Hieu-Pham/cpgQA huggingface dataset:
Recommendations

Psychological therapies (e.g., cognitive behavioral interventions such as Cognitive Behavioral Therapy  [CBT], biofeedback) have been found to be effective for pain reduction in multiple pain conditions.[80-82] Exercise treatments, including yoga, also have evidence of benefit for reducing pain intensity and disability  when compared to usual care in the treatment of chronic pain conditions.[83-85] Exercise and  psychological therapies may each exert their influence through multiple mechanisms including but not  limited to the reduction in fear-avoidance, reduction in catastrophizing, and/or enhancing mood.[80]  Similarly, multidisciplinary biopsychosocial rehabilitation (described as a combination of a physical  intervention such as graded exercise and a psychological, social, or occupational intervention) has been  shown to be more effective than usual care in improving pain and disability.[81] These interventions are  safe and have not been shown to increase morbidity or mortality. In light of the low harms associated with exercise and psychological therapies when compared with LOT these treatments are preferred over LOT, and should be offered to all patients with chronic pain including  those currently receiving LOT. There is insufficient evidence to recommend psychological over physical  therapies or vice versa; the choice of which to try first should be individualized based on patient  assessment and a shared decision making process (see Patient Focus Group Methods and Findings).[80]  

Question: How to choose between psychological and physical therapies as a first-try?
Answer: the choice of which to try first should be individualized based on patient  assessment and a shared decision making process
Recommendations

In addition to non-pharmacological therapies (e.g., exercise, CBT), appropriate mechanism and condition specific non-opioid pharmacologic agents should be tried and optimized before consideration of opioid  medications (e.g., gabapentin in neuropathic pain states).[83] Potential contraindications and long-term  risks of use should be considered for non-opioid pharmacologic agents as well, as these also can carry risk  of harm, depending on the specific patient and chosen medication. 

Question: In addition to non-pharmacological therapies, what should be tried and optimized before consideration of opioid medications?
Answer: appropriate mechanism and condition specific non-opioid pharmacologic agents
Recommendations

In addition to non-pharmacological therapies (e.g., exercise, CBT), appropriate mechanism and condition specific non-opioid pharmacologic agents should be tried and optimized before consideration of opioid  medications (e.g., gabapentin in neuropathic pain states).[83] Potential contraindications and long-term  risks of use should be considered for non-opioid pharmacologic agents as well, as these also can carry risk  of harm, depending on the specific patient and chosen medication. 

Question: What is an example of opioid medications?
Answer: gabapentin in neuropathic pain states
Recommendations

In addition to non-pharmacological therapies (e.g., exercise, CBT), appropriate mechanism and condition specific non-opioid pharmacologic agents should be tried and optimized before consideration of opioid  medications (e.g., gabapentin in neuropathic pain states).[83] Potential contraindications and long-term  risks of use should be considered for non-opioid pharmacologic agents as well, as these also can carry risk  of harm, depending on the specific patient and chosen medication. 

Question: What should be considered for non-opioid pharmacologic agents?
Answer: Potential contraindications and long-term  risks of use
Recommendations

In addition to non-pharmacological therapies (e.g., exercise, CBT), appropriate mechanism and condition specific non-opioid pharmacologic agents should be tried and optimized before consideration of opioid  medications (e.g., gabapentin in neuropathic pain states).[83] Potential contraindications and long-term  risks of use should be considered for non-opioid pharmacologic agents as well, as these also can carry risk  of harm, depending on the specific patient and chosen medication. 

Question: Why should the potential contraindications and long-term  risks of use be considered for non-opioid pharmacologic agents as well?
Answer: these also can carry risk  of harm, depending on the specific patient and chosen medication
Recommendations

Patient access to physical, psychological, and pain rehabilitation modalities should be considered. In some  cases access to care may be limited; all VA and DoD clinics may not have access to multidisciplinary pain  services. Still, all avenues for obtaining these treatments (e.g. Internet based CBT) and all appropriate non opioid medications should be exhausted before consideration of LOT.[82]  

Question: To which modalities should the patient have access?
Answer: physical, psychological, and pain rehabilitation modalities
Recommendations

Patient access to physical, psychological, and pain rehabilitation modalities should be considered. In some  cases access to care may be limited; all VA and DoD clinics may not have access to multidisciplinary pain  services. Still, all avenues for obtaining these treatments (e.g. Internet based CBT) and all appropriate non opioid medications should be exhausted before consideration of LOT.[82]  

Question: What should be exhausted before consideration of LOT?
Answer: all avenues for obtaining these treatments (e.g. Internet based CBT) and all appropriate non opioid medications
Recommendations

Further studies may help determine earlier in the course of treatment which patients are most likely to  benefit from a specific non-pharmacologic therapy (physical, psychological, and pain rehabilitation) or non opioid pharmacologic therapies alone or as part of a multimodal approach. 

Question: What may help determine earlier in the course of treatment which patients are most likely to  benefit from a specific non-pharmacologic therapy or non opioid pharmacologic therapies alone or as part of a multimodal approach?
Answer: Further studies
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: What timeframe is recommended if prescribing opioid therapy for patients with chronic pain?
Answer: a short duration
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: What does require re-evaluation and discussion with patient of risks and benefits?
Answer: Consideration of opioid therapy beyond 90 days
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: What is required when considering opioid therapy beyond 90 days?
Answer: re-evaluation and discussion with patient of risks and benefits
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: What is recommended for patients currently on long-term opioid therapy?
Answer: ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14)
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: For whom ongoing risk mitigation strategies are recommended?
Answer: patients currently on long-term opioid therapy
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: For whom assessment for opioid use disorder is recommended?
Answer: patients currently on long-term opioid therapy
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: For whom consideration for tapering when risks exceed benefits is recommended?
Answer: patients currently on long-term opioid therapy
Recommendations

If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for| Reviewed, New-replaced) Note: Consideration of opioid therapy beyond 90 days requires re-evaluation and discussion with patient of risks and benefits. For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies (see Recommendations 7-9), assessment for opioid use disorder, and consideration for tapering when risks exceed benefits (see Recommendation 14). (Strong for| Reviewed, New-replaced) 

Question: For whom ongoing risk mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits are recommended?
Answer: patients currently on long-term opioid therapy
Recommendations

The support for these recommendations is two-fold: a paucity of research showing benefit for LOT and the strength of the evidence demonstrating the potential for life-threatening harm. Of utmost concern is the heightened risk for developing OUD in patients who receive OT beyond 90 days (see Appendix C for  Diagnostic and Statistical Manual of Mental Disorders [DSM] 5 diagnostic criteria for OUD).  

Question: What is the utmost concern for patients who receive OT beyond 90 days?
Answer: the heightened risk for developing OUD
Recommendations

Similar to other risk factors, continuing OT beyond 90 days’ duration should be weighed heavily in the risk benefit calculus for LOT. Continuing OT for longer than 90 days is not an absolute contraindication to LOT.  There may be some situations where the benefits of LOT clearly outweigh the risks. That must be  determined through individual clinical assessment.  

Question: What should be weighed heavily in the risk benefit calculus for LOT?
Answer: continuing OT beyond 90 days’ duration
Recommendations

Similar to other risk factors, continuing OT beyond 90 days’ duration should be weighed heavily in the risk benefit calculus for LOT. Continuing OT for longer than 90 days is not an absolute contraindication to LOT.  There may be some situations where the benefits of LOT clearly outweigh the risks. That must be  determined through individual clinical assessment.  

Question: What is not an absolute contraindication to LOT?
Answer: Continuing OT for longer than 90 days
Recommendations

Similar to other risk factors, continuing OT beyond 90 days’ duration should be weighed heavily in the risk benefit calculus for LOT. Continuing OT for longer than 90 days is not an absolute contraindication to LOT.  There may be some situations where the benefits of LOT clearly outweigh the risks. That must be  determined through individual clinical assessment.  

Question: What must be determined through individual clinical assessment?
Answer: There may be some situations where the benefits of LOT clearly outweigh the risks.
Recommendations

Similar to other risk factors, continuing OT beyond 90 days’ duration should be weighed heavily in the risk benefit calculus for LOT. Continuing OT for longer than 90 days is not an absolute contraindication to LOT.  There may be some situations where the benefits of LOT clearly outweigh the risks. That must be  determined through individual clinical assessment.  

Question: How to determine the situations where the benefits of LOT clearly outweigh the risks?
Answer: through individual clinical assessment
Recommendations

Moderate quality evidence demonstrates that the prevalence of OUD in patients with CNCP is related to duration of opioid use as well as dose (see Recommendations 7-9).[86-88] There are two studies of  patients with CNCP which support the current recommendations. Edlund et al. (2014) conducted a large  retrospective cohort study where they examined claims data from a health insurance database between  2000 and 2005 to examine factors predictive of developing OUD.[86] Days’ supply of opioids was  categorized as none, acute duration (1-90 days), or chronic duration (91+ days). Average daily dose was  defined as none, low (1-36 mg MEDD), medium (36-120 mg MEDD), or high (>120 mg MEDD). The OR of  developing OUD ranged based on dose and duration (OR: 3.03, 95% CI: 2.32-3.95 for low dose, acute  opioid prescription; OR: 14.92, 95% CI: 10.38-21.46 for low dose, chronic opioids prescriptions; OR: 3.10,  95% CI: 1.67-5.77 for high dose, acute opioid prescriptions; OR: 122.45, 95% CI: 72.79-205.99 for high  dose, chronic opioid prescriptions). They found that even greater than opioid dose, duration of OT was the  strongest predictor of developing OUD. Additionally, a study by Boscarino et al. (2011) examined medical  records from a large healthcare system.[89] Through interviews with a random sample of patients on LOT,  they examined factors associated with and the prevalence of OUD (using DSM IV and 5 criteria). These  results showed that the prevalence of lifetime OUD for patients on LOT was 34.9% (based on DSM-5  criteria) and 35.5% (based on DSM-IV criteria).  

Question: To what the prevalence of OUD in patients with CNCP is related?
Answer: duration of opioid use as well as dose
Recommendations

Moderate quality evidence demonstrates that the prevalence of OUD in patients with CNCP is related to duration of opioid use as well as dose (see Recommendations 7-9).[86-88] There are two studies of  patients with CNCP which support the current recommendations. Edlund et al. (2014) conducted a large  retrospective cohort study where they examined claims data from a health insurance database between  2000 and 2005 to examine factors predictive of developing OUD.[86] Days’ supply of opioids was  categorized as none, acute duration (1-90 days), or chronic duration (91+ days). Average daily dose was  defined as none, low (1-36 mg MEDD), medium (36-120 mg MEDD), or high (>120 mg MEDD). The OR of  developing OUD ranged based on dose and duration (OR: 3.03, 95% CI: 2.32-3.95 for low dose, acute  opioid prescription; OR: 14.92, 95% CI: 10.38-21.46 for low dose, chronic opioids prescriptions; OR: 3.10,  95% CI: 1.67-5.77 for high dose, acute opioid prescriptions; OR: 122.45, 95% CI: 72.79-205.99 for high  dose, chronic opioid prescriptions). They found that even greater than opioid dose, duration of OT was the  strongest predictor of developing OUD. Additionally, a study by Boscarino et al. (2011) examined medical  records from a large healthcare system.[89] Through interviews with a random sample of patients on LOT,  they examined factors associated with and the prevalence of OUD (using DSM IV and 5 criteria). These  results showed that the prevalence of lifetime OUD for patients on LOT was 34.9% (based on DSM-5  criteria) and 35.5% (based on DSM-IV criteria).  

Question: Which one is the strongest predictor of developing OUD among opioid dose and duration of OT?
Answer: duration of OT
Recommendations

The relationship between OUD and duration of therapy is magnified when patients have a history of  previous opioid or non-opioid SUD. A cross-sectional cohort study found that provision of LOT (four  prescriptions within a 12 month period) to CNCP patients who had a history of severe OUD resulted in  increased odds of developing OUD (OR: 56.36, 95% CI: 32.49-97.76).[88]  

Question: When is the relationship between OUD and duration of therapy magnified?
Answer: when patients have a history of  previous opioid or non-opioid SUD
Recommendations

Patients should be informed that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient  understands the associated risks and benefits of LOT. Fully informed, some patients may desire  continuation of OT while others may decline its continued provision. Research is necessary to more accurately determine how long it takes for OUD to occur and whether the  nature of the pain is one of the factors that can influence either of this phenomena. 

Question: What to inform patient regarding progression from acute to long-term OT?
Answer: progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD
Recommendations

Patients should be informed that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient  understands the associated risks and benefits of LOT. Fully informed, some patients may desire  continuation of OT while others may decline its continued provision. Research is necessary to more accurately determine how long it takes for OUD to occur and whether the  nature of the pain is one of the factors that can influence either of this phenomena. 

Question: What is associated with little evidence for sustained analgesic efficacy but a substantial increase in risk for OUD?
Answer: progression from acute to long-term OT
Recommendations

Patients should be informed that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient  understands the associated risks and benefits of LOT. Fully informed, some patients may desire  continuation of OT while others may decline its continued provision. Research is necessary to more accurately determine how long it takes for OUD to occur and whether the  nature of the pain is one of the factors that can influence either of this phenomena. 

Question: What information should be discussed with patients at initiation of OT and continuously thereafter?
Answer: progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD
Recommendations

Patients should be informed that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient  understands the associated risks and benefits of LOT. Fully informed, some patients may desire  continuation of OT while others may decline its continued provision. Research is necessary to more accurately determine how long it takes for OUD to occur and whether the  nature of the pain is one of the factors that can influence either of this phenomena. 

Question: When should the providers discuss with patients that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD?
Answer: at initiation of OT and continuously thereafter
Recommendations

Patients should be informed that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient  understands the associated risks and benefits of LOT. Fully informed, some patients may desire  continuation of OT while others may decline its continued provision. Research is necessary to more accurately determine how long it takes for OUD to occur and whether the  nature of the pain is one of the factors that can influence either of this phenomena. 

Question: Why should the providers discuss with patients that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD?
Answer: to ensure that the patient  understands the associated risks and benefits of LOT
Recommendations

Patients should be informed that progression from acute to long-term OT is associated with little evidence  for sustained analgesic efficacy but a substantial increase in risk for OUD. Providers should discuss this information with patients at initiation of OT and continuously thereafter to ensure that the patient  understands the associated risks and benefits of LOT. Fully informed, some patients may desire  continuation of OT while others may decline its continued provision. Research is necessary to more accurately determine how long it takes for OUD to occur and whether the  nature of the pain is one of the factors that can influence either of this phenomena. 

Question: What is necessary to more accurately determine how long it takes for OUD to occur and whether the  nature of the pain is one of the factors that can influence either of this phenomena?
Answer: Research