks of SUD and overdose, need for risk mitigation strategies, naloxone rescue
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see if the patient is prepared to accept responsibilities and the provider is prepared to implement risk mitigation strategies
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exit algorithm; manage with non-opioid modalities
816
865
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discuss and complete written informed consent with patient and family, determine and document treatment plan, and proceed to module B
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exit algorithm; manage with non-opioid modalities
816
865
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pain assessment, patient functional goals, impact of pain on family, work, life, review of previous diagnostic studies, additional consultations and referrals, coexisting illness and treatments and effect on pain, significant psychological, social, or behavioral factors that may affect treatment, family history of chronic pain, collateral of family involvement, patient beliefs/knowledge of the cause of their pain and their treatment preferences along with the perceived efficacy of various treatment options
49
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psychological factors related to continuing vs. tapering OT
612
671