Algorithm

Module B is about treatment with opioid therapy. The treatment of opioid therapy is provided to the candidate for trial of OT with consent (in conjunction with a comprehensive pain care plan). Initiate OT using the following approach: short duration (e.g., 1 week initial prescription; no more than 3 months total), use the lowest effective dose recognizing that no dose is completely safe, long-acting opioids should not be prescribed for opioid-naive individuals, consider alternatives to methadone and transdermal fentanyl, assessment of improvement in pain and functional status and adverse effects, offer overdose education and naloxone distribution (OEND). A strategy of escalating dose to achieve benefit increases risk and has not been shown to improve function. Dose escalation above 20-50 mg MEDD has not been shown to improve function and increase risk. If a patient is medically or psychiatrically unstable, then admit/provide medical and psychiatric treatment to stabilize as indicated. If a patient is not medically or psychiatrically unstable, then see if there is a clinically meaningful improvement in function in the absence of significant risk factors. If there is a clinically meaningful improvement in function in the absence of significant risk factors, then review and optimize comprehensive pain care plan (e.g., non-opioid treatments, self-management strategies). If there is no clinically meaningful improvement in function in the absence of significant risk factors, then taper to discontinuation (consult Module C if needed), exit algorithm and manage with non-opioid modalities. Follow-up frequently based on patient risk factors (e.g., 1-4 weeks with any dose change; up to every 3 months without dose change if clinically and functionally stable). During a follow-up, assess function, risks, and benefits of OT, progress toward functional treatment goals, adverse effects, adherence to treatment plan, complications or co-occurring conditions (e.g., medical, mental health, and/or SUD); complete risk mitigation strategies; review and optimize comprehensive pain care plan. The factors that increase risks of OT are non-adherence, co-occurring conditions, behaviors suggesting OUD, indications for referral. If these factors are present, then consider one or more of the following: shortening prescribing interval, intensifying risk mitigation strategies, increasing intensity of monitoring, referring to interdisciplinary care and consulting with or referring to specialty care. If the factors that increase risks of OT are not present, then see if there are indications to discontinue or taper. If there are indications to discontinue or taper, then taper to reduced dose or taper to discontinuation. If there are no indications to discontinue or taper, then reassess in 1-3 months or more frequently as determined by patient risk factors.

Question: What is module B about?
Answer: treatment with opioid therapy

Question: Who are provided opioid therapy treatment?
Answer: the candidate for trial of OT with consent (in conjunction with a comprehensive pain care plan)

Question: Which approach to follow when initiating OT?
Answer: short duration (e.g., 1 week initial prescription; no more than 3 months total), use the lowest effective dose recognizing that no dose is completely safe, long-acting opioids should not be prescribed for opioid-naive individuals, consider alternatives to methadone and transdermal fentanyl, assessment of improvement in pain and functional status and adverse effects, offer overdose education and naloxone distribution (OEND)

Question: What should be the duration and dosage when initiatiing opioid thrapy? 
Answer: short duration (e.g., 1 week initial prescription; no more than 3 months total), use the lowest effective dose recognizing that no dose is completely safe

Question: What can happen with a strategy of escalating dose during OT?
Answer: A strategy of escalating dose to achieve benefit increases risk and has not been shown to improve function.

Question: How much dose escalation has not been shown to improve function and increase risk?
Answer: above 20-50 mg MEDD

Question: Who should not be prescribed long-acting opioids?
Answer: opioid-naive individuals

Question: Should the opioid-naive individuals be prescribed long-acting opioids?
Answer: long-acting opioids should not be prescribed for opioid-naive individuals

Question: Alternatives should be considered for which opioid pain medications?
Answer: methadone and transdermal fentanyl

Question: What to do if a patient is medically or psychiatrically unstable?
Answer: admit/provide medical and psychiatric treatment to stabilize as indicated

Question: What to do if a patient is not medically or psychiatrically unstable?
Answer: see if there is a clinically meaningful improvement in function in the absence of significant risk factors

Question: What to do if there is a clinically meaningful improvement in function in the absence of significant risk factors?
Answer: review and optimize comprehensive pain care plan (e.g., non-opioid treatments, self-management strategies)

Question: What are some examples of comprehensive pain care plan?
Answer: non-opioid treatments, self-management strategies

Question: What to do if there is no clinically meaningful improvement in function in the absence of significant risk factors?
Answer: taper to discontinuation (consult Module C if needed), exit algorithm and manage with non-opioid modalities

Question: On which basis the frequency of follow-ups with a patient on OT should be considered?
Answer: patient risk factors (e.g., 1-4 weeks with any dose change; up to every 3 months without dose change if clinically and functionally stable)

Question: What to do during a follow-up with a patient?
Answer: assess function, risks, and benefits of OT, progress toward functional treatment goals, adverse effects, adherence to treatment plan, complications or co-occurring conditions (e.g., medical, mental health, and/or SUD); complete risk mitigation strategies; review and optimize comprehensive pain care plan

Question: What to assess during a follow-up with a patient?
Answer: function, risks, and benefits of OT, progress toward functional treatment goals, adverse effects, adherence to treatment plan, complications or co-occurring conditions (e.g., medical, mental health, and/or SUD)

Question: What to review and optimize during a follow-up?
Answer: comprehensive pain care plan

Question: Which factors can increase the risks of OT?
Answer: non-adherence, co-occurring conditions, behaviors suggesting OUD, indications for referral

Question: What to do if the factors that increase risks of OT are present?
Answer: consider one or more of the following: shortening prescribing interval, intensifying risk mitigation strategies, increasing intensity of monitoring, referring to interdisciplinary care and consulting with or referring to specialty care

Question: What to do if the factors that increase risks of OT are not present?
Answer: see if there are indications to discontinue or taper

Question: What to do if there are indications to discontinue or taper?
Answer: taper to reduced dose or taper to discontinuation

Question: What to do if there are no indications to discontinue or taper?
Answer: reassess in 1-3 months or more frequently as determined by patient risk factors