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Recommendations

There may be some variation in what?

patient values and preferences

There may be some variation in patient values and preferences. Certain patients may appreciate the use of risk mitigation strategies and others may not. Participants in the patient focus group expressed an understanding of why various risk mitigation strategies were used (see Patient Focus Group Methods and Findings).

Recommendations

What does implementing more extensive risk mitigation strategies entail?

an investment of resources

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]

Recommendations

Why may primary care providers require more time with patients?

to allow for shared decision making and treatment planning

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]

Recommendations

What would happen if there were a more frequent follow-up of patients on LOT?

can affect access to care for all empaneled patients

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]

Recommendations

What must VHA providers follow when providing LOT for patients with non-cancer pain?

VHA policy regarding education and signature informed consent

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]

Recommendations

When must VHA providers follow VHA policy regarding education and signature informed consent?

when providing LOT for patients with non-cancer pain

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]

Recommendations

Who must follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain?

VHA providers

Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]

Recommendations

What did the 2010 OT CPG reflect?

prior practice of using opioid treatment (or pain care) agreements

There is a paradigm shift occurring in approaches to ensuring and documenting patient and provider understanding and expectations regarding the risks and benefits of LOT. The 2010 OT CPG reflected prior practice of using opioid treatment (or pain care) agreements. OTAs have been described as coercive rather than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful to the patient-provider relationship.[102-105]

Recommendations

How have OTAs been described in the 2010 OT CPG?

as coercive rather than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful to the patient-provider relationship

There is a paradigm shift occurring in approaches to ensuring and documenting patient and provider understanding and expectations regarding the risks and benefits of LOT. The 2010 OT CPG reflected prior practice of using opioid treatment (or pain care) agreements. OTAs have been described as coercive rather than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful to the patient-provider relationship.[102-105]

Recommendations

Why should an optimal approach to care should include a robust, signature informed consent process?

Given the recognized risks of opioid therapy

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).

Recommendations

Given the recognized risks of opioid therapy, what should be included in an optimal approach to care?

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

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).

Recommendations

Given the recognized risks of opioid therapy, what should include a robust, signature informed consent process?

an optimal approach to care

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).

Recommendations

What did VA establish in 2014 regarding OT and treatment alternatives?

a requirement for signature informed consent, consistent with VA policy for other treatments or procedures with a significant risk of complications or morbidity

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).

Recommendations

What may patients 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

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).

Recommendations

Why is UDT and confirmatory testing used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen?

As substance misuse in patients on LOT is more than 30% in some series

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.

Recommendations

What do UDTs do when used appropriately?

help to address safety, fairness, and trust with OT

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.

Recommendations

What is critical due to the false positive and negative rates associated with UDTs?

Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS])

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.

Recommendations

Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to what?

the false positive and negative rates associated with UDTs

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.

Recommendations

What does require education and knowledge of the local procedures and clinical scenario?

Interpretation of a UDT and confirmatory results

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.

Recommendations

What is required by the interpretation of a UDT and confirmatory results?

education and knowledge of the local procedures and clinical scenario

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.

Recommendations

What can identify active SUD or possible diversion?

UDT results

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.

Recommendations

What can UDT results do?

help identify active SUD or possible diversion

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.

Recommendations

What should clinicians obtain prior to initiating or continuing LOT and periodically thereafter?

UDT

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.

Recommendations

When should clinicians obtain UDT?

prior to initiating or continuing LOT and periodically thereafter

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.

Recommendations

What should be done when a patient is referred for SUD treatment or is engaged in on-going treatment?

close communication between the SUD and pain management providers

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.

Recommendations

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?

interdisciplinary

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.

Recommendations

What is a life-saving measure following opioid overdose?

Naloxone administration

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]

Recommendations

When to administer Naloxone?

as a life saving measure following opioid overdose

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]

Recommendations

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?

A systematic review of 22 observational studies provided moderate quality evidence

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]

Recommendations

What has reduced opioid-related emergency department visits?

prescription of naloxone rescue and accompanying education

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]

Recommendations

Who supports the distribution of naloxone for the reversal?

SAMHSA, the American Medical Association (AMA), and other medical societies

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]

Recommendations

Who facilitates the distribution of naloxone for the reversal?

the VA via Pharmacy Benefits Management

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]

Recommendations

On which kind of opioids the use of the distribution of naloxone has established clinical efficacy?

short-acting opioids

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]

Recommendations

On which kind of opioids the use of the distribution of naloxone does not have established clinical efficacy?

long-acting opioids such as methadone or exceptionally potent opioids

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]

Recommendations

Which opioids are responsible for a recent rise in death rates?

Synthetic opioids such as fentanyl analogs, potent opioid receptor agonists

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]

Recommendations

What are some examples of synthetic opioids?

fentanyl analogs, potent opioid receptor agonists

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]

Recommendations

What can cause a toxidrome?

Fentanyl analogs that may be used to create counterfeit opioid analgesic pills

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]

Recommendations

What can be caused by fentanyl analogs that may be used to create counterfeit opioid analgesic pills?

a toxidrome characterized by significant CNS and profound respiratory depression requiring multiple naloxone doses for reversal

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]

Recommendations

Who may benefit from an alternative management strategy?

Those patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD

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.

Recommendations

Patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD may benefit from what?

an alternative management strategy: close follow-up and CBT

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.

Recommendations

What is the alternative management strategy that is beneficial for patients receiving opioid analgesics who do not meet DSM-5 criteria for OUD?

close follow-up and CBT

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.

Recommendations

What has been explored as a strategy to reduce the amount of opioids in the community?

Returning unused opioid medications

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]

Recommendations

What is the ratio of opioid prescriptions that are left unused?

70%

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]

Recommendations

Returning unused opioid medications has been explored as a strategy for what?

to reduce the amount of opioids in the community

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]

Recommendations

Why has returning unused opioid medications been explored as a strategy to reduce the amount of opioids in the community?

it has been estimated that 70% of opioid prescriptions are left unused

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]

Recommendations

Who does advocate take back programs as an effective tool?

the National Drug Control Strategy

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]

Recommendations

What does the National Drug Control Strategy advocate?

take back programs

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]

Recommendations

The National Drug Control Strategy advocates take back programs as what?

an effective tool

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]

Recommendations

In a 2013 medication take back event in a Michigan community, how many containers were collected in four hours?

3,633 containers containing 345 different prescription medications

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]

Recommendations

What were the top five most common medications collected in a 2013 medication take back event in a Michigan community?

pain relievers

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]

Recommendations

What is the ratio of new users of injectable opioids who had previously used prescription oral opioid pain medication?

80%

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What is accompanied by an increased rate of the human immunodeficiency virus (HIV) and hepatitis infection?

Illicit use of injectable opioids

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What accompanies the illicit use of injectable opioids?

an increased rate of human immunodeficiency virus (HIV) and hepatitis infection

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What has been an effective risk mitigation strategy for reducing high-risk behaviors and infectious disease transmission among injection drug users?

Community-based needle exchange programs

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What is an example of high-risk behaviors?

sharing needles

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

Community-based needle exchange programs have been shown to do what?

be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

For which patients the first recommendation should be for medication assisted treatment (MAT) for OUD?

patients who develop OUD and progress to intravenous drug use

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What is the first recommendation for patients who develop OUD and progress to intravenous drug use?

medication assisted treatment (MAT) for OUD

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

For whom should clinicians consider educating the patient regarding sterile injection techniques and community-based needle exchange programs, if programs are available?

patients who decline MAT for OUD

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What should the clinicians do for patients who decline MAT for OUD?

educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy?

The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of what?

the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy

Community-based Needle Exchange Programs or Syringe Service Programs: Nearly 80% of new users of injectable opioids had previously used prescription oral opioid pain medication.[118,119] Illicit use of injectable opioids is accompanied by an increased rate of human immunodeficiency virus (HIV) and hepatitis infection. Community-based needle exchange programs have been shown to be an effective risk mitigation strategy for reducing high-risk behaviors (e.g., sharing needles) and infectious disease transmission among injection drug users.[120] For those patients who develop OUD and progress to intravenous drug use, the first recommendation should be for medication assisted treatment (MAT) for OUD (see Recommendation 17). For patients who decline MAT for OUD, clinicians should consider educating the patient regarding sterile injection techniques and community based needle exchange programs, if programs are available. The 2015 outbreak of HIV/hepatitis in rural Indiana and subsequent successful implementation of a needle exchange program is an example of the threat to rural communities from non-prescription opioid use and the potential benefits of needle exchange programs for use as a risk mitigation strategy.[121,122]

Recommendations

What is recommended when considering initiating or continuing long-term opioid therapy?

assessing suicide risk

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

Recommendations

Which medications are lethal?

Opioid

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).

Recommendations

What should be done at every phase of treatment?

an assessment of current suicide risk should be made

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).

Recommendations

When should an assessment of current suicide risk be made?

at every phase of treatment

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).

Recommendations

Who recommends restricting the availability of lethal means for patients considered to be at intermediate or high acute risk of suicide?

The VA/DoD Suicide CPG

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).

Recommendations

For which patients the VA/DoD Suicide CPG recommends restricting the availability of lethal means?

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.)

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).

Recommendations

How to determine the acuteness of suicide risk in patients?

presence and severity of suicidal ideation, level of intention to act, existence of risk factors, limited or absent protective factors, etc.

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).

Recommendations

What is considered to be an important risk factor for OT?

suicidality

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).

Recommendations

Is there any evidence that intensification of monitoring helps mitigate the risk of suicide among patients on LOT?

There is moderate quality evidence

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]

Recommendations

What does help mitigate the risk of suicide among patients on LOT?

intensification of monitoring

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]

Recommendations

Intensification of monitoring helps with what?

mitigate the risk of suicide among patients on LOT

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]

Recommendations

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?

Im et al. (2015) found moderate quality evidence

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]

Recommendations

What were associated with decreased risk of suicide attempt?

patients on long-acting opioids within the facilities providing more follow-up after new prescriptions

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]

Recommendations

Patients on long-acting opioids within the facilities providing more follow-up after new prescriptions were associated with what?

decreased risk of suicide attempt

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]

Recommendations

Who may threaten suicide when providers recommend discontinuation of opioids?

Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders

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.

Recommendations

Some patients on LOT who suffer from chronic pain and co-occurring OUD, depression, and/or personality disorders may do what?

threaten suicide when providers recommend discontinuation of opioid

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.

Recommendations

What is not recommended as an appropriate response if suicide risk is high or increases?

continuing LOT to “prevent suicide” in someone with chronic pain

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.

Recommendations

When is continuing LOT not recommended?

to “prevent suicide” in someone with chronic pain

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.

Recommendations

Why is continuing LOT not recommended to “prevent suicide” in someone with chronic pain?

an appropriate response if suicide risk is high or increases

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.

Recommendations

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?

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.

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.

Recommendations

What is essential to do when a patient becomes destabilized as a result of a medically appropriate decision to taper or cease LOT?

involve behavioral health to assess, monitor, and treat

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.

Recommendations

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?

Further research

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.

Recommendations

Further research is needed for what?

to identify strategies for safely managing patients at elevated risk of suicide who demand opioid medications or become further destabilized during tapering

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.

Recommendations

How often is it recommended to evaluate the benefits of continued opioid therapy and the risk for opioid-related adverse events?

at least every three months

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)

Recommendations

What to do before initiating OT?

an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed

Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months or more frequently (see Recommendation 7 and Recommendation 11) due to the balance of benefits and harms associated with this recommendation. Although the 2010 OT CPG recommended follow-up every six months, this recommended interval for follow-up and reassessment has not been sufficient to reduce the potential harm associated with LOT or adequately implement comprehensive biopsychosocial pain care. More frequent follow-up is needed in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care. Frequency of visits should thereafter be based on risk stratification. Similarly, the CDC guideline for OT recommends re-evaluating harms versus benefits within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed.[132]

Recommendations

What to do after initiating OT?

frequent visits contribute to the appropriate use and adjustment of the planned therapy

Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months or more frequently (see Recommendation 7 and Recommendation 11) due to the balance of benefits and harms associated with this recommendation. Although the 2010 OT CPG recommended follow-up every six months, this recommended interval for follow-up and reassessment has not been sufficient to reduce the potential harm associated with LOT or adequately implement comprehensive biopsychosocial pain care. More frequent follow-up is needed in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care. Frequency of visits should thereafter be based on risk stratification. Similarly, the CDC guideline for OT recommends re-evaluating harms versus benefits within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed.[132]

Recommendations

When to follow up?

at least every three months or more frequently

Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months or more frequently (see Recommendation 7 and Recommendation 11) due to the balance of benefits and harms associated with this recommendation. Although the 2010 OT CPG recommended follow-up every six months, this recommended interval for follow-up and reassessment has not been sufficient to reduce the potential harm associated with LOT or adequately implement comprehensive biopsychosocial pain care. More frequent follow-up is needed in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care. Frequency of visits should thereafter be based on risk stratification. Similarly, the CDC guideline for OT recommends re-evaluating harms versus benefits within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed.[132]

Recommendations

Why follow up at least every three months or more frequently?

due to the balance of benefits and harms

Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months or more frequently (see Recommendation 7 and Recommendation 11) due to the balance of benefits and harms associated with this recommendation. Although the 2010 OT CPG recommended follow-up every six months, this recommended interval for follow-up and reassessment has not been sufficient to reduce the potential harm associated with LOT or adequately implement comprehensive biopsychosocial pain care. More frequent follow-up is needed in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care. Frequency of visits should thereafter be based on risk stratification. Similarly, the CDC guideline for OT recommends re-evaluating harms versus benefits within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed.[132]

Recommendations

Why is frequent follow-up needed?

in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care

Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months or more frequently (see Recommendation 7 and Recommendation 11) due to the balance of benefits and harms associated with this recommendation. Although the 2010 OT CPG recommended follow-up every six months, this recommended interval for follow-up and reassessment has not been sufficient to reduce the potential harm associated with LOT or adequately implement comprehensive biopsychosocial pain care. More frequent follow-up is needed in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care. Frequency of visits should thereafter be based on risk stratification. Similarly, the CDC guideline for OT recommends re-evaluating harms versus benefits within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed.[132]

Recommendations

How to decide the frequency of follow-up visits?

based on risk stratification

Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months or more frequently (see Recommendation 7 and Recommendation 11) due to the balance of benefits and harms associated with this recommendation. Although the 2010 OT CPG recommended follow-up every six months, this recommended interval for follow-up and reassessment has not been sufficient to reduce the potential harm associated with LOT or adequately implement comprehensive biopsychosocial pain care. More frequent follow-up is needed in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care. Frequency of visits should thereafter be based on risk stratification. Similarly, the CDC guideline for OT recommends re-evaluating harms versus benefits within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed.[132]

Recommendations

How frequently should the harms versus benefits be re-evaluated according to the CDC guideline?

within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed

Prior to initiating OT, an individualized assessment of potential opioid-related harms relative to realistic treatment goals must be completed. After initiating OT, frequent visits contribute to the appropriate use and adjustment of the planned therapy. The Work Group recommends follow-up at least every three months or more frequently (see Recommendation 7 and Recommendation 11) due to the balance of benefits and harms associated with this recommendation. Although the 2010 OT CPG recommended follow-up every six months, this recommended interval for follow-up and reassessment has not been sufficient to reduce the potential harm associated with LOT or adequately implement comprehensive biopsychosocial pain care. More frequent follow-up is needed in order to increase the impact of risk mitigation strategies and enhance the delivery of comprehensive, biopsychosocial pain care. Frequency of visits should thereafter be based on risk stratification. Similarly, the CDC guideline for OT recommends re-evaluating harms versus benefits within one to four weeks of starting OT or at any dose change, and at least every three months or more frequently if needed.[132]

Recommendations

What to do at follow-up visits?

a clinician should re-examine the rationale for continuing the patient on OT

At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and lab abnormalities may change the risk/benefit calculus for LOT. Ongoing OT prescribing practice may include pharmacy review, informed consent, UDTs, and checking state PDMPs. A clinician should also be mindful of signs of diversion during follow-up (see Risk Factors for Adverse Outcomes of Opioid Therapy). The longer the patient is on opioids, the greater the potential for change in patient status and development of opioid-related harms.

Recommendations

What to consider at the time of re-examining at a follow-up visit?

changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT

At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and lab abnormalities may change the risk/benefit calculus for LOT. Ongoing OT prescribing practice may include pharmacy review, informed consent, UDTs, and checking state PDMPs. A clinician should also be mindful of signs of diversion during follow-up (see Risk Factors for Adverse Outcomes of Opioid Therapy). The longer the patient is on opioids, the greater the potential for change in patient status and development of opioid-related harms.

Recommendations

What may change the risk/benefit calculus for LOT?

Alcohol use, pregnancy, nursing of infants, and lab abnormalities

At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and lab abnormalities may change the risk/benefit calculus for LOT. Ongoing OT prescribing practice may include pharmacy review, informed consent, UDTs, and checking state PDMPs. A clinician should also be mindful of signs of diversion during follow-up (see Risk Factors for Adverse Outcomes of Opioid Therapy). The longer the patient is on opioids, the greater the potential for change in patient status and development of opioid-related harms.

Recommendations

What is included in the ongoing OT prescribing practice?

pharmacy review, informed consent, UDTs, and checking state PDMPs

At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and lab abnormalities may change the risk/benefit calculus for LOT. Ongoing OT prescribing practice may include pharmacy review, informed consent, UDTs, and checking state PDMPs. A clinician should also be mindful of signs of diversion during follow-up (see Risk Factors for Adverse Outcomes of Opioid Therapy). The longer the patient is on opioids, the greater the potential for change in patient status and development of opioid-related harms.

Recommendations

What to be aware of during follow-ups?

signs of diversion

At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and lab abnormalities may change the risk/benefit calculus for LOT. Ongoing OT prescribing practice may include pharmacy review, informed consent, UDTs, and checking state PDMPs. A clinician should also be mindful of signs of diversion during follow-up (see Risk Factors for Adverse Outcomes of Opioid Therapy). The longer the patient is on opioids, the greater the potential for change in patient status and development of opioid-related harms.

Recommendations

What is the relationship between the length of OT and opioid-related harms?

The longer the patient is on opioids, the greater the potential for change in patient status and development of opioid-related harms.

At follow-up visits, a clinician should re-examine the rationale for continuing the patient on OT. Clinicians should take into account changes in co-occurring conditions, diagnoses/medications, and functional status when conducting the risk/benefit analysis for LOT. Alcohol use, pregnancy, nursing of infants, and lab abnormalities may change the risk/benefit calculus for LOT. Ongoing OT prescribing practice may include pharmacy review, informed consent, UDTs, and checking state PDMPs. A clinician should also be mindful of signs of diversion during follow-up (see Risk Factors for Adverse Outcomes of Opioid Therapy). The longer the patient is on opioids, the greater the potential for change in patient status and development of opioid-related harms.

Recommendations

What is the recommended dose of opioids?

the lowest dose of opioids as indicated by patient-specific risks and benefits

If prescribing opioids, we recommend prescribing the lowest dose of opioids as indicated by patient-specific risks and benefits. (Strong for | Reviewed, New-replaced) Note: There is no absolutely safe dose of opioids. As opioid dosage and risk increase, we recommend more frequent monitoring for adverse events including opioid use disorder and overdose. Risks for opioid use disorder start at any dose and increase in a dose-dependent manner. • Risks for overdose and death significantly increase at a range of 20-50 mg morphine equivalent daily dose. (Strong for | Reviewed, New- replaced) We recommend against opioid doses over 90 mg morphine equivalent daily dose for treating chronic pain. (Strong against | Reviewed, New-replaced) Note: For patients who are currently prescribed doses over 90 mg morphine equivalent daily dose, evaluate for tapering to reduced dose or to discontinuation (see Recommendations 14 and 15).