Lornng/cpgQA huggingface dataset:
Features and overview

Short-term oral medications can be utilized to assist with managing the withdrawal symptoms, especially when prescribing fast tapers. Do not treat withdrawal symptoms with an opioid or benzodiazepine. Withdrawal symptoms are not life-threatening and may not be seen with a gradual taper. Early symptoms take hours to days to appear. Early symptoms include anxiety/restlessness, rapid short respirations, runny nose, tearing eyes, sweating, insomnia, and dilated reactive pupils. Late symptoms take days to weeks to appear. Late symptoms include runny nose, tearing eyes, rapid breathing, yawning, tremor, diffuse muscle spasms/aches, piloerection, nausea, vomiting, and diarrhea, abdominal pain, fever, chills, increased white blood cells if sudden withdrawal. Prolonged symptoms take weeks to months to appear. Prolonged symptoms include irritability, fatigue, bradycardia, decreased body temperature, craving, insomnia. Early symptoms generally resolve 5 to 10 days following opioid dose reduction/cessation but may take longer depending on the half-life of the opioid (e.g., methadone). Some symptoms of withdrawal such as dysphoria, insomnia and prolonged craving may take longer. Patients with chronic pain may find that symptoms, such as fatigue, mental functioning, pain, and well-being, improve over time.

Question: What can be utilized to assist with managing the withdrawal symptoms?
Answer: Short-term oral medications

Question: What not to use to treat withdrawal symptoms?
Answer: an opioid or benzodiazepine

Question: When we may not see withdrawal symptoms?
Answer: with a gradual taper

Question: How long does it take for early withdrawal symptoms to appear?
Answer: hours to days

Question: How long does it take for late withdrawal symptoms to appear?
Answer: days to weeks

Question: How long does it take for prolonged withdrawal symptoms to appear?
Answer: weeks to months

Question: What do early symptoms include?
Answer: anxiety/restlessness, rapid short respirations, runny nose, tearing eyes, sweating, insomnia, and dilated reactive pupils

Question: What do late symptoms include?
Answer: runny nose, tearing eyes, rapid breathing, yawning, tremor, diffuse muscle spasms/aches, piloerection, nausea, vomiting, and diarrhea, abdominal pain, fever, chills, increased white blood cells if sudden withdrawal

Question: What do prolonged symptoms include?
Answer: irritability, fatigue, bradycardia, decreased body temperature, craving, insomnia

Question: How long does it take to resolve early symptoms?
Answer: 5 to 10 days following opioid dose reduction/cessation but may take longer depending on the half-life of the opioid (e.g., methadone)

Question: Which symptoms of withdrawal may take longer?
Answer: dysphoria, insomnia

Question: Which withdrawal symptoms in patients with chronic pain may improve over time?
Answer: fatigue, mental functioning, pain, and well-being
Features and overview

The treatment options for anxiety, dysphoria, lacrimation, and rhinorrhea are hydroxyzine 25 to 50 mg three times a day as needed, diphenhydramine 25 mg every 6 hours as needed. Avoid diphenhydramine for Veterans older than 65 years. The treatment options for myalgias are NSAIDs (e.g., naproxen 375 to 500 mg twice daily or ibuprofen 400 to 600 mg four times daily), acetaminophen 650 mg every 6 hours as needed, topical medications like menthol/methylsalicylate cream, lidocaine cream/ointment. For NSAIDs, be cautious for patients with risk of GI bleed, renal compromise, cardiac disease. The treatment option for sleep disturbance is Trazodone 25 to 300 mg orally at bedtime.

Question: What are the treatment options for anxiety, dysphoria, lacrimation, and rhinorrhea?
Answer: hydroxyzine 25 to 50 mg three times a day as needed, diphenhydramine 25 mg every 6 hours as needed

Question: When to avoid diphenhydramine?
Answer: for Veterans older than 65 years

Question: What are the treatment options for myalgias?
Answer: NSAIDs (e.g., naproxen 375 to 500 mg twice daily or ibuprofen 400 to 600 mg four times daily), acetaminophen 650 mg every 6 hours as needed, topical medications like menthol/methylsalicylate cream, lidocaine cream/ointment

Question: For NSAIDs, be cautious for which patients?
Answer: patients with risk of GI bleed, renal compromise, cardiac disease

Question: What is the treatment option for sleep disturbance?
Answer: Trazodone 25 to 300 mg orally at bedtime
Features and overview

The treatment options for nausea are prochlorperazine 5 to 10 mg every 4 hours as needed, promethazine 25 mg orally or rectally every 6 hours as needed, ondansetron 4 mg every 6 hours as needed. The treatment option for abdominal cramping is dicyclomine 20 mg every 6 to 8 hours as needed. The treatment options for diarrhea are loperamide 4 mg orally initially, then 2 mg with each loose stool, not to exceed 16 mg daily; bismuth subsalicylate 524 mg every 0.5 to 1 hour orally, not to exceed 4192 mg/day.

Question: What are the treatment options for nausea?
Answer: prochlorperazine 5 to 10 mg every 4 hours as needed, promethazine 25 mg orally or rectally every 6 hours as needed, ondansetron 4 mg every 6 hours as needed

Question: What is the treatment option for abdominal cramping?
Answer: dicyclomine 20 mg every 6 to 8 hours as needed

Question: What are the treatment options for diarrhea?
Answer: loperamide 4 mg orally initially, then 2 mg with each loose stool, not to exceed 16 mg daily; bismuth subsalicylate 524 mg every 0.5 to 1 hour orally, not to exceed 4192 mg/day
Introductory information

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management.

Question: What are the guidelines based upon?
Answer: the best information available at the time of publication

Question: What are the guidelines designed to do?
Answer: provide information and assist decision making

Question: What is not the intention of the guideline?
Answer: define a standard of care

Question: What should the guidelines not be construed as?
Answer: a standard of care

Question: How should the guideline not be interpreted as?
Answer: as prescribing an exclusive course of management
Introductory information

 This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation.

Question: What is the clinical practice guideline based on?
Answer: a systematic review of both clinical and epidemiological evidence

Question: Who developed the guidelines?
Answer: a panel of multidisciplinary experts

Question: Being developed by a panel of multidisciplinary experts, what does the guideline do?
Answer: provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation
Introductory information

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.

Question: When will the variations in practice inevitably and appropriately occur?
Answer: when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice

Question: Who is responsible for evaluating the appropriateness of applying the guidelines?
Answer: Every healthcare professional making use of these guidelines

Question: Every healthcare professional making use of these guidelines is responsible for what?
Answer: evaluating the appropriateness of applying them in the setting of any particular clinical situation
Introductory information

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor.

Question: What does not guarantee coverage of civilian sector care?
Answer: inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines
Introductory information

The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the “…Health Executive Council on the use of clinical and epidemiological evidence to improve the health of the population across the Veterans Health Administration and Military Health System,” by facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations. This CPG is intended to provide healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with chronic pain who are on or being considered for long-term opioid therapy (LOT).

Question: When was the Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG) was established and first chartered?
Answer: 2004

Question: What is EBPWG?
Answer: Evidence-Based Practice Work Group

Question: What was the mission of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG)?
Answer: to advise the “…Health Executive Council on the use of clinical and epidemiological evidence to improve the health of the population across the Veterans Health Administration and Military Health System,” by facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations

Question: How does the Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work Group (EBPWG) advise the “…Health Executive Council on the use of clinical and epidemiological evidence to improve the health of the population across the Veterans Health Administration and Military Health System,”?
Answer: by facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations

Question: What are CPGs?
Answer: clinical practice guidelines

Question: What does this CPG intend to do?
Answer: provide healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with chronic pain who are on or being considered for long-term opioid therapy (LOT)

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

In 2010, the VA and DoD published the Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain (2010 OT CPG), which was based on evidence reviewed through March 2009. Since the release of that guideline, there has been growing recognition of an epidemic of opioid misuse and opioid use disorder (OUD) in America, including among America’s Veterans. At the same time, there is a mounting body of research expanding detailing the lack of benefit and severe harms of LOT.

Question: When was the Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain published?
Answer: 2010

Question: Who published the Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain (2010 OT CPG)?
Answer: the VA and DoD

Question: What was the basis for the Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain published in 2010?
Answer: evidence reviewed through March 2009

Question: Since when has there been growing recognition of an opioid misuse epidemic, including among America’s Veterans?
Answer: the release of that guideline

Question: Since when has there been growing recognition of opioid use disorder in America, including among America’s Veterans?
Answer: the release of that guideline

Question: Since the release of the Clinical Practice Guideline, what has been growingly recognized?
Answer: an epidemic of opioid misuse and opioid use disorder (OUD) in America, including among America’s Veterans
Introductory information

Consequently, a recommendation to update the 2010 OT CPG was initiated in 2015. The updated CPG, titled Clinical Practice Guideline for Opioid Therapy for Chronic Pain (OT CPG), includes objective, evidence-based information on the management of chronic pain. It is intended to assist healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, and follow-up.

Question: When was a recommendation to update the 2010 OT CPG initiated?
Answer: in 2015

Question: What does the updated CPG include?
Answer: objective, evidence-based information on the management of chronic pain

Question: What is the updated CPG intended for?
Answer: to assist healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, and follow-up
Introductory information

The system-wide goal of this guideline is to improve the patient’s health and well-being by providing evidence-based guidance to providers who are taking care of patients on or being considered for LOT. The expected outcome of successful implementation of this guideline is to assess the patient’s condition, provide education, and determine the best treatment methods in collaboration with the patient and a multidisciplinary care team, optimize the patient’s health outcomes and function and improve quality of life, minimize preventable complications and morbidity, emphasize the use of patient-centered care.

Question: What is the system-wide goal of the updated CPG guideline?
Answer: to improve the patient’s health and well-being by providing evidence-based guidance to providers who are taking care of patients on or being considered for LOT

Question: How does the updated CPG guideline fulfil its system-wide goal to improve the patient’s health and well-being?
Answer: by providing evidence-based guidance to providers who are taking care of patients on or being considered for LOT

Question: What is the expected outcome of successful implementation of this guideline?
Answer: to assess the patient’s condition, provide education, and determine the best treatment methods in collaboration with the patient and a multidisciplinary care team, optimize the patient’s health outcomes and function and improve quality of life, minimize preventable complications and morbidity, emphasize the use of patient-centered care
Introductory information

This guideline can be used in a variety of ways. This guideline can be used by general clinicians or specialists to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice. It can be used to provide specific information to guide a patient encounter, such as looking up the dosing of a medication used less frequently or the meaning of the urine drug testing (UDT) result. The section on tapering and its accompanying appendix can be used to assist in the development of a framework for guiding an individualized, informed discussion when tapering is being considered. Patients can examine the guideline to educate themselves and better understand their care. A health care system can use the CPG to assure that its clinicians and patients have the resources available to compassionately, effectively, and safely evaluate and deliver LOT in a timely, culturally sensitive manner. The guideline can also be used to suggest specific education for identified gaps.

Question: Who can use this guideline?
Answer: general clinicians or specialists

Question: When can this guideline be used?
Answer: to study and consider the latest information on opioid therapy (OT) and how and whether to incorporate that information or recommendations into their practice

Question: What can be used to study and consider the latest information on opioid therapy (OT) by general clinicians or specialists?
Answer: This guideline

Question: How can it guide a patient encounter?
Answer: provide specific information

Question: What specific information can this guideline provide to guide a patient encounter?
Answer: looking up the dosing of a medication used less frequently or the meaning of the urine drug testing (UDT) result

Question: When tapering is being considered, which section in the guideline can be used to assist in the development of a framework for guiding an individualized, informed discussion?
Answer: section on tapering and its accompanying appendix

Question: How can patients examine the guideline?
Answer: to educate themselves and better understand their care

Question: How can a health care system use the CPG?
Answer: to assure that its clinicians and patients have the resources available to compassionately, effectively, and safely evaluate and deliver LOT in a timely, culturally sensitive manner
Introductory information

This guideline is not intended as a standard of care and should not be used as such. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advances and patterns evolve. Today there is variation among state regulations, and this guideline does not cover the variety of ever-changing state regulations that may be pertinent. The ultimate judgement regarding a particular clinical procedure or treatment course must be made by the individual clinician, in light of the patient’s clinical presentation, patient preferences, and the available diagnostic and treatment options. As noted previously, the guideline can assist care 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, in the care for an individual patient.

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

Question: What does this guideline not cover?
Answer: the variety of ever-changing state regulations that may be pertinent

Question: Who must make the ultimate judgement regarding a particular clinical procedure or treatment course?
Answer: the individual clinician

Question: The ultimate judgement regarding a particular clinical procedure or treatment course must be made in light of what?
Answer: the patient’s clinical presentation, patient preferences, and the available diagnostic and treatment options

Question: The use of a CPG must always be considered as what?
Answer: a recommendation, within the context of a provider’s clinical judgment and patient values and preferences, in the care for an individual patient.
Recommendations

The following recommendations were made using a systematic approach considering four domains as per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. These domains include: confidence in the quality of the evidence, balance of desirable and undesirable outcomes (i.e., benefits and harms), patient or provider values and preferences, and other implications, as appropriate (e.g., resource use, equity, acceptability).

Question: What was used to make the recommendations?
Answer: a systematic approach considering four domains as per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach

Question: What is GRADE?
Answer: Grading of Recommendations Assessment, Development and Evaluation

Question: Which four domains were considered to make the recommendations?
Answer: confidence in the quality of the evidence, balance of desirable and undesirable outcomes (i.e., benefits and harms), patient or provider values and preferences, and other implications, as appropriate (e.g., resource use, equity, acceptability)
Recommendations

Given the relevance of all four domains in grading recommendations, the Work Group encountered multiple instances in which confidence in the quality of the evidence was low or very low, while there was marked imbalance of benefits and harms, as well as certain other important considerations arising from the domains of values and preferences and/or other implications. In particular, the harms due to the potential for severe adverse events associated with opioids, particularly overdose and OUD, often far outweigh the potential benefits. As such, in accounting for all four domains, these factors contributed to strong recommendations in multiple instances.

Question: Given the relevance of all four domains in grading recommendations, what did the Work Group encounter?
Answer: multiple instances in which confidence in the quality of the evidence was low or very low, while there was marked imbalance of benefits and harms, as well as certain other important considerations arising from the domains of values and preferences and/or other implications

Question: What often far outweighs the potential benefits?
Answer: the harms due to the potential for severe adverse events associated with opioids, particularly overdose and OUD

Question: What contributed to strong recommendations in multiple instances?
Answer: these factors
Recommendations

We strongly recommend against initiation of long-term opioid therapy for chronic pain. We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. When pharmacologic therapies are used, we recommend non-opioids over opioids. If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. Note: Consideration of opioid therapy beyond 90 days requires reevaluation and discussion with patient of risks and benefits.

Question: What are recommended as alternatives to opioid therapy?
Answer: self-management strategies and other non-pharmacological treatments

Question: Self-management strategies are recommended as alternatives to what?
Answer: opioid therapy

Question: When are non-opioids recommended over opioids?
Answer: When pharmacologic therapies are used

Question: What is recommended when pharmacologic therapies are used?
Answer: non-opioids over opioids

Question: What is the stance regarding the initiation of long-term opioid therapy for chronic pain?
Answer: strongly recommend against

Question: What is recommended if prescribing opioid therapy for patients with chronic pain?
Answer: a short duration

Question: When is a short duration recommended?
Answer: If prescribing opioid therapy for patients with chronic pain

Question: What does require reevaluation and discussion of risks and benefits with patients?
Answer: Consideration of opioid therapy beyond 90 days

Question: Consideration of opioid therapy beyond 90 days requires what?
Answer: reevaluation and discussion with patient of risks and benefits