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Background information
611
Define chronic pain according to the VA/DoD CPG.
pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization.
27
Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.
Background information
612
Which areas in the CNS are involved in the acute and subacute pain?
primarily nociceptive processing areas
223
Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.
Background information
613
What is CNS?
central nervous system
106
Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.
Background information
614
Which areas in the CNS are involved in the chronic pain?
chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.
274
Chronic pain is defined as pain lasting three months or more. It is often associated with changes in the central nervous system (CNS) known as central sensitization. Whereas acute and subacute pain are thought to involve primarily nociceptive processing areas in the CNS, chronic pain is thought to be associated with alterations in brain centers involved with emotions, reward, and executive function as well as central sensitization of nociceptive pathways across several CNS areas.
Background information
615
What are the causes of chronic pain?
Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.
39
There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.
Background information
616
Which pain can lead to well-localized nociceptive mechanism pain?
Pain arising from persistent peripheral stimulation
39
There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.
Background information
617
Which pain could be mechanical or chemical/inflammatory in nature?
Pain arising from persistent peripheral stimulation
39
There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.
Background information
618
Which pain may produce a less localized pain?
Mechanical or inflammatory pain with a visceral origin
211
There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.
Background information
619
Which pain may lead to poorly localized symptoms?
Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy)
302
There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.
Background information
620
What are some examples of poorly localized symptoms?
diffuse pain, burning, numbness, or a feeling of skin sensitivity
498
There are many causes of chronic pain. Pain arising from persistent peripheral stimulation could be mechanical or chemical/inflammatory in nature typically leading to well-localized nociceptive mechanism pain. Mechanical or inflammatory pain with a visceral origin may produce a less localized pain. Neuropathic pain due to injury or disease of the central or peripheral nervous system (e.g., spinal cord injury, diabetic neuropathy, radiculopathy) may lead to poorly localized symptoms such as diffuse pain, burning, numbness, or a feeling of skin sensitivity.
Background information
621
What does a comprehensive pain assessment include?
a biopsychosocial interview and focused physical exam
41
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
622
What are the elements of the biopsychosocial pain interview?
a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment
151
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
623
What may be experienced by the patients with chronic pain?
worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships
516
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
624
What can be associated with pain severity and the presence of psychiatric comorbidities?
Worsening of some of these factors (e.g., quality of life, change in employment status)
664
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
625
Who report psychological complaints more often?
Patients with chronic pain
468
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
626
What is reported more often by the patients with chronic pain than patients without chronic pain?
psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning)
882
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
627
What are some examples of psychological complaints made by patients with chronic pain?
depression, anxiety, poor self-efficacy, poor general emotional functioning
915
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
628
What are some examples of social and psychological consequences on account of chronic pain?
decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain
1,108
A comprehensive pain assessment includes a biopsychosocial interview and focused physical exam. Elements of the biopsychosocial pain interview include a pain-related history, assessment of pertinent medical and psychiatric comorbidities including personal and family history of SUD, functional status and functional goals, coping strategies, and a variety of psychosocial factors such as the patient’s beliefs and expectations about chronic pain and its treatment. Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships. Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities. Patients with chronic pain report psychological complaints (e.g., depression, anxiety, poor self-efficacy, poor general emotional functioning) more often than patients without chronic pain. Further, there can be social and psychological consequences such as decreased ability to successfully maintain relationship and career roles and increased depression, fear, and anxiety as a result of pain.
Background information
640
What was the increment of the prevalence of opioid prescriptions among Veterans from fiscal years 2004 to 2012?
from 18.9% to 33.4%, an increase of 76.7%
96
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
641
Which groups had the highest prevalence of opioid use?
women and young adults (i.e., 18-34 years old)
198
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
642
In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, how many reported chronic pain?
44%
379
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
643
In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, how many reported using opioids?
15%
410
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
644
In Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans, chronic pain was associated with what?
poorer physical function, independent of comorbid mental health concerns
531
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
645
In a study of Veterans with chronic pain who had been on opioids for at least 90 days, how many continued to use opioids one year later?
over 90%
766
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
646
In a study of Veterans with chronic pain who had been on opioids for at least 90 days, how many continued to use opioids after completion of the 3.5 year follow-up period?
nearly 80%
819
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
647
In a study of civilian patients who had been on opioids for at least 90 days, how many remained on opioids through the 4.8 year follow-up period?
approximately 65%
992
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
648
Based on the study, which factors influence the rates of opioid-use continuation in Veterans?
age, marital status, race, geography, mental health comorbidity, and dosage
1,151
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
649
Depending on age, marital status, race, and living conditions, who were more likely to continue using opioids?
those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting
1,249
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
650
Among the Veterans, who were more likely to continue their opioid use?
Veterans on higher doses of opioids
1,418
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
651
Among the Veterans, who were less likely to continue their opioid use?
those with mental health diagnoses
1,504
From fiscal years 2004 to 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%, an increase of 76.7%. The groups with the highest prevalence of opioid use were women and young adults (i.e., 18-34 years old). In a sample of non-treatment-seeking members of the military who were interviewed within three months of returning from Afghanistan, 44% reported chronic pain and 15% reported using opioids—percentages much higher than in the general population. Chronic pain was also associated with poorer physical function, independent of comorbid mental health concerns in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. In a study of Veterans with chronic pain who had been on opioids for at least 90 days, over 90% continued to use opioids one year later and nearly 80% continued to use opioids after completion of the 3.5 year follow-up period; while, in a study of civilian patients who had been on opioids for at least 90 days, approximately 65% remained on opioids through the 4.8 year follow-up period. Rates of continuation in Veterans, based on this study, appeared to be related to age, marital status, race, geography, mental health comorbidity, and dosage. Compared to others, those who were aged 50-65 years, were married, were of a race other than African American, and who lived in a rural setting were more likely to continue using opioids. Veterans on higher doses of opioids were more likely to continue their use. Notably, those with mental health diagnoses were less likely to continue opioids, including those with schizophrenia and bipolar diagnoses.
Background information
652
Who may have different needs or respond to treatment differently than individuals with chronic pain alone?
Individuals with conditions that result in or co-occur with chronic pain
0
Individuals with conditions that result in or co-occur with chronic pain may have different needs or respond to treatment differently than individuals with chronic pain alone. Many different physical and psychological conditions have a pain component that can be difficult to distinguish from the underlying mechanism of illness. Furthermore, the treatment of co-occurring pain and other conditions may vary or require special considerations during their management. Readers are encouraged to consult other VA/DoD CPGs for further information (see VA/DoD Clinical Practice Guidelines website: www.healthquality.va.gov).
Background information
653
What can be difficult to distinguish from the underlying mechanism of illness?
Many different physical and psychological conditions have a pain component
176
Individuals with conditions that result in or co-occur with chronic pain may have different needs or respond to treatment differently than individuals with chronic pain alone. Many different physical and psychological conditions have a pain component that can be difficult to distinguish from the underlying mechanism of illness. Furthermore, the treatment of co-occurring pain and other conditions may vary or require special considerations during their management. Readers are encouraged to consult other VA/DoD CPGs for further information (see VA/DoD Clinical Practice Guidelines website: www.healthquality.va.gov).
Background information
659
Which conditions significantly increase the risk of adverse outcomes from LOT?
Duration and dose of OT, Severe respiratory instability or sleep disordered breathing, Acute psychiatric instability or intermediate to high acute suicide risk, Mental health disorders, History of drug overdose, Under 30 years of age, Co-administration of a drug capable of inducing fatal drug-drug interactions, QTc interval >450 ms for using methadone, Evidence for or history of diversion of controlled substances, Intolerance, serious adverse effects, or a history of inadequate beneficial response to opioids, Impaired bowel motility unresponsive to therapy, Headache not responsive to other pain treatment modalities, Traumatic brain injury (TBI), True allergy to opioid agents
81
Conditions that significantly increase the risk of adverse outcomes from LOT are Duration and dose of OT, Severe respiratory instability or sleep disordered breathing, Acute psychiatric instability or intermediate to high acute suicide risk, Mental health disorders, History of drug overdose, Under 30 years of age, Co-administration of a drug capable of inducing fatal drug-drug interactions, QTc interval >450 ms for using methadone, Evidence for or history of diversion of controlled substances, Intolerance, serious adverse effects, or a history of inadequate beneficial response to opioids, Impaired bowel motility unresponsive to therapy, Headache not responsive to other pain treatment modalities, Traumatic brain injury (TBI), True allergy to opioid agents.
Background information
660
What does include severe respiratory instability or sleep disordered breathing?
any co-occurring condition that significantly affects respiratory rate or function such as chronic obstructive pulmonary disease (COPD), asthma, pneumonia, sleep apnea, or a neuromuscular condition (e.g., amyotrophic lateral sclerosis)
224
Duration and dose of OT: See Recommendation 2 for more guidance on duration of OT and Recommendations 10-12 for more guidance on dosing of OT. Severe respiratory instability or sleep disordered breathing: This would include any co-occurring condition that significantly affects respiratory rate or function such as chronic obstructive pulmonary disease (COPD), asthma, pneumonia, sleep apnea, or a neuromuscular condition (e.g., amyotrophic lateral sclerosis). Two large observational studies of patients with a history of COPD and sleep apnea who were prescribed opioids showed a weak but positive association with opioid-related toxicity/overdose and overdose-related death.[58,59]
Background information
661
Who showed a weak but positive association with opioid-related toxicity/overdose and overdose-related death?
Two large observational studies of patients with a history of COPD and sleep apnea who were prescribed opioids
461
Duration and dose of OT: See Recommendation 2 for more guidance on duration of OT and Recommendations 10-12 for more guidance on dosing of OT. Severe respiratory instability or sleep disordered breathing: This would include any co-occurring condition that significantly affects respiratory rate or function such as chronic obstructive pulmonary disease (COPD), asthma, pneumonia, sleep apnea, or a neuromuscular condition (e.g., amyotrophic lateral sclerosis). Two large observational studies of patients with a history of COPD and sleep apnea who were prescribed opioids showed a weak but positive association with opioid-related toxicity/overdose and overdose-related death.[58,59]
Background information
662
What does preclude the safe use of self-administered LOT?
Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder
74
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
663
What was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids?
a diagnosis of a mood disorder
285
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
664
In a study of patients on opioids, who had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder?
those with bipolar disorder
551
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
665
What are the odds of suicidal ideation within the past 12 months in those with bipolar disorder compared to those with no bipolar disorder?
2.9 times
583
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
666
What are the odds of a lifetime suicide attempt in those with bipolar disorder compared to those with no bipolar disorder?
3.2 times
660
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
667
Where can more information on suicidality be found?
the VA/DoD Suicide CPG
784
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
668
Where can more information on bipolar disorder be found?
the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG)
849
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
669
What was associated with depressed mood?
high dose chronic opioid therapy for pain
1,028
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
670
Which treatment for chronic pain may have benefits in treating depression, PTSD, and in reducing suicide risk?
Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain
1,110
Acute psychiatric instability or intermediate to high acute suicide risk: Intermediate to high acute suicide risk, severe depression, unstable bipolar disorder, or unstable psychotic disorder precludes the safe use of self-administered LOT.[60] Im et al. (2015) (n=487,462) found that a diagnosis of a mood disorder was significantly associated with suicide attempts for the chronic use of short-acting and long-acting opioids compared with no diagnosis of a mood disorder.[61] In a study of patients on opioids, Campbell et al. (2015) reported that those with bipolar disorder had 2.9 times the odds of suicidal ideation within the past 12 months as well as 3.2 times the odds of a lifetime suicide attempt compared to those with no bipolar disorder.[62] See Recommendation 8 and the VA/DoD Suicide CPG2 for more information on suicidality. See the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (VA/DoD BD CPG) for more information on bipolar disorder.3 Merrill and colleagues found that high dose chronic opioid therapy for pain was associated with depressed mood.[63] Treatment for chronic pain with movement, exercise, and cognitive-behavioral therapy for pain may have benefits in treating depression, PTSD, and in reducing suicide risk.[64]
Background information
671
What can signal an emerging SUD as well as diversion?
Frequent requests for early refills or atypically large quantities required to control pain
139
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
672
What can be signalled by frequent requests for early refills required to control pain?
an emerging SUD as well as diversion
242
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
673
What can be signalled by frequent requests for atypically large quantities required to control pain?
an emerging SUD as well as diversion
242
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
674
Among patients being treated by the VHA system that received opioids, what was significantly associated with opioid-related toxicity/overdose compared to no history of depression?
a history of depression
518
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
675
Among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with what?
opioid-related toxicity/overdose
577
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
676
What has been associated with worsening depressive symptoms?
LOT
653
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
677
LOT has been associated with what kinds of symptoms?
worsening depressive symptoms
682
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
678
Among patients on OT, a prevalence of self inflicted injuries was significantly higher among which patients?
patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses
883
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
679
Among patients on OT, what was significantly higher among patients with a history of PTSD as compared to patients with other (or no) mental health diagnoses?
a prevalence of self inflicted injuries
812
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
680
Where can more information be found on PTSD?
VA/DoD PTSD CPG
1,067
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
681
What is a red flag in the presence of which providers should proceed with utmost caution when considering LOT for these patients?
A history of overdose
1,111
Current or history of SUD: For patients with untreated SUD, see Recommendation 4. For patients with diagnosed OUD, see Recommendation 17. Frequent requests for early refills or atypically large quantities required to control pain can signal an emerging SUD as well as diversion (see Evidence for or history of diversion of controlled substances). See the VA/DoD SUD CPG.4 Depression or history of depression: Zedler et al. (2014) reported that among patients being treated by the VHA system that received opioids, a history of depression was significantly associated with opioid-related toxicity/overdose compared to no history of depression.[58] LOT has been associated with worsening depressive symptoms.[63] See the VA/DoD MDD CPG.5 PTSD: Seal et al. (2012) (n=15,676) noted that among patients on OT, a prevalence of self inflicted injuries was significantly higher among patients with a history of PTSD (with or without other mental health diagnoses) as compared to patients with other (or no) mental health diagnoses.[65] For more information, see the VA/DoD PTSD CPG.6 History of drug overdose: A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients. Under 30 years of age: See Recommendation 6.
Background information
682
What should providers carefully rule out and avoid?
potential drug interactions prior to initiating LOT
124
Co-administration of a drug capable of inducing fatal drug-drug interactions: Providers should carefully rule out and avoid potential drug interactions prior to initiating LOT. For example, the following combinations are dangerous:[66] i)Opioids with benzodiazepines (compared to patients with no prescription, the odds ratio [OR] and 95% confidence interval [CI] for drug-related death was OR: 14.92, 95% CI: 7.00- 31.77 for patients who filled a prescription for opioids and benzodiazepines; OR: 3.40, 95% CI: 1.60-7.21 for patients who filled only an opioid prescription, and 7.21, 95% CI: 3.33-15.60 for patients who filled only a benzodiazepine prescription) (see Recommendation 5) [66,67], ii)Fentanyl with CYP3A4 inhibitors, iii) Methadone with drugs that can prolong the QT interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) (e.g., CYP450 2B6 inhibitors)
Background information
683
What combinations of drugs are dangerous?
i)Opioids with benzodiazepines (compared to patients with no prescription, the odds ratio [OR] and 95% confidence interval [CI] for drug-related death was OR: 14.92, 95% CI: 7.00- 31.77 for patients who filled a prescription for opioids and benzodiazepines; OR: 3.40, 95% CI: 1.60-7.21 for patients who filled only an opioid prescription, and 7.21, 95% CI: 3.33-15.60 for patients who filled only a benzodiazepine prescription) (see Recommendation 5) [66,67], ii)Fentanyl with CYP3A4 inhibitors, iii) Methadone with drugs that can prolong the QT interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) (e.g., CYP450 2B6 inhibitors)
236
Co-administration of a drug capable of inducing fatal drug-drug interactions: Providers should carefully rule out and avoid potential drug interactions prior to initiating LOT. For example, the following combinations are dangerous:[66] i)Opioids with benzodiazepines (compared to patients with no prescription, the odds ratio [OR] and 95% confidence interval [CI] for drug-related death was OR: 14.92, 95% CI: 7.00- 31.77 for patients who filled a prescription for opioids and benzodiazepines; OR: 3.40, 95% CI: 1.60-7.21 for patients who filled only an opioid prescription, and 7.21, 95% CI: 3.33-15.60 for patients who filled only a benzodiazepine prescription) (see Recommendation 5) [66,67], ii)Fentanyl with CYP3A4 inhibitors, iii) Methadone with drugs that can prolong the QT interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) (e.g., CYP450 2B6 inhibitors)
Background information
684
Which opioid has unique pharmacodynamic properties that can prolong the QTc interval and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia?
methadone
31
QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).
Background information
685
What is QTc interval?
the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave
166
QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).
Background information
686
What is torsades de pointes?
a dangerous or fatal cardiac arrhythmia
299
QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).
Background information
687
Which one is a dangerous or fatal cardiac arrhythmia?
torsades de pointes
278
QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).
Background information
688
What unique properties does methadone have?
unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia
97
QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).
Background information
689
Why are ECGs highly advised before and after initiating methadone?
Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope.
340
QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).
Background information
690
Which patients may be at risk?
those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope
376
QTc interval >450 ms for using methadone: Unlike most other commonly used opioids, methadone has unique pharmacodynamic properties that can prolong the QTc interval (the heart rate’s corrected time interval from the start of the Q wave to the end of the T wave) and precipitate torsades de pointes, a dangerous or fatal cardiac arrhythmia. Patients who may be at risk include those with other risk factors for QTc prolongation, current or prior electrocardiograms (ECGs) with a prolonged QTc >450 ms, or a history of syncope. Therefore, ECGs before and after initiating methadone are highly advised (see Methadone Dosing Guidance).
Background information
704
When may serious harm occur in patients?
should patients be prescribed additional (or different) opioids if prior administration of opioids led to serious adverse effects or was not tolerated
120
Intolerance, serious adverse effects, or a history of inadequate beneficial response to opioids: Serious harm may occur should patients be prescribed additional (or different) opioids if prior administration of opioids led to serious adverse effects or was not tolerated. It is also inadvisable to prescribe opioids to patients who already have had an adequate opioid trial (of sufficient dose and duration to determine whether or not it will optimize benefit) without a positive response.
Background information
705
It is inadvisable to prescribe opioids to which patients?
patients who already have had an adequate opioid trial (of sufficient dose and duration to determine whether or not it will optimize benefit) without a positive response
319
Intolerance, serious adverse effects, or a history of inadequate beneficial response to opioids: Serious harm may occur should patients be prescribed additional (or different) opioids if prior administration of opioids led to serious adverse effects or was not tolerated. It is also inadvisable to prescribe opioids to patients who already have had an adequate opioid trial (of sufficient dose and duration to determine whether or not it will optimize benefit) without a positive response.
Background information
706
What do opioids do to the bowel?
inhibit bowel peristalsis
57
Impaired bowel motility unresponsive to therapy: Opioids inhibit bowel peristalsis. Their use with patients with impaired bowel motility can increase the risk of severe constipation/impaction or possible obstruction.
Background information
707
How can the use of opioids affect patients with impaired bowel motility?
can increase the risk of severe constipation/impaction or possible obstruction
137
Impaired bowel motility unresponsive to therapy: Opioids inhibit bowel peristalsis. Their use with patients with impaired bowel motility can increase the risk of severe constipation/impaction or possible obstruction.
Background information
708
What is an ineffective treatment modality for patients with migraine headaches (with or without aura)?
LOT
60
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
709
What is an ineffective treatment modality for patients with tension-type headaches?
LOT
60
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
710
What is an ineffective treatment modality for patients with occipital neuralgia?
LOT
60
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
711
What is an ineffective treatment modality for patients with myofascial pain?
LOT
60
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
712
What is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain?
LOT
60
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
713
LOT is an ineffective treatment modality for patients with what kind of headaches?
migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain
120
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
714
How may LOT affect patients with migraine headaches, tension-type headaches, occipital neuralgia, or myofascial pain?
may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal
232
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
715
What treatment modality may result in worsening of the underlying headache condition in patients with migraine headaches, tension-type headaches, occipital neuralgia, or myofascial pain?
LOT
60
Headache not responsive to other pain treatment modalities: LOT is an ineffective treatment modality for patients with migraine headaches (with or without aura), tension-type headaches, occipital neuralgia, or myofascial pain and may result in worsening of the underlying headache condition through factors such as central sensitization and withdrawal.
Background information
716
Who are more likely to attempt suicide?
Patients with a history of TBI who use chronic short-acting and long-acting opioids
30
Traumatic brain injury (TBI): Patients with a history of TBI who use chronic short-acting and long-acting opioids are more likely to attempt suicide.[61]
Background information
717
Why does Morphine frequently cause itching?
Morphine causes a release of histamine
31
True allergy to opioid agents: Morphine causes a release of histamine that frequently results in itching, but this does not constitute an allergic reaction. True allergy to opioid agents (e.g., anaphylaxis) is not common, but does occur. Generally, allergy to one opioid does not mean the patient is allergic to other opioids; many times, rotating to a different opioid may be effective. When an opioid allergy is present and OT is being considered, consultation with an allergist may be helpful.
Background information
718
What is an example of true allergy to opioid agents?
anaphylaxis
196
True allergy to opioid agents: Morphine causes a release of histamine that frequently results in itching, but this does not constitute an allergic reaction. True allergy to opioid agents (e.g., anaphylaxis) is not common, but does occur. Generally, allergy to one opioid does not mean the patient is allergic to other opioids; many times, rotating to a different opioid may be effective. When an opioid allergy is present and OT is being considered, consultation with an allergist may be helpful.
Background information
719
When may a consultation with an allergist be helpful?
When an opioid allergy is present and OT is being considered
392
True allergy to opioid agents: Morphine causes a release of histamine that frequently results in itching, but this does not constitute an allergic reaction. True allergy to opioid agents (e.g., anaphylaxis) is not common, but does occur. Generally, allergy to one opioid does not mean the patient is allergic to other opioids; many times, rotating to a different opioid may be effective. When an opioid allergy is present and OT is being considered, consultation with an allergist may be helpful.
Background information
720
What to do when an opioid allergy is present and OT is being considered?
consultation with an allergist may be helpful
454
True allergy to opioid agents: Morphine causes a release of histamine that frequently results in itching, but this does not constitute an allergic reaction. True allergy to opioid agents (e.g., anaphylaxis) is not common, but does occur. Generally, allergy to one opioid does not mean the patient is allergic to other opioids; many times, rotating to a different opioid may be effective. When an opioid allergy is present and OT is being considered, consultation with an allergist may be helpful.
Recommendations
721
What is the recommendation regarding initiation of long-term opioid therapy for chronic pain?
recommend against
6
a) We recommend against initiation of long-term opioid therapy for chronic pain. (Strong against) b) We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. (Strong for) c) When pharmacologic therapies are used, we recommend non-opioids over opioids. (Strong for) (Reviewed, New-replaced)
Recommendations
722
What is the stance regarding alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments?
recommend
6
a) We recommend against initiation of long-term opioid therapy for chronic pain. (Strong against) b) We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. (Strong for) c) When pharmacologic therapies are used, we recommend non-opioids over opioids. (Strong for) (Reviewed, New-replaced)
Recommendations
723
When should non-opioids be recommended over opioids?
When pharmacologic therapies are used
238
a) We recommend against initiation of long-term opioid therapy for chronic pain. (Strong against) b) We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. (Strong for) c) When pharmacologic therapies are used, we recommend non-opioids over opioids. (Strong for) (Reviewed, New-replaced)
Recommendations
724
What are some alternatives to opioid therapy?
self-management strategies and other non-pharmacological treatments
153
a) We recommend against initiation of long-term opioid therapy for chronic pain. (Strong against) b) We recommend alternatives to opioid therapy such as self-management strategies and other non-pharmacological treatments. (Strong for) c) When pharmacologic therapies are used, we recommend non-opioids over opioids. (Strong for) (Reviewed, New-replaced)
Recommendations
725
Why non-opioid treatments are preferred for chronic pain?
Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms
486
As outlined in this CPG, there is a rapidly growing understanding of the significant harms of LOT even at doses lower than 50 mg oral morphine equivalent daily dose [MEDD], including but not limited to overdose and OUD. At the same time there is a lack of high quality evidence that LOT improves pain, function, and/or quality of life. The literature review conducted for this CPG identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain. Patient values, goals, concerns, and preferences must be factored into clinical decision making on a case-by-case basis. When considering the initiation or continuation of LOT, it is important to consider whether LOT will result in clinically meaningful improvements in function such as readiness to return to work/duty and/or measurable improvement in other areas of function, such that the benefits outweigh the potential harms.
Recommendations
726
In the literature review conducted for this CPG, are there any study evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks?
no
188
As outlined in this CPG, there is a rapidly growing understanding of the significant harms of LOT even at doses lower than 50 mg oral morphine equivalent daily dose [MEDD], including but not limited to overdose and OUD. At the same time there is a lack of high quality evidence that LOT improves pain, function, and/or quality of life. The literature review conducted for this CPG identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain. Patient values, goals, concerns, and preferences must be factored into clinical decision making on a case-by-case basis. When considering the initiation or continuation of LOT, it is important to consider whether LOT will result in clinically meaningful improvements in function such as readiness to return to work/duty and/or measurable improvement in other areas of function, such that the benefits outweigh the potential harms.
Recommendations
727
What must be factored into clinical decision making on a case-by-case basis?
Patient values, goals, concerns, and preferences
652
As outlined in this CPG, there is a rapidly growing understanding of the significant harms of LOT even at doses lower than 50 mg oral morphine equivalent daily dose [MEDD], including but not limited to overdose and OUD. At the same time there is a lack of high quality evidence that LOT improves pain, function, and/or quality of life. The literature review conducted for this CPG identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain. Patient values, goals, concerns, and preferences must be factored into clinical decision making on a case-by-case basis. When considering the initiation or continuation of LOT, it is important to consider whether LOT will result in clinically meaningful improvements in function such as readiness to return to work/duty and/or measurable improvement in other areas of function, such that the benefits outweigh the potential harms.
Recommendations
728
What needs to be considered when considering the initiation or continuation of LOT?
consider whether LOT will result in clinically meaningful improvements in function such as readiness to return to work/duty and/or measurable improvement in other areas of function, such that the benefits outweigh the potential harms
850
As outlined in this CPG, there is a rapidly growing understanding of the significant harms of LOT even at doses lower than 50 mg oral morphine equivalent daily dose [MEDD], including but not limited to overdose and OUD. At the same time there is a lack of high quality evidence that LOT improves pain, function, and/or quality of life. The literature review conducted for this CPG identified no studies evaluating the effectiveness of LOT for outcomes lasting longer than 16 weeks. Given the lack of evidence showing sustained functional benefit of LOT and moderate evidence outlining harms, non-opioid treatments are preferred for chronic pain. Patient values, goals, concerns, and preferences must be factored into clinical decision making on a case-by-case basis. When considering the initiation or continuation of LOT, it is important to consider whether LOT will result in clinically meaningful improvements in function such as readiness to return to work/duty and/or measurable improvement in other areas of function, such that the benefits outweigh the potential harms.
Recommendations
729
What does the literature say about the the benefit of LOT?
there is currently no evidence in the literature documenting the benefit of LOT that demonstrates improvement in pain and function
6
While there is currently no evidence in the literature documenting the benefit of LOT that demonstrates improvement in pain and function, we recognize that in a rare subset of individuals a decision to initiate LOT may be considered (e.g., for intermittent severe exacerbations of chronic painful conditions). If a decision is made to initiate LOT, a careful assessment of benefits and risks should be made to ensure that the benefits are expected to outweigh the well-documented risks. In addition, prior to this consideration, a multimodal treatment plan should be integrated into the patient’s care. Once opioid therapy is initiated, all opioid risk mitigation strategies outlined in this guideline (see Recommendation 7) should be put into place.
Recommendations
730
What to do if a decision is made to initiate LOT?
a careful assessment of benefits and risks should be made to ensure that the benefits are expected to outweigh the well-documented risks
352
While there is currently no evidence in the literature documenting the benefit of LOT that demonstrates improvement in pain and function, we recognize that in a rare subset of individuals a decision to initiate LOT may be considered (e.g., for intermittent severe exacerbations of chronic painful conditions). If a decision is made to initiate LOT, a careful assessment of benefits and risks should be made to ensure that the benefits are expected to outweigh the well-documented risks. In addition, prior to this consideration, a multimodal treatment plan should be integrated into the patient’s care. Once opioid therapy is initiated, all opioid risk mitigation strategies outlined in this guideline (see Recommendation 7) should be put into place.
Recommendations
731
What kind of treatment plan should be integrated into the patient’s care prrior to considering LOT?
multimodal
536
While there is currently no evidence in the literature documenting the benefit of LOT that demonstrates improvement in pain and function, we recognize that in a rare subset of individuals a decision to initiate LOT may be considered (e.g., for intermittent severe exacerbations of chronic painful conditions). If a decision is made to initiate LOT, a careful assessment of benefits and risks should be made to ensure that the benefits are expected to outweigh the well-documented risks. In addition, prior to this consideration, a multimodal treatment plan should be integrated into the patient’s care. Once opioid therapy is initiated, all opioid risk mitigation strategies outlined in this guideline (see Recommendation 7) should be put into place.
Recommendations
732
What to do once opioid therapy is initiated?
all opioid risk mitigation strategies outlined in this guideline (see Recommendation 7) should be put into place
643
While there is currently no evidence in the literature documenting the benefit of LOT that demonstrates improvement in pain and function, we recognize that in a rare subset of individuals a decision to initiate LOT may be considered (e.g., for intermittent severe exacerbations of chronic painful conditions). If a decision is made to initiate LOT, a careful assessment of benefits and risks should be made to ensure that the benefits are expected to outweigh the well-documented risks. In addition, prior to this consideration, a multimodal treatment plan should be integrated into the patient’s care. Once opioid therapy is initiated, all opioid risk mitigation strategies outlined in this guideline (see Recommendation 7) should be put into place.
Recommendations
733
Why did the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. in 2011?
in response to the recognition of pain and its management as a public health problem
9
In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly.
Recommendations
734
In response to the recognition of pain and its management as a public health problem in 2011, who investigated and reported on the state of pain research, treatment, and education in the U.S.?
the National Academy of Medicine
95
In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly.
Recommendations
735
In response to the recognition of pain and its management as a public health problem in 2011, what was investigated and reported by the National Academy of Medicine?
the state of pain research, treatment, and education in the U.S.
158
In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly.
Recommendations
736
What was the impact of the report on the state of pain research, treatment, and education in the U.S. by the National Academy of Medicine in 2011?
The report called for a cultural transformation in the way pain is viewed and treated.
224
In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly.
Recommendations
737
What does the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommend?
a biopsychosocial approach to pain care that is multimodal and interdisciplinary
431
In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly.
Recommendations
738
Who does recommend a biopsychosocial approach to pain care that is multimodal and interdisciplinary?
the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016)
328
In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly.
Recommendations
739
What are included in the underlying concepts of the biopsychosocial model of pain?
pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone
602
In 2011, in response to the recognition of pain and its management as a public health problem, the National Academy of Medicine investigated and reported on the state of pain research, treatment, and education in the U.S. The report called for a cultural transformation in the way pain is viewed and treated.[3] Accordingly, the U.S. Department of Health and Human Services (HHS) National Pain Strategy (March 2016) recommends a biopsychosocial approach to pain care that is multimodal and interdisciplinary.[26] The underlying concepts of the biopsychosocial model of pain include the idea that pain perception and its effects on the patient’s function is mediated by multiple factors (e.g., mood, social support, prior experience, biomechanical factors), not just biology alone. With this overall change in construct, a biopsychosocial assessment and treatment plan should be tailored accordingly.