Opioid therapy for chronic pain

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Management of Opioid Therapy for Chronic Pain Working Group. VA/DoD clinical practice guideline for management of opioid therapy for chronic pain. Washington (DC): Department of Veterans Affairs, Department of Defense (DO NOT EDIT)

Recommendations for patients with chronic pain (DO NOT EDIT)

Assessment of patient

"1. A trial of opioid therapy (OT) is indicated for a patient with chronic pain who meets all of the following criteria: Moderate to severe pain that has failed to adequately respond to indicated non-opioid and non-drug therapeutic interventions The potential benefits of OT are likely to outweigh the risks (i.e., no absolute contraindications) The patient is fully informed and consents to the therapy Clear and measurable treatment goals are established "

"2. The ethical imperative is to provide the pain treatment with the best benefit-to-harm profile for the individual patient."

Obtain Comprehensive Assessment Including: History, Physical Examination, and a Review of Diagnostic Studies (1) A comprehensive patient assessment should be completed to identify clinical conditions that may interfere with the appropriate and safe use of OT. The comprehensive assessment should include: Medical history Age, sex History of present illness, including a complete pain assessment (see Annotation C below) History of injury, if applicable Past medical and surgical history Past psychiatric history (including depression, anxiety, other emotional disorders, risk of suicide including family history and previous suicidal attempts) Medications (including current and past analgesics, their effectiveness, side effects, and tolerability, as well as drugs that may interact with OT) Substance use history (personal, family, peer group) Family history Social history (including employment, cultural background, social network, marital history, and legal history, other behavioral patterns [i.e., impulse behaviors]) Review of systems Allergies Abuse (sexual, physical, and mental) Physical examination A general examination A pain-focused musculoskeletal and neurologic examination Mental Status Examination (MSE) (including level of alertness, ability to understand and follow instruction, and suicidal ideation) Review of diagnostic studies and assessments Evaluation of occupational risks and ability to perform duty {2) Information from the pain history and physical exam should be reviewed to ensure that the patient has had an adequate therapeutic trial of non-opioid medication therapies. (3) A urine drug test (UDT) (also referred to as urine drug screen [UDS]) should be used to screen for the presence of illegal drugs, unreported prescribed medication, or unreported alcohol use prior to starting therapy. [B] (4) Patients on chronic OT should be assessed for suicide risk at onset of therapy and regularly thereafter. High suicide risk is a relative contraindication for OT. (5) OT should be used only after careful consideration of the risks and benefits.