Lornng/cpgQA huggingface dataset:
Features and overview

Opioids are not first-line or routine therapy for chronic pain. Establish treatment goals before starting opioid therapy and a plan if therapy is discontinued. Only continue opioid if there is clinically meaningful improvement in pain and function. Discuss risks, benefits and responsibilities for managing therapy before starting and during treatment.

Question: What should be done before starting opioid therapy?
Answer: Establish treatment goals

Question: What should be done if an opioid thrapy is discontinued?
Answer: plan

Question: When to continue opioid therapy?
Answer: if there is clinically meaningful improvement in pain and function

Question: What to discuss before starting the treatment?
Answer: risks, benefits and responsibilities for managing therapy

Question: What to discuss during the treatment?
Answer: risks, benefits and responsibilities for managing therapy

Question: What is not first-line or routine therapy for chronic pain management?
Answer: Opioids
Features and overview

Use immediate-release (IR) opioids when starting therapy. Prescribe the lowest effective dose. When using opioids for acute pain, provide no more than needed for the condition. Follow up and review benefits and risks before starting and during therapy. If benefits do not outweigh harms, consider tapering opioids to lower doses or taper and discontinue.

Question: What kind of opioids to use when starting therapy?
Answer: immediate-release

Question: Should you prescribe the highest or lowest effective dose when starting therapy?
Answer: lowest

Question: What to follow up or review before starting opioid therapy?
Answer: benefits and risks

Question: What to follow up or review during opioid therapy?
Answer: benefits and risks

Question: When to consider tapering opioids to lower doses?
Answer: If benefits do not outweigh harms

Question: When to consider tapering opioids to taper and discontinue?
Answer: If benefits do not outweigh harms
Features and overview

Offer risk mitigation strategies, including naloxone for patients at risk for overdose.  Review PDMP (Prescription Drug Monitoring Program) data at least every 3 months and perform UDT (Urine Drug Testing) at least annually. Avoid prescribing opioid and benzodiazepines concurrently when possible. Clinicians should offer or arrange MAT (Medication-Assisted Treatment) for patients with OUD (Opioid Use Disorder).

Question: For patients at risk for overdose, what should be done?
Answer: Offer risk mitigation strategies, including naloxone

Question: How often the PDMP data need to be reviewed?
Answer: at least every 3 months

Question: How often the UDT needs to be performed?
Answer: at least annually

Question: How often the prescription drug monitoring program data need to be reviewed?
Answer: at least every 3 months

Question: How often the urine drug testing needs to be performed?
Answer: at least annually

Question: For patients at risk for overdose, how to address the harms of opioid use?
Answer: Offer risk mitigation strategies, including naloxone

Question: What should not be prescribed concurrently when possible?
Answer: opioid and benzodiazepines

Question: What should be offered for patients with OUD?
Answer: MAT (Medication-Assisted Treatment)

Question: What should be arranged for patients with OUD?
Answer: MAT (Medication-Assisted Treatment)

Question: What should be offered for patients with opioid use disorder?
Answer: MAT (Medication-Assisted Treatment)

Question: Who should be offered MAT?
Answer: patients with OUD (Opioid Use Disorder)

Question: Who should be offered medication-assisted treatment?
Answer: patients with OUD (Opioid Use Disorder)
Features and overview

Medical comorbidities that can increase risk are lung disease, sleep apnea, liver disease, renal disease, fall risk, advanced age. Consider tapering opioids when there is concomitant use of medications that increase risk (e.g., benzodiazepines). Mental health comorbidities that can worsen with opioid therapy are PTSD, depression, anxiety. Prior to any changes in therapy, discuss the risks of continued use, along with possible benefits, with the Veteran. Establish a plan to consider dose reduction, consultation with specialists, or consider alternative pain management strategies. Personal history of SUD includes alcohol use disorder (AUD), opioid use disorder (OUD), and/or a use disorder involving other substances

Question: Which medical comorbidities can increase risk during opioid therapy?
Answer: lung disease, sleep apnea, liver disease, renal disease, fall risk, advanced age

Question: What to do when there is concomitant use of medications that increase risk?
Answer: Consider tapering opioids

Question: Which mental health comorbidities can worsen with opioid therapy?
Answer: PTSD, depression, anxiety

Question: Prior to any changes in therapy, what should be discussed with the Veteran?
Answer: the risks of continued use, along with possible benefits

Question: What includes personal history of SUD?
Answer: alcohol use disorder (AUD), opioid use disorder (OUD), and/or a use disorder involving other substances

Question: What is an example of medication that can increase risk during opioid therapy, if used concomitantly?
Answer: benzodiazepines
Features and overview

When considering an opioid taper, monitor for conditions that may warrant evaluation and arrange primary care and/or emergency department follow-up when indicated. If a patient is taking more than their prescribed dosage of opioids or showing signs of aberrant behavior, before deciding to change therapy, look for “red flags”. The red flags are progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection. An urgent evaluation may be needed when there is progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, a history of internal malignancy that has not been re-staged, signs of/risk factors for infection such as fever, recent skin or urinary infection, immunosuppression, IV drug use.

Question: What to monitor for when considering an opioid taper?
Answer: conditions that may warrant evaluation

Question: What to do if a patient is taking more than their prescribed dosage of opioids?
Answer: before deciding to change therapy, look for “red flags”. The red flags are progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection.

Question: What to do if a patient is showing signs of aberrant behavior?
Answer: before deciding to change therapy, look for “red flags”. The red flags are progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection.

Question: What are the red flags in a patient who is taking more than their prescribed dose or showing signs of aberrant behavior?
Answer: progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, history of internal malignancy that has not been re-staged, signs of/risk factors for infection

Question: What warrants an urgent evaluation during opioid therapy?
Answer: when there is progressive numbness or weakness, progressive changes in bowel or bladder function, unexplained weight loss, a history of internal malignancy that has not been re-staged, signs of/risk factors for infection such as fever, recent skin or urinary infection, immunosuppression, IV drug use

Question: What is needed when there is progressive numbness or weakness?
Answer: An urgent evaluation

Question: What is needed when there are progressive changes in bowel or bladder function?
Answer: An urgent evaluation

Question: What is needed when there is unexplained weight loss?
Answer: An urgent evaluation

Question: What is needed when there is a history of internal malignancy that has not been re-staged?
Answer: An urgent evaluation

Question: What is needed when there are signs of/risk factors for infection?
Answer: An urgent evaluation

Question: What are the signs of/risk factors for infection?
Answer: fever, recent skin or urinary infection, immunosuppression, IV drug use
Features and overview

Use a shared decision-making approach to discuss options for OUD treatment. Medication-Assisted Therapy (MAT) is the first-line treatment for OUD. The preferred OUD treatment is Opioid Agonist Therapy (OAT). Opioid agonist treatment involves taking opioid agonist medications such as buprenorphine/naloxone (Suboxone) or methadone. Methadone must be provided through a federally regulated opioid treatment program for OUD therapy. The alternative OUD treatment is extended-release (ER) injectable naltrexone (Vivitrol). MAT can be provided in a variety of treatment settings including residential SUD treatment, intensive outpatient SUD treatment, regular SUD specialty care clinic, primary care or general mental health clinic, or federally regulated opioid treatment program. Moral injury is an act of transgression that leads to serious inner conflict typically brought on by betrayal, disproportionate violence, incidents involving civilians, within-rank violence. For moral injury, treatment via psychologists or chaplains is available. Central sensitization (e .g., fibromyalgia, chronic headaches, and likely many other types of complex chronic pain). Some examples of medical complications are lung disease, hepatic disease, renal disease, or fall risk. Sleep apnea is a sleep disorder.

Question: What kind of approach should be used to discuss options for OUD treatment?
Answer: shared decision-making

Question: What is the first-line treatment for OUD?
Answer: Medication-Assisted Therapy (MAT)

Question: What is the preferred OUD treatment?
Answer: Opioid Agonist Therapy (OAT)

Question: What does opioid agonist treatment involve?
Answer: taking opioid agonist medications such as buprenorphine/naloxone (Suboxone) or methadone

Question: What are some examples of opioid agonist medications?
Answer: buprenorphine/naloxone (Suboxone) or methadone

Question: How to provide methadone for OUD therapy?
Answer: through a federally regulated opioid treatment program for OUD therapy

Question: What is the alternative OUD treatment?
Answer: extended-release (ER) injectable naltrexone (Vivitrol)

Question: Name the treatment settings in which MAT can be provided.
Answer: residential SUD treatment, intensive outpatient SUD treatment, regular SUD specialty care clinic, primary care or general mental health clinic, or federally regulated opioid treatment program

Question: What is moral injury?
Answer: an act of transgression that leads to serious inner conflict typically brought on by betrayal, disproportionate violence, incidents involving civilians, within-rank violence

Question: What can cause moral injury?
Answer: betrayal, disproportionate violence, incidents involving civilians, within-rank violence

Question: How to treat a moral injury?
Answer: via psychologists or chaplains

Question: Name a sleep disorder.
Answer: Sleep apnea
Features and overview

When a decision is made to taper, special attention must be given to ensure that the Veteran does not feel abandoned. Prior to any changes being made in opioid prescribing, a discussion should occur between the Veteran, family members/caregivers, and the provider either during a face-to-face appointment or on the telephone. The strategies that will help in the transition are discussion, asking about goals, educating the veteran. Discussion includes listening to the Veteran’s story, letting the Veteran know that you believe that their pain is real, using Motivational Interviewing (MI) techniques to acknowledge the Veteran’s fears about tapering. Include family members or other supporters in the discussion. Asking about goals includes drawing out their goals for life, having the Veteran fill out the PHI, asking how we can support them during the taper. The drawn-out life goals should not be just being pain-free. PHI is the Personal Health Inventory.

Question: How to make sure that the veteran does not feel abandoned when a decision is made to taper?
Answer: special attention must be given to ensure that the Veteran does not feel abandoned

Question: When must special attention be given to ensure that the Veteran does not feel abandoned?
Answer: When a decision is made to taper

Question: What should be done prior to any changes being made in opioid prescribing?
Answer: a discussion should occur between the Veteran, family members/caregivers, and the provider either during a face-to-face appointment or on the telephone

Question: Prior to any changes being made in opioid prescribing, a discussion should occur between whom?
Answer: the Veteran, family members/caregivers, and the provider

Question: A discussion should occur between the Veteran, family members/caregivers, and the provider prior to what?
Answer: any changes being made in opioid prescribing

Question: What strategies will help in the transition?
Answer: discussion, asking about goals, educating the veteran

Question: What is included in the discussion?
Answer: listening to the Veteran’s story, letting the Veteran know that you believe that their pain is real, using Motivational Interviewing (MI) techniques to acknowledge the Veteran’s fears about tapering

Question: Who to include in the discussion?
Answer: family members or other supporters

Question: Which techniques to use to acknowledge the Veteran’s fears about tapering?
Answer: Motivational Interviewing (MI)

Question: What are Motivational Interviewing (MI) techniques used for?
Answer: to acknowledge the Veteran’s fears about tapering

Question: What should not be the drawn-out life goals?
Answer: just being pain-free

Question: What is PHI?
Answer: Personal Health Inventory
Features and overview

Educate the Veteran by using Bio-Psycho-Social Model e.g., PHI’s “Whole Health” approach. Offer Veterans pain education groups [especially Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT) for Pain, if available]. Clinicians should offer physical therapy and Complementary and Integrative Health (CIH) interventions such as acupuncture, meditation, yoga. Clinicians should offer slow tapering of opioids to reduce opioid risks while not “cutting off” the Veteran. Clinicians should offer non-opioid pain medications when appropriate. Clinicians should commit to working with the Veteran on other options for improved function and some decrease in pain.

Question: What to use to educate the Veteran?
Answer: Bio-Psycho-Social Model e.g., PHI’s “Whole Health” approach

Question: What is an example of Bio-Psycho-Social Model?
Answer: PHI’s “Whole Health” approach

Question: What kinds of pain education groups should be offered to Veterans?
Answer: Cognitive Behavioral Therapy (CBT) or Acceptance and Commitment Therapy (ACT) for Pain

Question: What are some examples of Complementary and Integrative Health (CIH) interventions?
Answer: acupuncture, meditation, yoga

Question: What is CIH?
Answer: Complementary and Integrative Health

Question: What should the clinicians offer to reduce opioid risk?
Answer: slow tapering of opioids to reduce opioid risks while not “cutting off” the Veteran
Features and overview

Slower Taper is done over months or years. In the slower taper, reduce opioid by 5 to 20% every 4 weeks with pauses in taper as needed. Slower taper is the most common taper.  An example of the slower taper is given below. During the first month in the slower taper, 16% opioid reduction of morphine SR 90 mg Q8h = 270 MEDD consists of 75 mg (60 mg+15 mg)SR Q8h. The subsequent monthly dosage for the slower taper is 60 mg SR Q8h for month 2, 45 mg SR Q8h for month 3, 30 mg SR Q8h for month 4, 15 mg SR Q8h for month 5, 15 mg SR Q12h for month 6, 15mg SR QHS for month 7. Stop slower tapering after month 7 and may consider morphine IR 15 mg ½ tablet (7.5 mg) twice daily.

Question: How long does the slower taper take?
Answer: over months or years

Question: How much opioid to reduce in the slower taper?
Answer: 5 to 20% every 4 weeks with pauses in taper as needed

Question: Which one is the most common taper?
Answer: Slower Taper

Question: During the first month in the slower taper what does consist of 16% reduction of morphine SR 90 mg Q8h = 270 MEDD?
Answer: 75 mg (60 mg+15 mg)SR Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month two of the slower opioid tapering?
Answer: 60 mg SR Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month three of the slower opioid tapering?
Answer: 45 mg SR Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month four of the slower opioid tapering?
Answer: 30 mg SR Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month five of the slower opioid tapering?
Answer: 15 mg SR Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month six of the slower opioid tapering?
Answer: 15 mg SR Q12h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on month 1, what dose should be taken on month seven of the slower opioid tapering?
Answer: 15mg SR QHS

Question: When to stop slower tapering?
Answer: after month 7

Question: What may be considered after stopping faster tapering after month 7?
Answer: morphine IR 15 mg ½ tablet (7.5 mg) twice daily
Features and overview

Faster Taper is done over weeks. In faster taper, reduce opioid by 10 to 20% every week.  An example of the faster taper is given below. During the first week in the faster taper, 16% reduction of morphine SR 90 mg Q8h = 270 MEDD consists of 75 mg SR Q8h. The subsequent weekly dosage for the faster taper is 60 mg SR (15 mg x 4) Q8h for week 2, 45 mg SR (15 mg x 3) Q8h for week 3, 30 mg SR (15 mg x 2) Q8h for week 4, 15 mg SR Q8h for week 5, 15 mg SR Q12h for week 6, 15 mg SR QHS x 7 days for week 7. Stop faster tapering after week 7 and may consider morphine IR 15 mg ½ tablet (7.5 mg) twice daily.

Question: How long does the faster taper take?
Answer: over weeks

Question: How much opioid to reduce in the faster taper?
Answer: 10 to 20% every week

Question: During the first week in the faster taper what does consist of 16% reduction of morphine SR 90 mg Q8h = 270 MEDD?
Answer: 75 mg SR Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week two of the faster opioid tapering?
Answer: 60 mg SR (15 mg x 4) Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week three of the faster opioid tapering?
Answer: 45 mg SR (15 mg x 3) Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week four of the faster opioid tapering?
Answer: 30 mg SR (15 mg x 2) Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week five of the faster opioid tapering?
Answer: 15 mg SR Q8h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week six of the faster opioid tapering?
Answer: 15 mg SR Q12h

Question: When reducing 16% of morphine SR 90 mg Q8h = 270 MEDD on week 1, what dose should be taken on week seven of the faster opioid tapering?
Answer: 15 mg SR QHS x 7 days

Question: When to stop faster tapering?
Answer: after week 7

Question: What may be considered after stopping faster tapering after week 7?
Answer: morphine IR 15 mg ½ tablet (7.5 mg) twice daily
Features and overview

Here is an example of an opioid taper plan for a Veteran. Veteran is currently taking morphine SR 60 mg, 1 tablet every 8 hours. Goal is to reduce the dose of morphine to SR 30 mg every 8 hours using a slow taper. Dose will be reduced by 15 mg every 10 days. Using morphine SR 15 mg tablets, follow the schedule below. From days 1 to 10, take 4 tablets = 60 mg in the morning, 3 tablets = 45 mg in the afternoon, 4 tablets = 60 mg in the evening. From days 11 to 20, take 3 tablets = 45 mg in the morning, 3 tablets = 45 mg in the afternoon, 4 tablets = 60 mg in the evening. From days 21 to 30, take 3 tablets = 45 mg in the morning, 3 tablets = 45 mg in the afternoon, 3 tablets = 45 mg in the evening.

Question: If a Veteran is currently taking morphine SR 60 mg, 1 tablet every 8 hours and the goal is to reduce the dose of morphine to SR 30 mg every 8 hours using a slow taper, how to reduce opioid dose?
Answer: 15 mg every 10 days

Question: How much to take from days 1 to 10, when using morphine SR 15 mg tablets?
Answer: 4 tablets = 60 mg in the morning, 3 tablets = 45 mg in the afternoon, 4 tablets = 60 mg in the evening

Question: How much to take from days 11 to 20, when using morphine SR 15 mg tablets?
Answer: 3 tablets = 45 mg in the morning, 3 tablets = 45 mg in the afternoon, 4 tablets = 60 mg in the evening

Question: How much to take from days 21 to 30, when using morphine SR 15 mg tablets?
Answer: 3 tablets = 45 mg in the morning, 3 tablets = 45 mg in the afternoon, 3 tablets = 45 mg in the evening
Features and overview

Follow up in the first 1 to 4 weeks of taper. If Veteran feels supported and is adjusting to the dose reduction, continue the strategy of reducing to morphine SR 30 mg every 8 hours, follow up in 1 to 4 weeks to determine the next step in the taper. If Veteran strongly resists reduction, then request mental health support and consider the possibility of OUD. If the Veteran is resisting further dose reductions, explore the reason for the reluctance. The reasons for the reluctance can be medical (increased pain), mental health (worsening depression, anxiety, etc.), and substance use disorder (SUD)/opioid use disorder (OUD). Refer to OUD Provider Education Guide on VA PBM Academic Detailing SharePoint for more information. https://vaww.portal2.va.gov/sites/ad/SitePages/OUD.aspx . If safe, remain at morphine SR 45 mg every 8 hours for 1 to 2 months then reassess. If possible, the Veteran should be actively involved in skills training and/or have a comprehensive pain care plan. At each step in the taper, review the risk of the taper vs. the benefit of remaining at the current dose, and if necessary, adjust the speed of the taper according to the response of the Veteran.

Question: What to do when Veteran feels supported and is adjusting to the dose reduction?
Answer: continue the strategy of reducing to morphine SR 30 mg every 8 hours, follow up in 1 to 4 weeks to determine the next step in the taper

Question: What to do when Veteran strongly resists reduction?
Answer: request mental health support and consider the possibility of OUD

Question: What to do when Veteran is resisting further dose reductions?
Answer: explore the reason for the reluctance

Question: What can be the reasons for the reluctance in further dose reductions?
Answer: medical (increased pain), mental health (worsening depression, anxiety, etc.), and substance use disorder (SUD)/opioid use disorder (OUD)

Question: What to do when Veteran is safe?
Answer: remain at morphine SR 45 mg every 8 hours for 1 to 2 months then reassess

Question: The veteran undergoing slow tapering should be involved in what?
Answer: skills training and/or have a comprehensive pain care plan

Question: What to review at each step in the taper?
Answer: review the risk of the taper vs. the benefit of remaining at the current dose

Question: What to do at each step in the taper?
Answer: review the risk of the taper vs. the benefit of remaining at the current dose, and if necessary, adjust the speed of the taper according to the response of the Veteran