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On July 22, 2016, the Comprehensive Addiction and Recovery Act (CARA) was enacted with the aim of addressing the epidemic of overdoses from prescription opioids and other prescription drugs and heroin. While this act was primarily focused on opioid abuse treatment and prevention, it also gave specific instruction to the VA in regard to broad aspects of OT including consideration of the CDC guideline in revising the prior VA/DoD OT CPG and adopting it for the VA. There are, however, some important distinctions between the CDC guideline and the VA/DoD OT CPG.

Background information

What is the primary focus of the CARA?

The VA/DoD OT CPG was developed with a specific patient population in mind—Service Members, Veterans, and their families—that has unique characteristics and needs related to the military culture and communities to which they return. Throughout the VA/DoD OT CPG, attention is paid to the characteristics and needs of these patients, particularly regarding 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. Further, these recommendations were made keeping in mind 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.

Background information

Who are the target population for the VA/DoD OT CPG?

The VA/DoD OT CPG was developed with a specific patient population in mind—Service Members, Veterans, and their families—that has unique characteristics and needs related to the military culture and communities to which they return. Throughout the VA/DoD OT CPG, attention is paid to the characteristics and needs of these patients, particularly regarding 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. Further, these recommendations were made keeping in mind 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.

Background information

Throughout the VA/DoD OT CPG, particular attention is paid regarding which factors?

The VA/DoD OT CPG was developed with a specific patient population in mind—Service Members, Veterans, and their families—that has unique characteristics and needs related to the military culture and communities to which they return. Throughout the VA/DoD OT CPG, attention is paid to the characteristics and needs of these patients, particularly regarding 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. Further, these recommendations were made keeping in mind 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.

Background information

What was the considerations behind the recommendations made in the CPG?

There were also some differences in the methodology used between the development of the VA/DoD OT CPG and the CDC guideline. 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). The CDC guideline development process included notice in the Federal Register for a public review and comment period as well as peer review. Thus, the recommendations made in the CDC guideline, although similar to those made in this CPG, were likely 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. Thus, while the VA/DoD OT Work Group was aware of the release of the CDC guideline and considered potential implications, the CDC guideline did not form the basis of the deliberations on the strength or direction of these recommendations. The Work Group followed the VA/DoD Guideline for Guidelines, a document that details the process by which VA/DoD guidelines will be developed, including the use of the GRADE methodology. As required by Congress in CARA, the Work Group reviewed and considered the CDC guideline and its inclusion in the VA/DoD OT CPG.

Background information

Mention some differences in the methodology used between the development of the VA/DoD OT CPG and the CDC guideline.

There were also some differences in the methodology used between the development of the VA/DoD OT CPG and the CDC guideline. 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). The CDC guideline development process included notice in the Federal Register for a public review and comment period as well as peer review. Thus, the recommendations made in the CDC guideline, although similar to those made in this CPG, were likely 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. Thus, while the VA/DoD OT Work Group was aware of the release of the CDC guideline and considered potential implications, the CDC guideline did not form the basis of the deliberations on the strength or direction of these recommendations. The Work Group followed the VA/DoD Guideline for Guidelines, a document that details the process by which VA/DoD guidelines will be developed, including the use of the GRADE methodology. As required by Congress in CARA, the Work Group reviewed and considered the CDC guideline and its inclusion in the VA/DoD OT CPG.

Background information

What did the CDC guideline development process include?

There were also some differences in the methodology used between the development of the VA/DoD OT CPG and the CDC guideline. 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). The CDC guideline development process included notice in the Federal Register for a public review and comment period as well as peer review. Thus, the recommendations made in the CDC guideline, although similar to those made in this CPG, were likely 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. Thus, while the VA/DoD OT Work Group was aware of the release of the CDC guideline and considered potential implications, the CDC guideline did not form the basis of the deliberations on the strength or direction of these recommendations. The Work Group followed the VA/DoD Guideline for Guidelines, a document that details the process by which VA/DoD guidelines will be developed, including the use of the GRADE methodology. As required by Congress in CARA, the Work Group reviewed and considered the CDC guideline and its inclusion in the VA/DoD OT CPG.

Background information

What are differences in the recommendations between the CDC guideline and the CPG?

There were also some differences in the methodology used between the development of the VA/DoD OT CPG and the CDC guideline. 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). The CDC guideline development process included notice in the Federal Register for a public review and comment period as well as peer review. Thus, the recommendations made in the CDC guideline, although similar to those made in this CPG, were likely 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. Thus, while the VA/DoD OT Work Group was aware of the release of the CDC guideline and considered potential implications, the CDC guideline did not form the basis of the deliberations on the strength or direction of these recommendations. The Work Group followed the VA/DoD Guideline for Guidelines, a document that details the process by which VA/DoD guidelines will be developed, including the use of the GRADE methodology. As required by Congress in CARA, the Work Group reviewed and considered the CDC guideline and its inclusion in the VA/DoD OT CPG.

Background information

What is the VA/DoD Guideline for Guidelines?

Pain is defined as “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.” All of these facets signify the complexity of pain as a condition by itself and how it relates to both the brain and the body. Pain as a symptom is multifaceted and is described and characterized by many factors such as its quality (e.g., sharp versus dull), intensity, timing, location, and whether it is associated with position or movement.

Background information

Define pain according to the VA/DoD CPG.

Pain is defined as “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.” All of these facets signify the complexity of pain as a condition by itself and how it relates to both the brain and the body. Pain as a symptom is multifaceted and is described and characterized by many factors such as its quality (e.g., sharp versus dull), intensity, timing, location, and whether it is associated with position or movement.

Background information

How to characterize pain as a symptom?

Pain is defined as “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.” All of these facets signify the complexity of pain as a condition by itself and how it relates to both the brain and the body. Pain as a symptom is multifaceted and is described and characterized by many factors such as its quality (e.g., sharp versus dull), intensity, timing, location, and whether it is associated with position or movement.

Background information

Which factors can describe and characterize pain as a symptom?

Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.

Background information

Define chronic pain according to the VA/DoD CPG.

Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.

Background information

Which areas in the CNS are involved in the acute and subacute pain?

Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.

Background information

What is CNS?

Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.

Background information

Which areas in the CNS are involved in the chronic pain?

There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.

Background information

What are the causes of chronic pain?

There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.

Background information

Which pain can lead to well-localized nociceptive mechanism pain?

There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.

Background information

Which pain could be mechanical or chemical/inflammatory in nature?

There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.

Background information

Which pain may produce a less localized pain?

There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.

Background information

Which pain may lead to poorly localized symptoms?

There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.

Background information

What are some examples of poorly localized symptoms?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

What does a comprehensive pain assessment include?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

What are the elements of the biopsychosocial pain interview?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

What may be experienced by the patients with chronic pain?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

What can be associated with pain severity and the presence of psychiatric comorbidities?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

Who report psychological complaints more often?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

What is reported more often by the patients with chronic pain than patients without chronic pain?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

What are some examples of psychological complaints made by patients with chronic pain?

A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.

Background information

What are some examples of social and psychological consequences on account of chronic pain?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

What is one of the most common chronic medical conditions in the U.S.?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

What is one of the most costly chronic medical conditions in the U.S.?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

What is one of the most disabling chronic medical conditions in the U.S.?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

How many adults in the U.S. experience chronic pain?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

Since when has there been a significant increment of opioid prescriptions during pain visits?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

Since when has there been a significant increment of opioid-related morbidity, mortality, overdose death, and SUD treatment admissions?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

What is the ratio of patients with non-cancer pain or pain-related diagnoses who receive opioid prescriptions in office-based settings?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

What were the changes in the sales of prescription opioids in the U.S. from 1999 and 2014, according to CDC?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

How much has the absolute number of deaths associated with the use of opioids increased since 2000?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

How much has the absolute number of deaths associated with the use of opioids increased from 2013 to 2014?

Chronic pain is among the most common, costly, and disabling chronic medical conditions in the U.S. In the U.S., approximately 100 million adults experience chronic pain, and pain is associated with approximately 20% of ambulatory primary care and specialty visits. Since the late 1990s and early 2000s, the proportion of pain visits during which patients received opioids has increased significantly, as have opioid-related morbidity, mortality, overdose death, and SUD treatment admissions. Approximately one in five patients with non-cancer pain or pain related diagnoses is prescribed opioids in office-based settings. According to the CDC, sales of prescription opioids U.S. quadrupled from 1999 and 2014. The absolute number of deaths associated with use of opioids has increased four-fold since 2000, including by 14% from 2013 to 2014 alone. Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. In one survey, approximately one-third of patients receiving OT for CNCP (or their family members) indicated thinking that they were “addicted” to or “dependent” on the medication or used the medication for “fun” or to “get high.” From 2000 through 2013, the rate of heroin overdose deaths increased nearly four-fold. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

Background information

How many people died between 1999 and 2015 from overdoses related to prescription opioids?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

What was the increment of the prevalence of opioid prescriptions among Veterans from fiscal years 2004 to 2012?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

Which groups had the highest prevalence of opioid use?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, how many reported chronic pain?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, how many reported using opioids?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

In Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans, chronic pain was associated with what?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

In a study of Veterans with chronic pain who had been on opioids for at least 90 days, how many continued to use opioids one year later?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

In a study of Veterans with chronic pain who had been on opioids for at least 90 days, how many continued to use opioids after completion of the 3.5 year follow-up period?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

In a study of civilian patients who had been on opioids for at least 90 days, how many remained on opioids through the 4.8 year follow-up period?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

Based on the study, which factors influence the rates of opioid-use continuation in Veterans?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

Depending on age, marital status, race, and living conditions, who were more likely to continue using opioids?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

Among the Veterans, who were more likely to continue their opioid use?

From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.

Background information

Among the Veterans, who were less likely to continue their opioid use?

Individuals with conditions that result in or co-occur with chronic pain may have different needs or respond to treatment differently than individuals with chronic pain alone. Many different physical and psychological conditions have a pain component that can be difficult to distinguish from the underlying mechanism of illness. Furthermore, the treatment of co-occurring pain and other conditions may vary or require special considerations during their management. Readers are encouraged to consult other VA/DoD CPGs for further information (see VA/DoD Clinical Practice Guidelines website: www.healthquality.va.gov).

Background information

Who may have different needs or respond to treatment differently than individuals with chronic pain alone?

Individuals with conditions that result in or co-occur with chronic pain may have different needs or respond to treatment differently than individuals with chronic pain alone. Many different physical and psychological conditions have a pain component that can be difficult to distinguish from the underlying mechanism of illness. Furthermore, the treatment of co-occurring pain and other conditions may vary or require special considerations during their management. Readers are encouraged to consult other VA/DoD CPGs for further information (see VA/DoD Clinical Practice Guidelines website: www.healthquality.va.gov).

Background information

What can be difficult to distinguish from the underlying mechanism of illness?

The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insufficient evidence of benefit for LOT, the clinician must carefully weigh harms and benefits and educate the patient as well as his or her family or caregiver prior to proceeding with treatment. As patient values and preferences may be impacted by other clinical considerations, some patients with one or more risk factors for adverse outcomes may differ with the clinician’s assessment that the risks of OT outweigh the potential for modest short-term benefits. Thus, it is important to consider patients’ values and concerns, address misconceptions, express empathy, and fully explain to patients with one or more risk factors that they may not benefit from, and may even be harmed by, treatment with OT. Conditions that significantly increase the risk of adverse outcomes from LOT are listed below. Patients for whom LOT is initiated should be carefully monitored, and ongoing assessment of risk should be performed with vigilance for the development of additional risk factors and adverse outcomes (see Recommendations 7-9). Consider consultation with appropriate specialty care providers if there is uncertainty about whether the benefits of OT, such as improved function (e.g., return-to-work), outweigh the risks.

Background information

What are the risk factors with the greatest impact on the development of opioid-related adverse events?

The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insufficient evidence of benefit for LOT, the clinician must carefully weigh harms and benefits and educate the patient as well as his or her family or caregiver prior to proceeding with treatment. As patient values and preferences may be impacted by other clinical considerations, some patients with one or more risk factors for adverse outcomes may differ with the clinician’s assessment that the risks of OT outweigh the potential for modest short-term benefits. Thus, it is important to consider patients’ values and concerns, address misconceptions, express empathy, and fully explain to patients with one or more risk factors that they may not benefit from, and may even be harmed by, treatment with OT. Conditions that significantly increase the risk of adverse outcomes from LOT are listed below. Patients for whom LOT is initiated should be carefully monitored, and ongoing assessment of risk should be performed with vigilance for the development of additional risk factors and adverse outcomes (see Recommendations 7-9). Consider consultation with appropriate specialty care providers if there is uncertainty about whether the benefits of OT, such as improved function (e.g., return-to-work), outweigh the risks.

Background information

Why must the clinician carefully weigh harms and benefits and educate the patient as well as his or her family or caregiver prior to proceeding with treatment?

The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insufficient evidence of benefit for LOT, the clinician must carefully weigh harms and benefits and educate the patient as well as his or her family or caregiver prior to proceeding with treatment. As patient values and preferences may be impacted by other clinical considerations, some patients with one or more risk factors for adverse outcomes may differ with the clinician’s assessment that the risks of OT outweigh the potential for modest short-term benefits. Thus, it is important to consider patients’ values and concerns, address misconceptions, express empathy, and fully explain to patients with one or more risk factors that they may not benefit from, and may even be harmed by, treatment with OT. Conditions that significantly increase the risk of adverse outcomes from LOT are listed below. Patients for whom LOT is initiated should be carefully monitored, and ongoing assessment of risk should be performed with vigilance for the development of additional risk factors and adverse outcomes (see Recommendations 7-9). Consider consultation with appropriate specialty care providers if there is uncertainty about whether the benefits of OT, such as improved function (e.g., return-to-work), outweigh the risks.

Background information

Why is it important to consider patients’ values and concerns, address misconceptions, express empathy, and fully explain to patients with one or more risk factors that they may not benefit from, and may even be harmed by, treatment with OT?

The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insufficient evidence of benefit for LOT, the clinician must carefully weigh harms and benefits and educate the patient as well as his or her family or caregiver prior to proceeding with treatment. As patient values and preferences may be impacted by other clinical considerations, some patients with one or more risk factors for adverse outcomes may differ with the clinician’s assessment that the risks of OT outweigh the potential for modest short-term benefits. Thus, it is important to consider patients’ values and concerns, address misconceptions, express empathy, and fully explain to patients with one or more risk factors that they may not benefit from, and may even be harmed by, treatment with OT. Conditions that significantly increase the risk of adverse outcomes from LOT are listed below. Patients for whom LOT is initiated should be carefully monitored, and ongoing assessment of risk should be performed with vigilance for the development of additional risk factors and adverse outcomes (see Recommendations 7-9). Consider consultation with appropriate specialty care providers if there is uncertainty about whether the benefits of OT, such as improved function (e.g., return-to-work), outweigh the risks.

Background information

What should be done for patients for whom LOT is initiated?

The risk factors with the greatest impact on the development of opioid-related adverse events are the duration and dose of opioid analgesic use. Beyond duration and dose of OT, many factors increase the risk of adverse outcomes and must be considered prior to initiating or continuing OT (Box 1). Given the insufficient evidence of benefit for LOT, the clinician must carefully weigh harms and benefits and educate the patient as well as his or her family or caregiver prior to proceeding with treatment. As patient values and preferences may be impacted by other clinical considerations, some patients with one or more risk factors for adverse outcomes may differ with the clinician’s assessment that the risks of OT outweigh the potential for modest short-term benefits. Thus, it is important to consider patients’ values and concerns, address misconceptions, express empathy, and fully explain to patients with one or more risk factors that they may not benefit from, and may even be harmed by, treatment with OT. Conditions that significantly increase the risk of adverse outcomes from LOT are listed below. Patients for whom LOT is initiated should be carefully monitored, and ongoing assessment of risk should be performed with vigilance for the development of additional risk factors and adverse outcomes (see Recommendations 7-9). Consider consultation with appropriate specialty care providers if there is uncertainty about whether the benefits of OT, such as improved function (e.g., return-to-work), outweigh the risks.

Background information

What to do if there is uncertainty about whether the benefits of OT, such as improved function (e.g., return-to-work), outweigh the risks?

Conditions that significantly increase the risk of adverse outcomes from LOT are Duration and dose of OT, Severe respiratory instability or sleep disordered breathing, Acute psychiatric instability or intermediate to high acute suicide risk, Mental health disorders, History of drug overdose, Under 30 years of age, Co-administration of a drug capable of inducing fatal drug-drug interactions, QTc interval >450 ms for using methadone, Evidence for or history of diversion of controlled substances, Intolerance, serious adverse effects, or a history of inadequate beneficial response to opioids, Impaired bowel motility unresponsive to therapy, Headache not responsive to other pain treatment modalities, Traumatic brain injury (TBI), True allergy to opioid agents.

Background information

Which conditions significantly increase the risk of adverse outcomes from LOT?

Duration and dose of OT: See Recommendation 2 for more guidance on duration of OT and Recommendations 10-12 for more guidance on dosing of OT. Severe respiratory instability or sleep disordered breathing: This would include any co-occurring condition that significantly affects respiratory rate or function such as chronic obstructive pulmonary disease (COPD), asthma, pneumonia, sleep apnea, or a neuromuscular condition (e.g., amyotrophic lateral sclerosis). Two large observational studies of patients with a history of COPD and sleep apnea who were prescribed opioids showed a weak but positive association with opioid-related toxicity/overdose and overdose-related death.[58,59]

Background information

What does include severe respiratory instability or sleep disordered breathing?

Duration and dose of OT: See Recommendation 2 for more guidance on duration of OT and Recommendations 10-12 for more guidance on dosing of OT. Severe respiratory instability or sleep disordered breathing: This would include any co-occurring condition that significantly affects respiratory rate or function such as chronic obstructive pulmonary disease (COPD), asthma, pneumonia, sleep apnea, or a neuromuscular condition (e.g., amyotrophic lateral sclerosis). Two large observational studies of patients with a history of COPD and sleep apnea who were prescribed opioids showed a weak but positive association with opioid-related toxicity/overdose and overdose-related death.[58,59]

Background information

Who showed a weak but positive association with opioid-related toxicity/overdose and overdose-related death?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

What does preclude the safe use of self-administered LOT?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

What was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

In a study of patients on opioids, who had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

What are the odds of suicidal ideation within the past 12 months in those with bipolar disorder compared to those with no bipolar disorder?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

What are the odds of a lifetime suicide attempt in those with bipolar disorder compared to those with no bipolar disorder?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

Where can more information on suicidality be found?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

Where can more information on bipolar disorder be found?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

What was associated with depressed mood?

Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]

Background information

Which treatment for chronic pain may have benefits in treating depression, PTSD, and in reducing suicide risk?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

What can signal an emerging SUD as well as diversion?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

What can be signalled by frequent requests for early refills required to control pain?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

What can be signalled by frequent requests for atypically large quantities required to control pain?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

Among patients being treated by the VHA system that received opioids, what was significantly associated with opioid-related toxicity/overdose compared to no history of depression?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

Among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with what?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

What has been associated with worsening depressive symptoms?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

LOT has been associated with what kinds of symptoms?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

Among patients on OT, a prevalence of self inflicted injuries was significantly higher among which patients?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

Among patients on OT, what was significantly higher among patients with a history of PTSD as compared to patients with other (or no) mental health diagnoses?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

Where can more information be found on PTSD?

Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.

Background information

What is a red flag in the presence of which providers should proceed with utmost caution when considering LOT for these patients?

Co-administration of a drug capable of inducing fatal drug-drug interactions: Providers should carefully rule out and avoid potential drug interactions prior to initiating LOT. For example, the following combinations are dangerous:[66] i)Opioids with benzodiazepines (compared to patients with no prescription, the odds ratio [OR] and 95% confidence interval [CI] for drug-related death was OR: 14.92, 95% CI: 7.00- 31.77 for patients who filled a prescription for opioids and benzodiazepines; OR: 3.40, 95% CI: 1.60-7.21 for patients who filled only an opioid prescription, and 7.21, 95% CI: 3.33-15.60 for patients who filled only a benzodiazepine prescription) (see Recommendation 5) [66,67], ii)Fentanyl with CYP3A4 inhibitors, iii) Methadone with drugs that can prolong the QT interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) (e.g., CYP450 2B6 inhibitors)

Background information

What should providers carefully rule out and avoid?

Co-administration of a drug capable of inducing fatal drug-drug interactions: Providers should carefully rule out and avoid potential drug interactions prior to initiating LOT. For example, the following combinations are dangerous:[66] i)Opioids with benzodiazepines (compared to patients with no prescription, the odds ratio [OR] and 95% confidence interval [CI] for drug-related death was OR: 14.92, 95% CI: 7.00- 31.77 for patients who filled a prescription for opioids and benzodiazepines; OR: 3.40, 95% CI: 1.60-7.21 for patients who filled only an opioid prescription, and 7.21, 95% CI: 3.33-15.60 for patients who filled only a benzodiazepine prescription) (see Recommendation 5) [66,67], ii)Fentanyl with CYP3A4 inhibitors, iii) Methadone with drugs that can prolong the QT interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) (e.g., CYP450 2B6 inhibitors)

Background information

What combinations of drugs are dangerous?

QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).

Background information

Which opioid has unique pharmacodynamic properties that can prolong the QTc interval and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia?

QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).

Background information

What is QTc interval?

QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).

Background information

What is torsades de pointes?

QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).

Background information

Which one is a dangerous or fatal cardiac arrhythmia?

QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).

Background information

What unique properties does methadone have?

QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).

Background information

Why are ECGs highly advised before and after initiating methadone?

QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).

Background information

Which patients may be at risk?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

What should the clinician communicate to patients?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

What is a crime and constitutes an absolute contraindication to prescribing additional medications?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

Why is it important that providers who suspect diversion base treatment plans on objective evidence?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

On what kind of evidence should the providers who suspect diversion base treatment plans?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

How to confirm suspicions regarding drug diversion?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

What could also by itself be a sign of diversion?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

What may not reliably detect synthetic or semi-synthetic opioids?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

What are some examples of synthetic opioids?

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Background information

What are some examples of semi-synthetic opioids?