Lornng/cpgQA huggingface dataset:
Recommendations

Given the recognized risks of opioid therapy, an optimal approach to care should include a robust,  signature informed consent process that is patient-centered and provides patients with information about  known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for  signature informed consent, consistent with VA policy for other treatments or procedures with a  significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety  and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found  at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012).

Question: Why should an optimal approach to care should include a robust,  signature informed consent process?
Answer: Given the recognized risks of opioid therapy

Question: Given the recognized risks of opioid therapy, what should be included in an optimal approach to care?
Answer: a robust,  signature informed consent process that is patient-centered and provides patients with information about  known benefits and harms of OT and treatment alternatives

Question: Given the recognized risks of opioid therapy, what should include a robust,  signature informed consent process?
Answer: an optimal approach to care

Question: What did VA establish in 2014 regarding OT and treatment alternatives?
Answer: a requirement for  signature informed consent, consistent with VA policy for other treatments or procedures with a  significant risk of complications or morbidity
Recommendations

Patients may decline offered treatments (e.g., OT) and may also decline risk mitigation strategies (e.g.,  UDT, pill counts) that are recommended in the course of clinical care. However, providers should discuss  this decision with the patient, including the likelihood that their decision may result in the risks of LOT  outweighing its potential benefits. This would require a consideration of patient’s safety, and a clinical  decision may be made not to initiate OT or to discontinue ongoing OT through tapering (see  Recommendation 14 and Recommendation 17).

Question: What may patients decline?
Answer: offered treatments (e.g., OT) and may also decline risk mitigation strategies (e.g.,  UDT, pill counts) that are recommended in the course of clinical care
Recommendations

State database queries for detection of multi-sourcing of controlled substances are used throughout the  country. Data comparing states with an implemented state database program to states without one  showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly  checks of the state database system.[33]

Question: What are used throughout the country for detection of multi-sourcing of controlled substances?
Answer: State database queries

Question: For what purpose state database queries are used throughout the country?
Answer: detection of multi-sourcing of controlled substances

Question: According to CDC, how often the state database system needs to be checked?
Answer: at least quarterly

Question: Who recommends at least quarterly checks of the state database system?
Answer: The CDC

Question: According to CDC, what needs to be checked at least quarterly?
Answer: the state database system
Recommendations

As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory  testing is used as an additional method of examining for patient substance misuse and adherence to the  prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT.  Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry  [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a  UDT and confirmatory results requires education and knowledge of the local procedures and clinical  scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for  SUD treatment or is engaged in on-going treatment there should be close communication between the  SUD and pain management providers. The ideal approach is an interdisciplinary format (see  Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.

Question: Why is UDT and confirmatory testing used as an additional method of examining for patient substance misuse and adherence to the  prescribed regimen?
Answer: As substance misuse in patients on LOT is more than 30% in some series

Question: What do UDTs do when used appropriately?
Answer: help to address safety, fairness, and trust with OT

Question: What is critical due to the false positive and negative rates associated with UDTs?
Answer: Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry  [GCMS])

Question: Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry  [GCMS]) is critical due to what?
Answer: the false positive and negative rates associated with UDTs

Question: What does require education and knowledge of the local procedures and clinical  scenario?
Answer: Interpretation of a  UDT and confirmatory results

Question: What is required by the interpretation of a UDT and confirmatory results?
Answer: education and knowledge of the local procedures and clinical  scenario

Question: What can identify active SUD or possible diversion?
Answer: UDT results

Question: What can UDT results do?
Answer: help identify active SUD or possible diversion

Question: What should clinicians obtain prior to initiating or continuing LOT and periodically thereafter?
Answer: UDT

Question: When should clinicians obtain UDT?
Answer: prior to initiating or continuing LOT and periodically thereafter

Question: What should be done when a patient is referred for  SUD treatment or is engaged in on-going treatment?
Answer: close communication between the  SUD and pain management providers

Question: What is the format of the ideal approach to communicate between the  SUD and pain management providers when a patient is referred for  SUD treatment or is engaged in ongoing treatment?
Answer: interdisciplinary
Recommendations

Naloxone administration has been identified as a life saving measure following opioid overdose. A  systematic review of 22 observational studies provided moderate quality evidence that take home  naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate  of adverse events.[108] One meta-analysis of nine studies determined that take home naloxone kits were  used approximately nine times within the first three months of follow-up for every 100 individuals  trained.[109] Further, studies have shown that naloxone administration has been efficacious whether  given by medical personnel or lay people, with more than 26,000 reversals documented by the CDC from  1996-2014.[110,111] In addition, prescription of naloxone rescue and accompanying education has also  been found to reduce opioid-related emergency department visits.[112] Distribution of naloxone for  reversal is supported by SAMHSA, the American Medical Association (AMA), and other medical societies,  and is facilitated through the VA via Pharmacy Benefits Management. Clinical efficacy has been established  for its use on short-acting opioids, but not for its use on long-acting opioids such as methadone or  exceptionally potent opioids.[108]

Question: What is a life-saving measure following opioid overdose?
Answer: Naloxone administration

Question: When to administer Naloxone?
Answer: as a life saving measure following opioid overdose

Question: Is there any evidence that take-home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse events?
Answer: A  systematic review of 22 observational studies provided moderate quality evidence

Question: What has reduced opioid-related emergency department visits?
Answer: prescription of naloxone rescue and accompanying education

Question: Who supports the distribution of naloxone for the reversal?
Answer: SAMHSA, the American Medical Association (AMA), and other medical societies

Question: Who facilitates the distribution of naloxone for the reversal?
Answer: the VA via Pharmacy Benefits Management

Question: On which kind of opioids the use of the distribution of naloxone has established clinical efficacy?
Answer: short-acting opioids

Question: On which kind of opioids the use of the distribution of naloxone does not have established clinical efficacy?
Answer: long-acting opioids such as methadone or  exceptionally potent opioids
Recommendations

Synthetic opioids such as fentanyl analogs, potent opioid receptor agonists, are responsible for a recent  rise in death rates. Fentanyl analogs that may be used to create counterfeit opioid analgesic pills can cause  a toxidrome characterized by significant CNS and profound respiratory depression requiring multiple  naloxone doses for reversal.[113]

Question: Which opioids are responsible for a recent rise in death rates?
Answer: Synthetic opioids such as fentanyl analogs, potent opioid receptor agonists

Question: What are some examples of synthetic opioids?
Answer: fentanyl analogs, potent opioid receptor agonists

Question: What can cause a toxidrome?
Answer: Fentanyl analogs that may be used to create counterfeit opioid analgesic pills

Question: What can be caused by fentanyl analogs that may be used to create counterfeit opioid analgesic pills?
Answer: a toxidrome characterized by significant CNS and profound respiratory depression requiring multiple  naloxone doses for reversal
Recommendations

Those patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD may benefit from an  alternative management strategy: close follow-up and CBT. Jamison et al. (2010) randomized patients at  high-risk for OUD (as measured by standard rating scales) to receive either standard pain management or  close follow-up with CBT for pain.[114] Both of these groups were compared to a low-risk, chronic pain  control group receiving standard management. The authors report that, compared to a matched high-risk  group receiving standard care, patients receiving additional monitoring and CBT exhibited significantly  reduced illicit substance use over six months (percentage of patients with positive drug misuse index  scores: 73.7% versus 26.3% versus 25.0%; p<0.01). At six months, there was no difference between the  high-risk group receiving close follow-up and the low-risk group receiving standard therapy. Authors also  reported that pain perception was less in the high-risk group receiving additional monitoring and behavior  therapy; however, analysis of activity interference reporting reflected no significant difference between  study groups.

Question: Who may benefit from an alternative management strategy?
Answer: Those patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD

Question: Patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD may benefit from what?
Answer: an  alternative management strategy: close follow-up and CBT

Question: What is the alternative management strategy that is beneficial for patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD?
Answer: close follow-up and CBT
Recommendations

Take Back Programs: Returning unused opioid medications has been explored as a strategy to reduce the amount of opioids in  the community, as it has been estimated that 70% of opioid prescriptions are left unused.[115]  Accordingly, the National Drug Control Strategy advocates take back programs as an effective tool.[24] For  example, in a 2013 medication take back event in a Michigan community, 3,633 containers containing 345  different prescription medications were collected in four hours. The top five most common medications  collected were pain relievers.[116] System-wide efficacy of a nationwide program is unknown.[117]

Question: What has been explored as a strategy to reduce the amount of opioids in  the community?
Answer: Returning unused opioid medications

Question: What is the ratio of opioid prescriptions that are left unused?
Answer: 70%

Question: Returning unused opioid medications has been explored as a strategy for what?
Answer: to reduce the amount of opioids in  the community

Question: Why has returning unused opioid medications been explored as a strategy to reduce the amount of opioids in  the community?
Answer: it has been estimated that 70% of opioid prescriptions are left unused

Question: Who does advocate take back programs as an effective tool?
Answer: the National Drug Control Strategy

Question: What does the National Drug Control Strategy advocate?
Answer: take back programs

Question: The National Drug Control Strategy advocates take back programs as what?
Answer: an effective tool

Question: In a 2013 medication take back event in a Michigan community, how many containers were collected in four hours?
Answer: 3,633 containers containing 345  different prescription medications

Question: What were the top five most common medications collected in a 2013 medication take back event in a Michigan community?
Answer: pain relievers
Recommendations

We recommend assessing suicide risk when considering initiating or continuing long-term opioid therapy and intervening when necessary. (Strong for | Reviewed, Amended)

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

Opioid medications are potentially lethal and an assessment of current suicide risk should be made at every phase of treatment. The VA/DoD Suicide CPG recommends restricting the availability of lethal means for patients considered to be at intermediate or high acute risk of suicide (determined by presence and severity of suicidal ideation, level of intention to act, existence of risk factors, limited or absent protective factors, etc.). Accordingly, suicidality is considered to be an important risk factor for OT (see Risk  Factors for Adverse Outcomes of Opioid Therapy).

Question: Which medications are lethal?
Answer: Opioid

Question: What should be done at every phase of treatment?
Answer: an assessment of current suicide risk should be made

Question: When should an assessment of current suicide risk be made?
Answer: at every phase of treatment

Question: Who recommends restricting the availability of lethal means for patients considered to be at intermediate or high acute risk of suicide?
Answer: The VA/DoD Suicide CPG

Question: For which patients the VA/DoD Suicide CPG recommends restricting the availability of lethal means?
Answer: patients considered to be at intermediate or high acute risk of suicide (determined by presence and severity of suicidal ideation, level of intention to act, existence of risk factors, limited or absent protective factors, etc.)

Question: How to determine the acuteness of suicide risk in patients?
Answer: presence and severity of suicidal ideation, level of intention to act, existence of risk factors, limited or absent protective factors, etc.

Question: What is considered to be an important risk factor for OT?
Answer: suicidality
Recommendations

A number of studies suggest certain chronic pain conditions represent an independent risk factor for suicide.[123-130] A recent large retrospective cohort study also suggests an association with prescribed opioid dose and suicide risk among Veterans receiving OT for CNCP.[131] Suicide risk is not static, and many factors influence an individual’s risk of suicide at any given point in time, as noted in the VA/DoD  Suicide CPG. Thus, ongoing assessment of suicide risk is important whether one is initiating, maintaining,  or terminating LOT.

Question: Is there any evidence that certain chronic pain conditions represent an independent risk factor for suicide?
Answer: A number of studies suggest

Question: Which represent an independent risk factor for suicide?
Answer: certain chronic pain conditions

Question: What is represented by chronic pain conditions?
Answer: an independent risk factor for suicide

Question: Is there any evidence that suggests an association with prescribed opioid dose and suicide risk among Veterans receiving OT for CNCP?
Answer: A recent large retrospective cohort study

Question: What is associated with prescribed opioid dose?
Answer: suicide risk among Veterans receiving OT for CNCP

Question: What is associated with suicide risk among Veterans receiving OT for CNCP?
Answer: prescribed opioid dose

Question: What is not static?
Answer: Suicide risk

Question: What is influenced by many factors?
Answer: an individual’s risk of suicide at any given point in time

Question: What influence an individual’s risk of suicide at any given point in time?
Answer: many factors

Question: Why is ongoing assessment of suicide risk important whether one is initiating, maintaining,  or terminating LOT?
Answer: Suicide risk is not static, and many factors influence an individual’s risk of suicide at any given point in time, as noted in the VA/DoD  Suicide CPG.

Question: When is it important to assess suicide risk?
Answer: whether one is initiating, maintaining,  or terminating LOT
Recommendations

There is moderate quality evidence that intensification of monitoring helps mitigate the risk of suicide among patients on LOT. Im et al. (2015) found moderate quality evidence that, at the facility level, patients on LOT within facilities ordering more drug screens than the comparison group were associated with decreased risk of suicide attempt (chronic short-acting opioid group: OR: 0.2, 95% CI: 0.1-0.3; chronic long acting opioid group: OR: 0.3, 95% CI: 0.2-0.6). In addition, patients on long-acting opioids within the facilities providing more follow-up after new prescriptions were associated with decreased risk of suicide attempt (OR: 0.2, 95% CI: 0.0-0.7).[61]

Question: Is there any evidence that intensification of monitoring helps mitigate the risk of suicide among patients on LOT?
Answer: There is moderate quality evidence

Question: What does help mitigate the risk of suicide among patients on LOT?
Answer: intensification of monitoring

Question: Intensification of monitoring helps with what?
Answer: mitigate the risk of suicide among patients on LOT

Question: Is there any evidence that, at the facility level, patients on LOT within facilities ordering more drug screens than the comparison group were associated with decreased risk of suicide attempt?
Answer: Im et al. (2015) found moderate quality evidence

Question: What were associated with decreased risk of suicide attempt?
Answer: patients on long-acting opioids within the facilities providing more follow-up after new prescriptions

Question: Patients on long-acting opioids within the facilities providing more follow-up after new prescriptions  were associated with what?
Answer: decreased risk of suicide attempt
Recommendations

Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However,  continuing LOT to “prevent suicide” in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases. In such cases, it is essential to involve behavioral health to assess, monitor, and treat a patient who becomes destabilized as a result of a medically appropriate decision to taper or cease LOT. Further research is needed to identify strategies for safely managing patients at elevated risk of suicide who demand opioid medications or become further destabilized during tapering.

Question: Who may threaten suicide when providers recommend discontinuation of opioids?
Answer: Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders

Question: Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may do what?
Answer: threaten suicide when providers recommend discontinuation of opioid

Question: What is not recommended as an appropriate response if suicide risk is high or increases?
Answer: continuing LOT to “prevent suicide” in someone with chronic pain

Question: When is continuing LOT not recommended?
Answer: to “prevent suicide” in someone with chronic pain

Question: Why is continuing LOT not recommended to “prevent suicide” in someone with chronic pain?
Answer: an appropriate response if suicide risk is high or increases

Question: In which cases it is essential to involve behavioral health to assess, monitor, and treat a patient who becomes destabilized as a result of a medically appropriate decision to taper or cease LOT?
Answer: However,  continuing LOT to “prevent suicide” in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases.

Question: What is essential to do when a patient becomes destabilized as a result of a medically appropriate decision to taper or cease LOT?
Answer: involve behavioral health to assess, monitor, and treat

Question: What is needed to identify strategies for safely managing patients at elevated risk of suicide who demand opioid medications or become further destabilized during tapering?
Answer: Further research

Question: Further research is needed for what?
Answer: to identify strategies for safely managing patients at elevated risk of suicide who demand opioid medications or become further destabilized during tapering
Recommendations

We recommend evaluating benefits of continued opioid therapy and risk for opioid-related adverse events at least every three months. (Strong for | Reviewed, New-replaced)

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