Lornng/cpgQA huggingface dataset:
Recommendations

For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits. We recommend against long-term opioid therapy for pain in patients with untreated substance use disorder. For patients currently on long-term opioid therapy with evidence of untreated substance use disorder, we recommend close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering.

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

Question: What is the stance regarding the long-term opioid therapy for pain in patients with untreated substance use disorder?
Answer: recommend against

Question: What is recommended for patients currently on long-term opioid therapy with evidence of untreated substance use disorder?
Answer: close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering
Recommendations

We recommend against the concurrent use of benzodiazepines and opioids. Note: For patients currently on long-term opioid therapy and benzodiazepines, consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate. We recommend against long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose. For patients less than 30 years of age currently on long-term opioid therapy, we recommend close monitoring and consideration for tapering when risks exceed benefits.

Question: What is the stance regarding the concurrent use of benzodiazepines and opioids?
Answer: recommend against

Question: What to consider for patients currently on long-term opioid therapy and benzodiazepines?
Answer: consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate

Question: What is the stance regarding long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose?
Answer: recommend against

Question: What to recommend for patients less than 30 years of age currently on long-term opioid therapy?
Answer: close monitoring and consideration for tapering when risks exceed benefits
Recommendations

We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include ongoing, random urine drug testing (including appropriate confirmatory testing), checking state prescription drug monitoring programs, monitoring for overdose potential and suicidality, providing overdose education, prescribing of naloxone rescue and accompanying education.

Question: What is recommended upon initiation of long-term opioid therapy?
Answer: implementing risk mitigation strategies

Question: How to implement the risk mitigation strategies upon initiation of long-term opioid therapy?
Answer: starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies

Question: What should be commensurate with risk factors?
Answer: The strategies and their frequency

Question: What are included in the strategies and their frequency?
Answer: ongoing, random urine drug testing (including appropriate confirmatory testing), checking state prescription drug monitoring programs, monitoring for overdose potential and suicidality, providing overdose education, prescribing of naloxone rescue and accompanying education
Recommendations

We recommend assessing suicide risk and intervening when necessary when considering initiating or continuing long-term opioid therapy. We recommend evaluating benefits of continued opioid therapy and risk for opioid-related adverse events at least every three months. If prescribing opioids, we recommend prescribing the lowest dose of opioids as indicated by patient-specific risks and benefits. Note: There is no absolutely safe dose of opioids.

Question: What is recommended when considering initiating or continuing long-term opioid therapy?
Answer: assessing suicide risk and intervening when necessary

Question: When is assessing suicide risk and intervening recommended?
Answer: when considering initiating or continuing long-term opioid therapy

Question: When is it recommended to evaluate benefits of continued opioid therapy and risk for opioid-related adverse events?
Answer: at least every three months

Question: What is recommended at least every 3 months?
Answer: evaluating benefits of continued opioid therapy and risk for opioid-related adverse events

Question: What risk is recommended to be evaluated at least every 3 months?
Answer: risk for opioid-related adverse events

Question: What benefits are recommended to be evaluated at least every 3 months?
Answer: benefits of continued opioid therapy

Question: If prescribing opioids, what is the recommended dose?
Answer: lowest dose of opioids as indicated by patient-specific risks and benefits

Question: The lowest dose of opioids is prescribed indicated by which factor?
Answer: patient-specific risks and benefits

Question: What kind of dose of opioids do not exist?
Answer: absolutely safe
Recommendations

As opioid dosage and risk increase, we recommend more frequent monitoring for adverse events including opioid use disorder and overdose. Note: Risks for opioid use disorder start at any dose and increase in a dose dependent manner. Risks for overdose and death significantly increase at a range of 20- 50 mg morphine equivalent daily dose.

Question: What is recommended as opioid dosage and risk increase?
Answer: more frequent monitoring for adverse events including opioid use disorder and overdose

Question: When is it recommended more frequent monitoring for adverse events?
Answer: As opioid dosage and risk increase

Question: When do the risks for opioid use disorder start?
Answer: at any dose

Question: How do the risks for opioid use disorder increase?
Answer: in a dose dependent manner

Question: At what range of dose the risks for overdose and death significantly increase?
Answer: 20- 50 mg morphine equivalent daily dose

Question: What does significantly increase at a range of 20- 50 mg morphine equivalent daily dose?
Answer: Risks for overdose and death
Recommendations

We recommend against opioid doses over 90 mg morphine equivalent daily dose for treating chronic pain. Note: For patients who are currently prescribed doses over 90 mg morphine equivalent daily dose, evaluate for tapering to reduced dose or to discontinuation. We recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of long-term opioid therapy.

Question: What is the stance regarding opioid doses over 90 mg morphine equivalent daily dose for treating chronic pain?
Answer: recommend against

Question: What to do for patients who are currently prescribed doses over 90 mg morphine equivalent daily dose?
Answer: evaluate for tapering to reduced dose or to discontinuation

Question: For whom to evaluate for tapering to reduced dose or to discontinuation?
Answer: patients who are currently prescribed doses over 90 mg morphine equivalent daily dose

Question: What is the stance regarding prescribing long-acting opioids for acute pain?
Answer: recommend against

Question: What is the stance regarding prescribing long-acting opioids as an as-needed medication?
Answer: recommend against
Recommendations

We recommend tapering to reduced dose or to discontinuation of long-term opioid therapy when risks of long-term opioid therapy outweigh benefits. Note: Abrupt discontinuation should be avoided unless required for immediate safety concerns. We recommend individualizing opioid tapering based on risk assessment and patient needs and characteristics. Note: There is insufficient evidence to recommend for or against specific tapering strategies and schedules.

Question: What is recommended when risks of long-term opioid therapy outweigh benefits?
Answer: tapering to reduced dose or to discontinuation of long-term opioid therapy

Question: When is it recommended to taper to reduced dose or to discontinuation of long-term opioid therapy?
Answer: when risks of long-term opioid therapy outweigh benefits

Question: What should be avoided unless required for immediate safety concerns?
Answer: Abrupt discontinuation

Question: It is recommended to individualize opioid tapering based on what?
Answer: risk assessment and patient needs and characteristics
Recommendations

We recommend interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior. We recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder. Note: See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders.

Question: What kind of care is recommended that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior?
Answer: interdisciplinary

Question: What does interdisciplinary care do?
Answer: addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior

Question: What treatment is recommended to offer for opioid use disorder to patients with chronic pain and opioid use disorder?
Answer: medication assisted treatment

Question: Who are recommended to be offered medication assisted treatment? 
Answer: patients with chronic pain and opioid use disorder

Question: Medication assisted treatment is recommended for what?
Answer: opioid use disorder

Question: Where can we find information on the Management of Substance Use Disorders?
Answer: VA/DoD Clinical Practice Guideline
Recommendations

We recommend alternatives to opioids for mild-to-moderate acute pain. We suggest use of multimodal pain care including non-opioid medications as indicated when opioids are used for acute pain. If take-home opioids are prescribed, we recommend that immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated. Note: Patient education about opioid risks and alternatives to opioid therapy should be offered.

Question: What is recommended for mild-to-moderate acute pain?
Answer: alternatives to opioids

Question: Alternatives to opioids are recommended for what?
Answer: mild-to-moderate acute pain

Question: When is it suggested to use multimodal pain care including non-opioid medications as indicated?
Answer: when opioids are used for acute pain

Question: What is suggested to be used when opioids are used for acute pain?
Answer: multimodal pain care including non-opioid medications as indicated

Question: What is recommended if take-home opioids are prescribed?
Answer: immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated

Question: If take-home opioids are prescribed, what is the recommended dose of immediate-release opioids?
Answer: lowest effective

Question: If take-home opioids are prescribed, when is the opioid therapy reassessment recommended?
Answer: no later than 3-5 days

Question: If take-home opioids are prescribed, why is it recommended to have opioid therapy reassessment no later than 3-5 days?
Answer: to determine if adjustments or continuing opioid therapy is indicated

Question: What should be offered to patients?
Answer: education about opioid risks and alternatives to opioid therapy
Algorithm

This CPG follows an algorithm that is designed to facilitate understanding of the clinical pathway and decision making process used in management of LOT. The use of the algorithm format as a way to represent patient management was chosen based on the understanding that such a format may promote more efficient diagnostic and therapeutic decision making and has the potential to change patterns of resource use. Although the Work Group recognizes that not all clinical practices are linear, the simplified linear approach depicted through the algorithm and its format allows the provider to assess the critical information needed at the major decision points in the clinical process. It includes an ordered sequence of steps of care, recommended observations and examinations, decisions to be considered, actions to be taken.

Question: The CPG follows an algorithm that is designed to do what?
Answer: facilitate understanding of the clinical pathway and decision making process used in management of LOT

Question: The use of the algorithm format as a way to represent patient management was chosen based on what?
Answer: the understanding that such a format may promote more efficient diagnostic and therapeutic decision making and has the potential to change patterns of resource use

Question: What does the work Group recognize?
Answer: not all clinical practices are linear

Question: What does the simplified linear approach depicted through the algorithm and its format allow?
Answer: to assess the critical information needed at the major decision points in the clinical process

Question: Who does assess the critical information needed at the major decision points in the clinical process?
Answer: the provider

Question: What does the algorithm include?
Answer: an ordered sequence of steps of care, recommended observations and examinations, decisions to be considered, actions to be taken
Algorithm

The components of biopsychosocial assessment are pain assessment, patient functional goals, impact of pain on family, work, life, review of previous diagnostic studies, additional consultations and referrals, coexisting illness and treatments and effect on pain, significant psychological, social, or behavioral factors that may affect treatment, family history of chronic pain, collateral of family involvement, patient beliefs/knowledge of the cause of their pain and their treatment preferences along with the perceived efficacy of various treatment options. For patients already on OT, include assessment of psychological factors related to continuing vs. tapering OT. The psychological factors are beliefs, expectations, fears. Pain assessment includes history, physical exam, comorbidities, previous treatment and medications, duration of symptoms, onset and triggers. Examples of absolute contraindications to initiating opioid therapy for chronic pain are true life-threatening allergy to opioids, active SUD, elevated suicide risk, concomitant use of benzodiazepines. LOT refers to long-term opioid therapy; OT refers to opioid therapy; PDMP refers to Prescription Drug Monitoring Program; SUD refers to substance use disorder; UDT refers to urine drug test; VA/DoD Suicide CPG refers to VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide.

Question: What are the components of biopsychosocial assessment?
Answer: pain assessment, patient functional goals, impact of pain on family, work, life, review of previous diagnostic studies, additional consultations and referrals, coexisting illness and treatments and effect on pain, significant psychological, social, or behavioral factors that may affect treatment, family history of chronic pain, collateral of family involvement, patient beliefs/knowledge of the cause of their pain and their treatment preferences along with the perceived efficacy of various treatment options

Question: What to assess for patients already on OT?
Answer: psychological factors related to continuing vs. tapering OT

Question: What does pain assessment include?
Answer: history, physical exam, comorbidities, previous treatment and medications, duration of symptoms, onset and triggers

Question: What are psychological factors?
Answer: beliefs, expectations, fears

Question: What are some examples of absolute contraindications to initiating opioid therapy for chronic pain?
Answer: true life-threatening allergy to opioids, active SUD, elevated suicide risk, concomitant use of benzodiazepines

Question: What is LOT?
Answer: long-term opioid therapy

Question: What is OT?
Answer: opioid therapy

Question: What does PDMP mean?
Answer: Prescription Drug Monitoring Program

Question: What does it mean by SUD?
Answer: substance use disorder

Question: What does UDT refer to?
Answer: urine drug test

Question: What does VA/DoD Suicide CPG refer to?
Answer: VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide
Algorithm

When safety allows, a gradual taper rate (5-10% reduction every 4 weeks) allows time for neurobiological, psychological, and behavioral adaptations. When there are concerns regarding risks of tapering (e.g., unmasked OUD, exacerbation of underlying mental health conditions), consider interdisciplinary services that may include mental health, SUD, primary care, and specialty pain care. Address concerns that may negatively impact taper (e.g., inability for adequate follow-up, inability to provide adequate treatment for co-occurring medical and mental health conditions and SUD). Patient and treatment characteristics to consider when determining tapering strategy are as follows: opioid dose, duration of therapy, type of opioid formulation, psychiatric, medical and SUD comorbidities and other patient risk factors (e.g., non-adherence, high-risk medication-related behavior, strength of social support, and coping).

Question: When safety allows, what are the advantages of a gradual taper?
Answer: a gradual taper rate (5-10% reduction every 4 weeks) allows time for neurobiological, psychological, and behavioral adaptations

Question: What is the rate of a gradual taper?
Answer: 5-10% reduction every 4 weeks

Question: What does a gradual taper rate allow?
Answer: time for neurobiological, psychological, and behavioral adaptations

Question: What to do when there are concerns regarding risks of tapering?
Answer: consider interdisciplinary services that may include mental health, SUD, primary care, and specialty pain care

Question: What are the risks associated with tapering?
Answer: unmasked OUD, exacerbation of underlying mental health conditions

Question: What maybe included in interdisciplinary services?
Answer: mental health, SUD, primary care, and specialty pain care

Question: Which concerns need to be addressed at the time of opioid tapering?
Answer: concerns that may negatively impact taper (e.g., inability for adequate follow-up, inability to provide adequate treatment for co-occurring medical and mental health conditions and SUD)

Question: What are some examples of concerns that may negatively impact taper?
Answer: inability for adequate follow-up, inability to provide adequate treatment for co-occurring medical and mental health conditions and SUD

Question: Which patient and treatment characteristics should be considered when determining tapering strategy?
Answer: opioid dose, duration of therapy, type of opioid formulation, psychiatric, medical and SUD comorbidities and other patient risk factors (e.g., non-adherence, high-risk medication-related behavior, strength of social support, and coping)
Background information

Chronic pain is a national public health problem as outlined in the 2011 study by the National Academy of Medicine (previously the Institute of Medicine [IOM]). At least 100 million Americans suffer from some form of chronic pain. Until recently, the treatment of chronic pain with opioids was increasing at an alarming rate. The increase in prescriptions of these medications has been accompanied by an epidemic of opioid-related adverse events.

Question: What is a national public health problem as outlined in the 2011 study by the National Academy of Medicine?
Answer: Chronic pain

Question: What was the National Academy of Medicine formerly known as?
Answer: the Institute of Medicine [IOM]

Question: How many Americans suffer from some form of chronic pain?
Answer: At least 100 million

Question: What was increasing at an alarming rate until recently?
Answer: the treatment of chronic pain with opioids

Question: What was accompanying the increase in prescriptions of opioid medications?
Answer: an epidemic of opioid-related adverse events
Background information

From 2000 through 2010, the proportion of pain visits during which opioid and non-opioid pharmacologic therapies were prescribed increased from 11.3% to 19.6% and from 26% to 29%, respectively. In 2012, for every 100 persons in the United States (U.S.), 82.5 opioid prescriptions and 37.6 benzodiazepine prescriptions were written by healthcare providers. In the emergency department, at least 17% of discharges included prescriptions for opioids.

Question: From 2000 through 2010, what was the increment of the proportion of pain visits during which opioid was prescribed?
Answer: from 11.3% to 19.6%

Question: From 2000 through 2010, what was the increment of the proportion of pain visits during which non-opioid pharmacologic therapies were prescribed?
Answer: from 26% to 29%

Question: In 2012, how many opioid prescriptions were written by healthcare providers for every 100 persons in the U.S.?
Answer: 82.5

Question: In 2012, how many benzodiazepine prescriptions were written by healthcare providers for every 100 persons in the U.S.?
Answer: 37.6

Question: How many discharges in the emergency department included prescriptions for opioids?
Answer: at least 17%
Background information

There has been limited research on the effectiveness of LOT for non-end-of-life pain. At the same time, there is mounting evidence of the ill effects of LOT, including increased mortality, OUD, overdose, sexual dysfunction, fractures, myocardial infarction, constipation, and sleep-disordered breathing. Despite increasing awareness of the known harms of opioids, 259 million opioid prescriptions were still written in 2012.

Question: What is the state of research on the effectiveness of LOT for non-end-of-life pain?
Answer: limited

Question: What are the adverse effects of LOT?
Answer: increased mortality, OUD, overdose, sexual dysfunction, fractures, myocardial infarction, constipation, and sleep-disordered breathing

Question: How many opioid prescriptions were written in 2012?
Answer: 259 million