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VA/Dod CLINICAL PRACTICE GUIDELINE for OPIOID THERAPY for CHRONIC PAIN

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VA/DoD CLINICAL PRACTICE GUIDELINE FOR OPIOID THERAPY FOR CHRONIC PAIN Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 3.0 – 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Prepared by: The Opioid Therapy for Chronic Pain Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 3.0 – 2017 Based on evidence reviewed through December 2016 February 2017 Page 2 of 198 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain Table of Contents I. Introduction ..................................................................................................................................... 5 II. How to Use This Clinical Practice Guideline ...................................................................................... 6 III. Recommendations ........................................................................................................................... 7 IV. Algorithm ...................................................................................................................................... 10 A. Module A: Determination of Appropriateness for Opioid Therapy ................................................. 11 B. Module B: Treatment with Opioid Therapy ...................................................................................... 12 C. Module C: Tapering or Discontinuation of Opioid Therapy ............................................................. 13 D. Module D: Patients Currently on Opioid Therapy ............................................................................ 14 V. Background.................................................................................................................................... 15 A. Opioid Epidemic ................................................................................................................................. 15 B. Paradigm Shift in Pain and Its Treatment ......................................................................................... 16 C. Prioritizing Safe Opioid Prescribing Practices and Use ..................................................................... 16 D. Taxonomy ........................................................................................................................................... 19 E. Epidemiology and Impact .................................................................................................................. 20 F. Chronic Pain and Co-occurring Conditions ....................................................................................... 21 G. Risk Factors for Adverse Outcomes of Opioid Therapy .................................................................... 21 VI. About this Clinical Practice Guideline ............................................................................................. 26 A. Scope of this Clinical Practice Guideline ........................................................................................... 26 B. Highlighted Features of this Clinical Practice Guideline ................................................................... 27 C. Methods ............................................................................................................................................. 27 D. Implementation ................................................................................................................................. 31 E. Summary of Patient Focus Group Methods and Findings ................................................................ 31 F. Conflict of Interest ............................................................................................................................. 32 G. Patient-centered Care ....................................................................................................................... 33 H. Shared Decision Making .................................................................................................................... 34 I. Stepped Care Model for Pain Management ..................................................................................... 34 J. Transfer of Care ................................................................................................................................. 35 K. Clinical Decision Support Tools ......................................................................................................... 37 VII. Guideline Work Group ................................................................................................................... 38 VIII. Discussion of Recommendations .................................................................................................... 39 A. Initiation and Continuation of Opioids ............................................................................................. 39 February 2017 Page 3 of 198 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain B. Risk Mitigation ................................................................................................................................... 46 C. Type, Dose, Duration, Follow-up, and Taper of Opioids .................................................................. 51 D. Opioid Therapy for Acute Pain .......................................................................................................... 70 Appendix A: VA Signature Informed Consent ......................................................................................... 71 Appendix B: Urine Drug Testing ............................................................................................................. 75 A. Benefits of Urine Drug Testing .......................................................................................................... 75 B. Types of Urine Drug Testing .............................................................................................................. 75 Appendix C: Diagnostic and Statistical Manual of Mental Disorders for Opioid Use Disorders ................ 80 Appendix D: Drug Tables ....................................................................................................................... 81 A. Short-acting, Orally Administered Opioids ....................................................................................... 81 B. Long-acting/Extended-release Opioids ............................................................................................. 88 C. Morphine Milligram Equivalent Doses ............................................................................................. 99 D. Methadone Dosing Guidance .......................................................................................................... 100 Appendix E: Evidence Review Methodology ........................................................................................ 105 A. Developing the Scope and Key Questions ...................................................................................... 105 B. Conducting the Systematic Review ................................................................................................. 110 C. Convening the Face-to-face Meeting .............................................................................................. 116 D. Grading Recommendations ............................................................................................................. 116 E. Recommendation Categorization ................................................................................................... 120 F. Drafting and Submitting the Final Clinical Practice Guideline........................................................ 122 Appendix F: Patient Focus Group Methods and Findings ...................................................................... 123 A. Methods ..........................................................................................................................................
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