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appropriate mechanism and condition specific non-opioid pharmacologic agents
68
144
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Potential contraindications and long-term risks of use
270
325
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these also can carry risk of harm, depending on the specific patient and chosen medication
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Further studies
0
15
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Consideration of opioid therapy beyond 90 days
136
182
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re-evaluation and discussion with patient of risks and benefits
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ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14)
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the heightened risk for developing OUD
206
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duration of opioid use as well as dose
102
140
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duration of OT
1,097
1,111
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when patients have a history of previous opioid or non-opioid SUD
66
132
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recommend against
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127
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close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering
239
387
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OUD, overdose, and death, especially among patients with untreated SUD
37
108
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patients whose sole SUD relates to tobacco misuse
498
548
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those diagnosed with CNCP and an alcohol use or non-opioid drug use disorder
115
191
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the presence of a lifetime history of SUD for patients with CNCP
516
580
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28 times increased odds of therapeutic opioid addiction compared to patients with CNCP without a lifetime history of SUD
601
722
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Some patients with SUD
0
22
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the lack of evidence of efficacy of LOT and considerable evidence of significant harms of overdose, death from overdose, and increased risk of suicide
135
286
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tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate
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Harms may outweigh benefits
0
27
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increases the risk of overdose and overdose death
179
229
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the adjusted odds ratio (AOR) for drug overdose
268
316
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individuals on LOT for chronic pain (without anxiety or PTSD) who also received concurrent long-term benzodiazepine therapy
333
457
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Veterans receiving both opioids and benzodiazepines
574
626
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death from drug overdose
656
680
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Concurrent benzodiazepine and LOT use
250
287
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unintentional overdose death
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Concurrent benzodiazepine and LOT use
250
287
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due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety
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abrupt discontinuation of benzodiazepines
634
675
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abrupt
634
640
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as it can lead to serious adverse effects including seizures and death
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with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG)
813
916
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Tapering benzodiazepines
768
792
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Due to the difficulty of tapering or discontinuing benzodiazepines
919
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The VA/DoD PTSD CPG
1,125
1,145
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The VA/DoD PTSD CPG
1,125
1,145
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Benzodiazepines to treat acute anxiety symptoms after trauma
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a higher incidence of PTSD symptoms
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Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment.
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Concomitant use of benzodiazepines
1,815
1,849
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32
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the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone)
120
227
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the combination of zolpidem and opioids
446
485
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the AOR of overdose
496
516
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potential adverse outcomes (e.g., risk of overdose)
560
611
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the combined use of antidepressants and opioids
618
665
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669
704
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recommend against
6
23
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close monitoring and consideration for tapering when risks exceed benefits
263
337
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All patients who take opioids chronically
0
41
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OUD and overdose
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Similar to other risk factors, age <30 years
0
44
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288
347
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only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate
533
644
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Younger patients
0
16
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opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior)
46
133
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168
204
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an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC])
245
376
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394
426
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Patients in the 45-64 and ≥65 age groups
432
472
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20-44 year olds
509
524
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to have non-detection of a prescribed opioid as well (indicating possible diversion)
525
610
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An age of 30 years was chosen based on how age was categorized in the six studies that showed an inverse relationship between age and OUD or overdose.
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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
231
265
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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
321
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before the opioids are prescribed
37
70
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Risk mitigation for LOT should begin
0
36
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through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication
72
260
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use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT
492
614
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One identified study was a systematic review of 11 studies
834
892
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weak
1,051
1,055
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opioid treatment agreements
904
931
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There may be some variation
0
27