Algorithm

Module D is for patients currently on opioid therapy. For patients currently on OT, look for factors that would require immediate attention and possible discontinuation of OT due to unacceptable risk. If there are factors that would require immediate attention, then admit/provide treatment to stabilize, including opioid tapering or SUD treatment as indicated. If there are no factors that would require immediate attention, then obtain a biopsychosocial assessment. If prior medical records including current prescriber, prior and current UDT, PDMP are available for review, then review data and re-assess risks and benefits of continuing OT and consider strength and number of risk factors. If unavailable, then address factors related to incomplete data prior to prescribing. Then review data and re-assess risks and benefits of continuing OT and consider strength and number of risk factors. If risks outweigh benefits of continuing OT, then proceed to module C. If risks do not outweigh benefits of continuing OT, then educate/re-educate on the following: non-opioid management, self-management to improve function and quality of life, realistic expectations and limitations of medical treatment options, preferred treatment methods being non-pharmacotherapy and non-opioid pharmacotherapy, new information on risks and lack of benefits of long-term OT. After educating/re-educating the patient, identify if there is presence of prescribed opioid dose>90 mg MEDD or combined sedating medication that increases risk of adverse events (e.g., benzodiazepine) or patient non-participation in a comprehensive pain care plan or other indications for tapering. If any of these are present, then proceed to module C. Otherwise, reassess and optimize preferred non-opioid treatments for chronic pain (e.g., physical and psychological treatments) recognizing that the patient is willing to continue to engage in a comprehensive treatment plan including non-opioid treatments. If the patient is experiencing clear functional improvement with minimal risk, then continue OT using the following approach: shortest duration, using lowest effective dose (recognizing that no dose is completely safe and overdose risk increases at doses > 20-50 mg MEDD), continual assessment of improvement in pain and functional status and adverse effects. Then proceed to follow-up frequently based on patient risk factors. Otherwise, proceed to module C.

Question: What is module D for?
Answer: patients currently on opioid therapy

Question: What to do for patients currently on OT?
Answer: look for factors that would require immediate attention and possible discontinuation of OT due to unacceptable risk

Question: What to do if there are factors that would require immediate attention?
Answer: admit/provide treatment to stabilize, including opioid tapering or SUD treatment as indicated

Question: What to do if there are no factors requiring immediate attention?
Answer: obtain a biopsychosocial assessment

Question: What to do if prior medical records are available for review?
Answer: review data and re-assess risks and benefits of continuing OT and consider strength and number of risk factors

Question: What includes prior medical records?
Answer: current prescriber, prior and current UDT, PDMP

Question: What to do if prior medical records are not available for review?
Answer: address factors related to incomplete data prior to prescribing. Then review data and re-assess risks and benefits of continuing OT and consider strength and number of risk factors.

Question: What to do if risks outweigh benefits of continuing OT?
Answer: proceed to module C

Question: What to do if risks do not outweigh benefits of continuing OT?
Answer: educate/re-educate on the following: non-opioid management, self-management to improve function and quality of life, realistic expectations and limitations of medical treatment options, preferred treatment methods being non-pharmacotherapy and non-opioid pharmacotherapy, new information on risks and lack of benefits of long-term OT

Question: What to do after educating the patient?
Answer: identify if there is presence of prescribed opioid dose>90 mg MEDD or combined sedating medication that increases risk of adverse events (e.g., benzodiazepine) or patient non-participation in a comprehensive pain care plan or other indications for tapering

Question: What to do if there is no presence of prescribed opioid dose>90 mg MEDD or combined sedating medication that increases risk of adverse events or patient non-participation in a comprehensive pain care plan or other indications for tapering? 
Answer: reassess and optimize preferred non-opioid treatments for chronic pain (e.g., physical and psychological treatments) recognizing that the patient is willing to continue to engage in a comprehensive treatment plan including non-opioid treatments

Question: What are non-opioid treatments for chronic pain?
Answer: physical and psychological treatments

Question: What to do if the patient is experiencing clear functional improvement with minimal risk?
Answer: continue OT using the following approach: shortest duration, using lowest effective dose (recognizing that no dose is completely safe and overdose risk increases at doses > 20-50 mg MEDD), continual assessment of improvement in pain and functional status and adverse effects

Question: Follow-up with patients frequently based on what?
Answer: patient risk factors

Question: What to do if the patient is prescribed opioid dose>90 mg MEDD?
Answer: proceed to module C

Question: What to do if there is presence of combined sedating medication that increases risk of adverse events (e.g., benzodiazepine)?
Answer: proceed to module C

Question: What to do if the patient does not participate in a comprehensive pain care plan?
Answer: proceed to module C