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modest short-term improvement in pain, possible short-term improvement in function
929
1,011
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“Doctors used to think that opioids were safe and effective when used for long periods of time to treat chronic pain.”, “New information has taught us that long-term opioid use can lead to multiple problems including loss of pain relieving effects, increased pain, unintentional death, OUD, and problems with sleep, mood, hormonal dysfunction, and immune dysfunction,”, “We now know that the best treatments for chronic pain are not opioids. The best treatments for chronic pain are non-drug treatments such as psychological therapies and rehabilitation therapies and non-opioid medications.”
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the Institute of Medicine [IOM]
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At least 100 million
161
181
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the treatment of chronic pain with opioids
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139
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from 26% to 29%
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at least 17%
385
397
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morbidity, mortality, opioid-related overdose death rates, and substance use disorders (SUD) treatment admissions
72
186
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1.9 million Americans were affected by an OUD related to non-medical use of prescription pain relievers, and in the same year, 18,893 individuals died as a result of a prescription drug overdose
343
539
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a four-fold increase
556
576
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14% increase
660
672
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22%
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988
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34% of patients reported that they thought they were “addicted” or “dependent” on opioid pain medication, 34% said that they used the medication for “fun” or to “get high,” while 22% used the medication to relieve day-to-day stress
806
1,037
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the rate of heroin overdose deaths
57
91
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nearly four-fold
103
119
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prescription opioids
507
527
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increase in the use of opioids, as well as associated morbidity, mortality, and other adverse outcomes
556
658
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the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (VA/DoD SUD CPG)
760
861
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VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders
764
844
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in the way pain is viewed and treated
54
91
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The U.S. is in the midst of a cultural transformation in the way pain is viewed and treated
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the pain experience is reduced to a pain generator and pain treatment is aimed at fixing or numbing pain with medications, interventions, or surgery
137
285
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fixing or numbing pain with medications, interventions, or surgery
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the 1990s and the first decade of the 2000s
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As the cost, potential harm, and limited effectiveness of the approach in the biomedical model of pain care to chronic pain was becoming apparent
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a biopsychosocial, multimodal, interdisciplinary model
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A paradigm shift in the use of OT for chronic non-terminal pain
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tolerance, physical dependence, and addiction
236
281
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Efforts to destigmatize the use of prescription opioids for chronic non-terminal pain
504
589
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in the 1990s and the first decade of the 2000s
792
838
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absence
920
927
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in the decade of the 2010s
1,187
1,213
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The accumulation of evidence of harms and the absence of evidence of long-term benefits
0
87
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the evidence of both the safety and efficacy for non-pharmacologic and non-opioid pharmacologic pain therapies
188
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as a complex multidimensional experience that requires multimodal and integrated care approaches
436
532
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primarily in the treatment of severe acute pain, post-operative pain, and end-of-life pain
694
784
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limited
680
687
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The increasing use of opioids, as well as the accompanying rise in morbidity and mortality associated with opioid use
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The increasing use of opioids
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The increasing use of opioids
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29
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curtailing illicit drug consumption in America and improving the health and safety of the American people by reducing the consequences of drug abuse
444
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October 2015
723
735
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presidential memorandum on preventing prescription drug abuse and heroin use
633
709
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by calling for change in a number of key areas including preventing drug use in communities, seeking early intervention opportunities, and integrating SUD treatment and supporting recovery
814
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With the passage of the Patient Protection and Affordable Care Act (PPACA) in March 2010
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March 2010
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summarizing advances in pain care research, identifying gaps in research, and developing recommendations regarding ways to minimize duplicative efforts, disseminate pain care information, and expand public/private research partnerships and collaborations
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The Committee
233
246
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March 2016
576
586
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in response to the call from the National Academy of Medicine to increase awareness of pain as a significant public health issue in the U.S.
587
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decreasing the prevalence of all types of pain (acute and chronic) in the U.S., as well as the disability and morbidity associated with pain
900
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VA, DoD, and Substance Abuse and Mental Health Services Administration (SAMHSA)
35
115
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Substance Abuse and Mental Health Services Administration
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August 2013
274
285
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ensuring opioids are used in a safe, effective, and judicious manner.
421
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Opioid Safety Initiative
308
332
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increased education, monitoring, use of safe and effective prescribing and management methods, tool development, collaboration, and use of alternative pain treatment
539
705
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Veterans Health Administration (VHA’s) electronic health record
725
788
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Veterans Health Administration (VHA’s) electronic health record
725
788
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to identify patients who may be high-risk for adverse outcomes with use of opioids and providers whose prescribing practices do not reflect best evidence so that patient care can be improved
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specific indicators (e.g., the number of unique pharmacy patients dispensed an opioid, the unique patients on LOT who have received UDT)
1,012
1,149
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the Opioid Overdose Education and Naloxone Distribution (OEND) program
1,187
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implemented as a risk mitigation strategy aimed at reducing deaths from opioid overdose
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the Comprehensive Addiction and Recovery Act
18
62
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July 22, 2016
3
16
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addressing the epidemic of overdoses from prescription opioids and other prescription drugs and heroin
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Service Members, Veterans, and their families—that has unique characteristics and needs related to the military culture and communities to which they return
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specific risk factors such as risk for suicide, SUD, and other medical and mental health co-occurring conditions that may complicate the management of pain for these patients
357
531
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the implications they would have within the VA/DoD healthcare settings, particularly regarding considerations such as resource use, accessibility, and equity related to each recommendation and the urgent need for rigorous attention to the balance of risks and benefits for patients within the VA/DoD specifically
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Along with a clinical evidence review, during which the evidence was evaluated using GRADE, the CDC guideline developers also considered the findings of a contextual evidence review. Further, the CDC Core Expert Group, which consisted of subject matter experts, representatives of primary care professional societies and state agencies, and an expert in guideline methodology, reviewed recommendations drafted by the CDC and evaluated how the evidence was used in the development of the recommendations, rather than developing the recommendations themselves (as was the VA/DoD OT Work Group’s role in the development of the VA/DoD OT CPG). While experts provided feedback on the CDC recommendations and their development, the CDC determined the final recommendations. CDC also used a review process considering and incorporating feedback from federal partners (e.g., SAMHSA, VA, DoD), stakeholders (e.g., professional organizations, delivery systems, community organizations), and other constituents (e.g., clinicians, prospective patients).
126
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based on a slightly different evidence base and revised based on the feedback of individuals who were considering a larger group of potential patients relative to the VA/DoD
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a document that details the process by which VA/DoD guidelines will be developed, including the use of the GRADE methodology
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an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage…Pain is always subjective…It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience.
20
325
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quality (e.g., sharp versus dull), intensity, timing, location, and whether it is associated with position or movement
553
672