Lornng/cpgQA huggingface dataset:
Recommendations

Abuse Deterrent Formulations of Opioids: The aim of most abuse deterrent formulations is to present a physical barrier to prevent chewing,  crushing, cutting, grating, or grinding of the dosage form, or present a chemical barrier, such as a gelling  agent, that will resist extraction of the opioid with use of a common solvent. Alternatively, an opioid  antagonist (naloxone or naltrexone) can be added to interfere with, reduce, or defeat the euphoria  associated with abuse of an agent intended for oral use when taken nasally or parenterally.[142] While  these properties deter abuse they do not fully prevent abuse; no opioid formulation prevents consumption  of a large number of intact capsules or tablets which continues to be the most common method of abuse.

Question: What is the aim of most abuse deterrent formulations?
Answer: to present a physical barrier to prevent chewing,  crushing, cutting, grating, or grinding of the dosage form, or present a chemical barrier, such as a gelling  agent, that will resist extraction of the opioid with use of a common solvent

Question: What can be added to interfere with, reduce, or defeat the euphoria  associated with abuse of an agent intended for oral use when taken nasally or parenterally?
Answer: an opioid  antagonist (naloxone or naltrexone)

Question: What is the most common method of abuse?
Answer: consumption  of a large number of intact capsules or tablets
Recommendations

We do not recommend for or against abuse deterrent formulations for LOT. Our searches identified two  RCTs in which the benefits of co-prescribing of naloxone with opioids were examined.[143,144] However, both RCTs were rated as low to very low quality with short-term follow-up. One open-label RCT enrolling  453 patients with chronic low back pain considered the safety and tolerability of an abuse deterrent formulation of oxycodone/naloxone relative to oxycodone or morphine at 12-week follow-up.[143]  Another RCT considered the safety and efficacy of oxycodone/naloxone prolonged-release relative to  oxycodone prolonged-release in 184 patients with moderate-to-severe chronic cancer pain at four-week  follow-up.[144] An observational study (not included in the evidence review) suggested that the  Introductory information of abuse deterrent opioid formulations did not help reduce abuse of opioids as a class and  that patients may switch from one opioid to another based on the availability or the lack of availability of  abuse deterrent formulations.[145]

Question: What is the stance regarding the abuse deterrent formulations for LOT?
Answer: do not recommend for or against
Recommendations

Future research is needed to ascertain whether abuse deterrent formulations actually reduce OUD when  used for chronic pain, and whether said formulations differ across clinical outcomes such as pain, function,  and adverse events.

Question: What is needed to ascertain whether abuse deterrent formulations actually reduce OUD when used for chronic pain? 
Answer: Future research

Question: What is needed to ascertain whether said formulations differ across clinical outcomes such as pain, function,  and adverse events?  
Answer: Future research
Recommendations

Dual-Mechanism Opioids: Dual-mechanism opioids include formulations of an opioid medication with a selective serotonin reuptake  inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI). Two common examples are  tramadol and tapentadol. While both are dual-mechanism opioids, they differ in their affinity for the mu  opioid receptor, resulting in partial versus full agonist effects, and as such are discussed separately.

Question: What is included in the dual-mechanism opioids?
Answer: formulations of an opioid medication with a selective serotonin reuptake  inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI)

Question: What are the examples of dual-mechanism opioids?
Answer: tramadol and tapentadol

Question: What are the differences between tramadol and tapentadol?
Answer: While both are dual-mechanism opioids, they differ in their affinity for the mu  opioid receptor, resulting in partial versus full agonist effects
Recommendations

Tramadol: There is low quality evidence that tramadol may be more effective than placebo for pain relief. In one  short-term study, compared to placebo, tramadol was more effective for pain.[146] There is no long-term  evidence of the comparative efficacy of tramadol versus another opioid or a non-opioid comparison such  as non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. Due to tramadol’s partial mu  agonist activity and demonstrated safety profile when used in conjunction with acetaminophen in elderly  patients, it may be a preferred agent in that patient group.[147,148]

Question: Is there any evidence of the comparative efficacy of tramadol versus another opioid or a non-opioid comparison such  as non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen?
Answer: no long-term  evidence
Recommendations

We recommend alternatives to opioids for mild-to-moderate acute pain. (Strong for). We suggest use of multimodal pain care including non-opioid medications as indicated when opioids are used for acute pain. (Weak for). 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. (Strong for). 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: What is sugested when opioids are used for acute pain?
Answer: use of 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: What should be offered to patients?
Answer: Patient education about opioid risks and alternatives to opioid therapy
Recommendations

As this guideline is related to LOT, the use of opioids for acute pain is not reviewed in detail. However,  because acute OT can be a gateway to LOT, it is part of this CPG. A review of the literature indicates that  LOT can result from acute opioid use initially intended for short-term therapy. Further, there is a risk of  opioid-related overdose even during acute OT. While it is understood that acute OT for severe pain due to  injuries or surgery is the most effective option for many patients, the risks associated with acute therapy  must be addressed when opioids are prescribed or considered.

Question: What can can be a gateway to LOT?
Answer: acute OT
Recommendations

The risks of acute OT extending into LOT are increased in patients with mood disorders, those who refill  the initial prescription, higher prescribed dose (greater than 120 mg MEDD), and initiation using long acting opioids.[183-185] The risk of acute post-operative OT progressing into LOT is increased with a  history of depression, SUD, catastrophizing, higher preoperative total body pain, history of back pain, and  preoperative use of sedative-hypnotics or antidepressants.[186,187]

Question: Who are at an increased risks of acute OT extending into LOT?
Answer: patients with mood disorders, those who refill  the initial prescription, higher prescribed dose (greater than 120 mg MEDD), and initiation using long acting opioids

Question: What does increase the risk of acute post-operative OT progressing into LOT?
Answer: a  history of depression, SUD, catastrophizing, higher preoperative total body pain, history of back pain, and  preoperative use of sedative-hypnotics or antidepressants
Recommendations

In addition, the risk of overdose includes the use of opioids for acute pain. Factors that increase overdose  risk when opioids are used for acute pain include high prescribed dose, history of SUD, and history of  mental health concerns. While the risk of overdose increases at doses above 20 mg MEDD or greater, this  risk increases even further as doses increase to over 50 or 100 mg MEDD.[58,59,188]

Question: What does risk of overdose include?
Answer: the use of opioids for acute pain

Question: Which factors increase overdose risk when opioids are used for acute pain?
Answer: high prescribed dose, history of SUD, and history of  mental health concerns
Recommendations

There are situations in which opioids may be necessary therapy for acute pain, even when substantial risk  factors exist. It is important to incorporate opioid risk mitigation strategies into opioid prescribing for acute  pain. These strategies should include patient education, use of non-opioid adjunctive therapy, and  structured reassessment of opioid risks and benefits for all on acute OT. Also, consider checking the PDMP and performing a UDT.

Question: Which opioid risk mitigation strategies should be incorporateed into opioid prescribing for acute pain?
Answer: patient education, use of non-opioid adjunctive therapy, and  structured reassessment of opioid risks and benefits for all on acute OT. Also, consider checking the PDMP and performing a UDT.
Recommendations

For those at higher risk of adverse events related to opioid therapy, the following strategies may help to  decrease opioid-related overdose events and unintended long-term use: checking the PDMP, performing a  UDT, placement in an inpatient setting or monitored environment, and/or providing OEND.

Question: Which strategies may be helpful for those at higher risk of adverse events related to opioid therapy?
Answer: checking the PDMP, performing a  UDT, placement in an inpatient setting or monitored environment, and/or providing OEND
Recommendations

Monitoring standards with administration of OT for acute pain vary depending on a number of factors  including the setting, specifics of the painful insult, patient medical factors, and selected medication  potency/dose/route of administration/adjunct selection.

Question: Depending on which factors monitoring standards with administration of OT for acute pain vary?
Answer: the setting, specifics of the painful insult, patient medical factors, and selected medication  potency/dose/route of administration/adjunct selection
Features and overview

This OT CPG is in line with the efforts described above to improve our understanding and treatment of  pain, as well as to mitigate the inappropriate prescribing and ill effects of opioids. It is intended for VA and  DoD healthcare practitioners including physicians, nurse practitioners, physician assistants, physical and  occupational therapists, psychologists, social workers, nurses, clinical pharmacists, chaplains, addiction  counselors, and others involved in the care of Service Members and their beneficiaries, retirees and their  beneficiaries, or Veterans on or being considered for LOT. In conjunction with other efforts already under  way, this CPG is aimed at improving safe and appropriate prescribing and use of opioids to treat chronic  pain.

Question: For whom is this guideline intended?
Answer: VA and  DoD healthcare practitioners including physicians, nurse practitioners, physician assistants, physical and  occupational therapists, psychologists, social workers, nurses, clinical pharmacists, chaplains, addiction  counselors, and others involved in the care of Service Members and their beneficiaries, retirees and their  beneficiaries, or Veterans on or being considered for LOT
Features and overview

As with other CPGs, there are limitations, including significant evidence gaps. Further, there is a need to  develop effective strategies for guideline implementation and evaluation of the effect of guideline  adherence on clinical outcomes. Thus, as stated in the qualifying statements at the beginning of the CPG,  this CPG is not intended to serve as a standard of care. Standards of care are determined on the basis of all  clinical data available for an individual patient and are subject to change as scientific knowledge and  technology advance and patterns evolve. This CPG is based on evidence available by December 2016 and is  intended to provide a general guide to best practices. The guideline can assist healthcare providers, but  the use of a CPG must always be considered as a recommendation, within the context of a provider’s  clinical judgment and patient values and preferences, for the care of an individual patient.

Question: What are the limitation of this CPG?
Answer: As with other CPGs, there are limitations, including significant evidence gaps. Further, there is a need to  develop effective strategies for guideline implementation and evaluation of the effect of guideline  adherence on clinical outcomes.

Question: How are the standards of care determined?
Answer: on the basis of all  clinical data available for an individual patient and are subject to change as scientific knowledge and  technology advance and patterns evolve

Question: What is not the intention of this guideline?
Answer: to serve as a standard of care

Question: This CPG is based on what?
Answer: evidence available by December 2016

Question: How to use a CPG?
Answer: the use of a CPG must always be considered as a recommendation, within the context of a provider’s  clinical judgment and patient values and preferences, for the care of an individual patient
Features and overview

This OT CPG is designed to assist healthcare providers in managing or co-managing patients on or being  considered for LOT. Specifically, this CPG is intended for adults, including Veterans as well as deployed and  non-deployed Active Duty Service Members, their beneficiaries, and retirees and their beneficiaries, with  chronic pain who are receiving care from the VA or DoD healthcare delivery systems. This CPG is not  intended for and does not provide recommendations for the management of pain with LOT in children or  adolescents, in patients with acute pain, or in patients receiving end-of-life care. As is so for any  pharmacotherapy, any decision about prescribing opioids, or alternative medications for pain, for pregnant  women should be made with due caution and cognizance of applicable U.S. Food and Drug Administration  (FDA) labeling. Any patient in the VA or DoD healthcare system should be offered access to the  interventions that are recommended in this guideline after taking into consideration the patient’s specific  circumstances.

Question: What is this OT CPG designed to do?
Answer: assist healthcare providers in managing or co-managing patients on or being  considered for LOT

Question: For whom is his CPG is intended?
Answer: adults, including Veterans as well as deployed and  non-deployed Active Duty Service Members, their beneficiaries, and retirees and their beneficiaries, with  chronic pain who are receiving care from the VA or DoD healthcare delivery systems

Question: What does this CPG not do?
Answer: does not provide recommendations for the management of pain with LOT in children or  adolescents, in patients with acute pain, or in patients receiving end-of-life care
Features and overview

While these guidelines are broadly recommended, their implementation is intended to be patient centered. Thus, treatment and care should take into account a patient’s needs and preferences. Good  communication between healthcare professionals and the patient about the patient’s pain experience,  treatment goals, and challenges is essential and should be guided by evidence-based information tailored  to the patient’s needs. An empathetic and non-judgmental (versus a confrontational or adversarial)  approach to communication with a patient is highly recommended in order to build trust and facilitate frank discussions relating to the social, economic, emotional, and cultural factors that influence patients’  perceptions, behaviors, and decision making.

Question: What kind of approach is highly recommended for communication with a patient?
Answer: An empathetic and non-judgmental (versus a confrontational or adversarial)
Features and overview

While these guidelines are broadly recommended, their implementation is intended to be patient centered. Thus, treatment and care should take into account a patient’s needs and preferences. Good  communication between healthcare professionals and the patient about the patient’s pain experience,  treatment goals, and challenges is essential and should be guided by evidence-based information tailored  to the patient’s needs. An empathetic and non-judgmental (versus a confrontational or adversarial)  approach to communication with a patient is highly recommended in order to build trust and facilitate frank discussions relating to the social, economic, emotional, and cultural factors that influence patients’  perceptions, behaviors, and decision making. The information that patients are given about treatment and care should be culturally appropriate and  also available to people with limited literacy skills. It should also be accessible to people with additional needs such as physical, sensory, or learning disabilities. Family involvement should be considered if  appropriate.

Question: Why is an empathetic and non-judgmental approach highly recommended for communication with a patient?
Answer: in order to build trust and facilitate frank discussions relating to the social, economic, emotional, and cultural factors that influence patients’  perceptions, behaviors, and decision making
Features and overview

The systematic review conducted for the update of this CPG encompassed interventional studies (primarily  randomized controlled trials [RCTs]) published between March 2009 and December 2016 and targeted nine key questions (KQs) focusing on the means by which the delivery of healthcare could be optimized for  patients on or being considered for LOT. Because a comprehensive review of the evidence related to LOT was not feasible, the nine selected KQs were prioritized from many possible KQs. Therefore, many of the  2010 OT CPG recommendations were considered for inclusion in the updated version of the guideline  without an updated review of the evidence. The section on Recommendations delineates whether or not  the current CPG recommendations were based on an updated evidence review. Appendix H delineates  whether the 2010 OT CPG recommendations were considered for inclusion in the update based on an  updated evidence review or based on the evidence included in the 2010 OT CPG. The section on  Recommendation Categorization further describes the methodology used for the categorization.

Question: Why only nine key questions (KQs) were prioritized from many possible KQs?
Answer: Because a comprehensive review of the evidence related to LOT was not feasible
Features and overview

The 2017 version of the VA/DoD OT CPG is the second update to the original CPG. It provides practice  recommendations for the care of populations with chronic pain already on or being considered for LOT.  Although there are many other approaches to the treatment of chronic pain, the scope of this CPG is to  focus on the use of opioids for chronic pain rather than being comprehensive about all treatment options.  A particular strength of this CPG is the multidisciplinary stakeholder involvement from its inception,  ensuring representation from the broad spectrum of clinicians engaged in the treatment and management  of patients with chronic pain on or being considered for LOT.

Question: What does the 2017 version of the VA/DoD OT CPG provide?
Answer: practice  recommendations for the care of populations with chronic pain already on or being considered for LOT

Question: What is the scope of this CPG?
Answer: to  focus on the use of opioids for chronic pain rather than being comprehensive about all treatment options

Question: What is the strength of this CPG?
Answer: the multidisciplinary stakeholder involvement from its inception,  ensuring representation from the broad spectrum of clinicians engaged in the treatment and management  of patients with chronic pain on or being considered for LOT
Features and overview

The framework for recommendations in this CPG considered factors beyond the strength of the evidence,  including balancing desired outcomes with potential harms of treatment, equity of resource availability,  the potential for variation in patient values and preferences, and other considerations (see Methods for  more information). Applicability of the evidence to VA/DoD populations was also taken into consideration.  A structured algorithm (see Algorithm) accompanies the guideline to provide an overview of the  recommendations in the context of the flow of patient care and clinician decision making and to assist with  training providers. The algorithm may be used to help facilitate translation of guideline recommendations  into effective practice.

Question: Which factors were considered for the framework for recommendations in this CPG?
Answer: balancing desired outcomes with potential harms of treatment, equity of resource availability,  the potential for variation in patient values and preferences, and other considerations
Features and overview

The current document is an update to the 2010 VA/DoD Clinical Practice Guideline for the Management of  Opioid Therapy for Chronic Pain. The methodology used in developing the 2017 CPG follows the VA/DoD  Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG. The VA/DoD Guideline for  Guidelines can be downloaded from http://www.healthquality.va.gov/policy/index.asp. This document  provides information regarding the process of developing guidelines, including the identification and  assembly of the Guideline Champions (“Champions”) and other subject matter experts from within the VA  and DoD, known as the “Work Group,” and ultimately, the development and submission of an updated OT  CPG. The VA Office of Quality, Safety and Value, in collaboration with the Office of Evidence Based  Practice, U.S. Army Medical Command, the proponent for CPGs for the DoD, identified two clinical leaders, Jack Rosenberg, MD, FASAM from the VA and Christopher Spevak, MD, MPH, JD from the DoD, as  Champions for the 2017 CPG.

Question: What methodology was used in developing the 2017 CPG?
Answer: the VA/DoD  Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG

Question: What does the VA/DoD Guideline for Guidelines provide?
Answer: information regarding the process of developing guidelines, including the identification and  assembly of the Guideline Champions (“Champions”) and other subject matter experts from within the VA  and DoD, known as the “Work Group,” and ultimately, the development and submission of an updated OT  CPG
Features and overview

VA/DoD CPGs encourage clinicians to use a patient-centered care approach that is tailored to the patient’s  capabilities, needs, goals, prior treatment experience, and preferences. Regardless of setting, all patients in  the healthcare system should be offered access to evidence-based interventions appropriate to that  patient. When properly executed, patient-centered care may decrease patient anxiety, increase trust in  clinicians,[77] and improve treatment adherence.[78] Improved patient-clinician communication through  patient-centered care can be used to convey openness to discuss any future concerns.

Question: What does VA/DoD CPGs encourage clinicians to do?
Answer: to use a patient-centered care approach that is tailored to the patient’s  capabilities, needs, goals, prior treatment experience, and preferences

Question: What should all patients in the healthcare system be offered?
Answer: access to evidence-based interventions appropriate to that  patient

Question: What is the purpose of patient-centered care?
Answer: decrease patient anxiety, increase trust in  clinicians,[77] and improve treatment adherence

Question: What can be used to convey openness to discuss any future concerns?
Answer: Improved patient-clinician communication through  patient-centered care