Hieu-Pham/cpgQA huggingface dataset:
Recommendations

Risk mitigation for LOT should begin before the opioids are prescribed, 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. It should also occur concurrently with the therapy  (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those  who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain  care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A  literature search was conducted dating back to the original 2010 recommendation to identify studies  comparing the effectiveness of different risk mitigation strategies for patients on or being considered for  LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements  (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The  study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective  database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT,  regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and  rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the  outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the  intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included  adverse events, pain management, and quality of life. Details of the actual intervention were vague and  did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low.  The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low  for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as  determined by an individual risk assessment.  

Question: What was the recommendation in the 2010 OT CPG?
Answer: use of an opioid pain  care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT
Recommendations

Risk mitigation for LOT should begin before the opioids are prescribed, 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. It should also occur concurrently with the therapy  (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those  who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain  care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A  literature search was conducted dating back to the original 2010 recommendation to identify studies  comparing the effectiveness of different risk mitigation strategies for patients on or being considered for  LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements  (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The  study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective  database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT,  regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and  rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the  outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the  intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included  adverse events, pain management, and quality of life. Details of the actual intervention were vague and  did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low.  The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low  for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as  determined by an individual risk assessment.  

Question: Is there any study looking at opioid treatment agreements  (OTAs)?
Answer: One identified study was a systematic review of 11 studies
Recommendations

Risk mitigation for LOT should begin before the opioids are prescribed, 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. It should also occur concurrently with the therapy  (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those  who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain  care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A  literature search was conducted dating back to the original 2010 recommendation to identify studies  comparing the effectiveness of different risk mitigation strategies for patients on or being considered for  LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements  (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The  study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective  database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT,  regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and  rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the  outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the  intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included  adverse events, pain management, and quality of life. Details of the actual intervention were vague and  did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low.  The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low  for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as  determined by an individual risk assessment.  

Question: What kind of evidence is there to support the use of OTAs and UDT?
Answer: weak
Recommendations

Risk mitigation for LOT should begin before the opioids are prescribed, 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. It should also occur concurrently with the therapy  (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those  who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain  care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A  literature search was conducted dating back to the original 2010 recommendation to identify studies  comparing the effectiveness of different risk mitigation strategies for patients on or being considered for  LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements  (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The  study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective  database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT,  regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and  rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the  outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the  intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included  adverse events, pain management, and quality of life. Details of the actual intervention were vague and  did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low.  The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low  for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as  determined by an individual risk assessment.  

Question: What is OTAs?
Answer: opioid treatment agreements
Recommendations

There may be some variation in patient values and preferences. Certain patients may appreciate the use of  risk mitigation strategies and others may not. Participants in the patient focus group expressed an  understanding of why various risk mitigation strategies were used (see Patient Focus Group Methods and  Findings). 

Question: What is the relationship between patient values and preferences?
Answer: There may be some variation
Recommendations

There may be some variation in patient values and preferences. Certain patients may appreciate the use of  risk mitigation strategies and others may not. Participants in the patient focus group expressed an  understanding of why various risk mitigation strategies were used (see Patient Focus Group Methods and  Findings). 

Question: There may be some variation in what?
Answer: patient values and preferences
Recommendations

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care  providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients.  VHA providers must also follow VHA policy regarding education and signature informed consent when  providing LOT for patients with non-cancer pain.[101]  

Question: What does implementing more extensive risk mitigation strategies entail?
Answer: an investment of resources
Recommendations

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care  providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients.  VHA providers must also follow VHA policy regarding education and signature informed consent when  providing LOT for patients with non-cancer pain.[101]  

Question: Why may primary care providers require more time with patients?
Answer: to allow for shared decision making and treatment planning
Recommendations

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care  providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients.  VHA providers must also follow VHA policy regarding education and signature informed consent when  providing LOT for patients with non-cancer pain.[101]  

Question: What would happen if there were a more frequent follow-up of patients on LOT?
Answer: can affect access to care for all empaneled patients
Recommendations

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care  providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients.  VHA providers must also follow VHA policy regarding education and signature informed consent when  providing LOT for patients with non-cancer pain.[101]  

Question: What must VHA providers follow when providing LOT for patients with non-cancer pain?
Answer: VHA policy regarding education and signature informed consent
Recommendations

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care  providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients.  VHA providers must also follow VHA policy regarding education and signature informed consent when  providing LOT for patients with non-cancer pain.[101]  

Question: When must VHA providers follow VHA policy regarding education and signature informed consent?
Answer: when  providing LOT for patients with non-cancer pain
Recommendations

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care  providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients.  VHA providers must also follow VHA policy regarding education and signature informed consent when  providing LOT for patients with non-cancer pain.[101]  

Question: Who must follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain?
Answer: VHA providers
Recommendations

There is a paradigm shift occurring in approaches to ensuring and documenting patient and provider  understanding and expectations regarding the risks and benefits of LOT. The 2010 OT CPG reflected prior  practice of using opioid treatment (or pain care) agreements. OTAs have been described as coercive rather  than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful  to the patient-provider relationship.[102-105]  

Question: What did the 2010 OT CPG reflect?
Answer: prior  practice of using opioid treatment (or pain care) agreements
Recommendations

There is a paradigm shift occurring in approaches to ensuring and documenting patient and provider  understanding and expectations regarding the risks and benefits of LOT. The 2010 OT CPG reflected prior  practice of using opioid treatment (or pain care) agreements. OTAs have been described as coercive rather  than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful  to the patient-provider relationship.[102-105]  

Question: How have OTAs been described in the 2010 OT CPG?
Answer: as coercive rather  than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful  to the patient-provider relationship
Recommendations

Given the recognized risks of opioid therapy, an optimal approach to care should include a robust,  signature informed consent process that is patient-centered and provides patients with information about  known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for  signature informed consent, consistent with VA policy for other treatments or procedures with a  significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety  and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found  at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012). 

Question: Why should an optimal approach to care should include a robust,  signature informed consent process?
Answer: Given the recognized risks of opioid therapy
Recommendations

Given the recognized risks of opioid therapy, an optimal approach to care should include a robust,  signature informed consent process that is patient-centered and provides patients with information about  known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for  signature informed consent, consistent with VA policy for other treatments or procedures with a  significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety  and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found  at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012). 

Question: Given the recognized risks of opioid therapy, what should be included in an optimal approach to care?
Answer: a robust,  signature informed consent process that is patient-centered and provides patients with information about  known benefits and harms of OT and treatment alternatives
Recommendations

Given the recognized risks of opioid therapy, an optimal approach to care should include a robust,  signature informed consent process that is patient-centered and provides patients with information about  known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for  signature informed consent, consistent with VA policy for other treatments or procedures with a  significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety  and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found  at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012). 

Question: Given the recognized risks of opioid therapy, what should include a robust,  signature informed consent process?
Answer: an optimal approach to care
Recommendations

Given the recognized risks of opioid therapy, an optimal approach to care should include a robust,  signature informed consent process that is patient-centered and provides patients with information about  known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for  signature informed consent, consistent with VA policy for other treatments or procedures with a  significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety  and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found  at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012). 

Question: What did VA establish in 2014 regarding OT and treatment alternatives?
Answer: a requirement for  signature informed consent, consistent with VA policy for other treatments or procedures with a  significant risk of complications or morbidity
Recommendations

Patients may decline offered treatments (e.g., OT) and may also decline risk mitigation strategies (e.g.,  UDT, pill counts) that are recommended in the course of clinical care. However, providers should discuss  this decision with the patient, including the likelihood that their decision may result in the risks of LOT  outweighing its potential benefits. This would require a consideration of patient’s safety, and a clinical  decision may be made not to initiate OT or to discontinue ongoing OT through tapering (see  Recommendation 14 and Recommendation 17). 

Question: What may patients decline?
Answer: offered treatments (e.g., OT) and may also decline risk mitigation strategies (e.g.,  UDT, pill counts) that are recommended in the course of clinical care
Recommendations

State database queries for detection of multi-sourcing of controlled substances are used throughout the  country. Data comparing states with an implemented state database program to states without one  showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly  checks of the state database system.[33]  

Question: What are used throughout the country for detection of multi-sourcing of controlled substances?
Answer: State database queries
Recommendations

State database queries for detection of multi-sourcing of controlled substances are used throughout the  country. Data comparing states with an implemented state database program to states without one  showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly  checks of the state database system.[33]  

Question: For what purpose state database queries are used throughout the country?
Answer: detection of multi-sourcing of controlled substances
Recommendations

State database queries for detection of multi-sourcing of controlled substances are used throughout the  country. Data comparing states with an implemented state database program to states without one  showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly  checks of the state database system.[33]  

Question: According to CDC, how often the state database system needs to be checked?
Answer: at least quarterly
Recommendations

State database queries for detection of multi-sourcing of controlled substances are used throughout the  country. Data comparing states with an implemented state database program to states without one  showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly  checks of the state database system.[33]  

Question: Who recommends at least quarterly checks of the state database system?
Answer: The CDC
Recommendations

State database queries for detection of multi-sourcing of controlled substances are used throughout the  country. Data comparing states with an implemented state database program to states without one  showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly  checks of the state database system.[33]  

Question: According to CDC, what needs to be checked at least quarterly?
Answer: the state database system
Recommendations

As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory  testing is used as an additional method of examining for patient substance misuse and adherence to the  prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT.  Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry  [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a  UDT and confirmatory results requires education and knowledge of the local procedures and clinical  scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for  SUD treatment or is engaged in on-going treatment there should be close communication between the  SUD and pain management providers. The ideal approach is an interdisciplinary format (see  Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing. 

Question: Why is UDT and confirmatory testing used as an additional method of examining for patient substance misuse and adherence to the  prescribed regimen?
Answer: As substance misuse in patients on LOT is more than 30% in some series