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Recommendations
| 806 |
Who has the highest adjusted odds ratio (AOR) for drug overdose?
|
individuals on LOT for chronic pain (without anxiety or PTSD) who also received concurrent long-term benzodiazepine therapy
| 333 |
Harms may outweigh benefits for the concurrent use of benzodiazepines and LOT. There is moderate quality evidence that concurrent use of benzodiazepines with prescription opioids increases the risk of overdose and overdose death.[66] In a retrospective cohort study, the adjusted odds ratio (AOR) for drug overdose was highest for individuals on LOT for chronic pain (without anxiety or PTSD) who also received concurrent long-term benzodiazepine therapy.[66] In another retrospective study that involved over 200,000 participants (not included in the evidence review), Veterans receiving both opioids and benzodiazepines were at an increased risk of death from drug overdose.[90] Furthermore, there is a lack of evidence in favor of long-term therapy with benzodiazepines and opioids for chronic pain.[91]
|
Recommendations
| 807 |
Who were at an increased risk of death from drug overdose?
|
Veterans receiving both opioids and benzodiazepines
| 574 |
Harms may outweigh benefits for the concurrent use of benzodiazepines and LOT. There is moderate quality evidence that concurrent use of benzodiazepines with prescription opioids increases the risk of overdose and overdose death.[66] In a retrospective cohort study, the adjusted odds ratio (AOR) for drug overdose was highest for individuals on LOT for chronic pain (without anxiety or PTSD) who also received concurrent long-term benzodiazepine therapy.[66] In another retrospective study that involved over 200,000 participants (not included in the evidence review), Veterans receiving both opioids and benzodiazepines were at an increased risk of death from drug overdose.[90] Furthermore, there is a lack of evidence in favor of long-term therapy with benzodiazepines and opioids for chronic pain.[91]
|
Recommendations
| 808 |
Veterans receiving both opioids and benzodiazepines were at an increased risk of what?
|
death from drug overdose
| 656 |
Harms may outweigh benefits for the concurrent use of benzodiazepines and LOT. There is moderate quality evidence that concurrent use of benzodiazepines with prescription opioids increases the risk of overdose and overdose death.[66] In a retrospective cohort study, the adjusted odds ratio (AOR) for drug overdose was highest for individuals on LOT for chronic pain (without anxiety or PTSD) who also received concurrent long-term benzodiazepine therapy.[66] In another retrospective study that involved over 200,000 participants (not included in the evidence review), Veterans receiving both opioids and benzodiazepines were at an increased risk of death from drug overdose.[90] Furthermore, there is a lack of evidence in favor of long-term therapy with benzodiazepines and opioids for chronic pain.[91]
|
Recommendations
| 809 |
What is a serious risk factor for unintentional overdose death?
|
Concurrent benzodiazepine and LOT use
| 250 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 810 |
What kind of risk is associated with concurrent benzodiazepine and LOT use?
|
unintentional overdose death
| 318 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 811 |
What should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents?
|
Concurrent benzodiazepine and LOT use
| 250 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 813 |
Why can benzodiazepines be challenging to discontinue once initiated?
|
due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety
| 526 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 814 |
What should be avoided?
|
abrupt discontinuation of benzodiazepines
| 634 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 815 |
What kind of discontinuation of benzodiazepines should be avoided?
|
abrupt
| 634 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 816 |
Why should abrupt discontinuation of benzodiazepines be avoided?
|
as it can lead to serious adverse effects including seizures and death
| 695 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 817 |
How to perform tapering of benzodiazepines?
|
with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG)
| 813 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 818 |
What should be performed with caution and within a team environment when possible?
|
Tapering benzodiazepines
| 768 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 819 |
Why should particular caution be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain?
|
Due to the difficulty of tapering or discontinuing benzodiazepines
| 919 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 822 |
What does recommend against benzodiazepines for the prevention of PTSD?
|
The VA/DoD PTSD CPG
| 1,125 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 823 |
What is the stance regarding the use of benzodiazepines for the prevention of PTSD?
|
recommends against
| 1,146 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 824 |
What does caution against the use of benzodiazepines in treatment of PTSD?
|
The VA/DoD PTSD CPG
| 1,125 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 825 |
What are associated with a higher incidence of PTSD symptoms?
|
Benzodiazepines to treat acute anxiety symptoms after trauma
| 1,262 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 826 |
Benzodiazepines to treat acute anxiety symptoms after trauma are associated with what?
|
a higher incidence of PTSD symptoms
| 1,343 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 827 |
What is the effect of benzodiazepines in patients with PTSD?
|
Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment.
| 1,547 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 828 |
What may gradual benzodiazepine taper result in?
|
exacerbation of severe PTSD symptoms
| 1,777 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 829 |
Exacerbation of severe PTSD symptoms may result from what?
|
gradual benzodiazepine taper
| 1,733 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 830 |
What is considered a contraindication to initiation of OT?
|
Concomitant use of benzodiazepines
| 1,815 |
There is a large variation in patient preference regarding the concurrent use of benzodiazepines and LOT. This is especially true for patients who are already accustomed to receiving both medications (see Patient Focus Group Methods and Findings). Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death and should be weighed heavily in the risk-benefit evaluation for tapering versus continuing one or both agents. Once initiated, benzodiazepines can be challenging to discontinue due to symptoms related to benzodiazepine dependence, exacerbations of PTSD, and/or anxiety.[91] Moreover, abrupt discontinuation of benzodiazepines should be avoided, as it can lead to serious adverse effects including seizures and death. Tapering benzodiazepines should be performed with caution and within a team environment when possible (see Recommendation 26 in the VA/DoD SUD CPG).7 Due to the difficulty of tapering or discontinuing benzodiazepines, particular caution should be used when considering initiating benzodiazepines for Veterans with PTSD who have co-occurring chronic pain. The VA/DoD PTSD CPG recommends against benzodiazepines for the prevention of PTSD and cautions against their use in treatment of PTSD. Benzodiazepines to treat acute anxiety symptoms after trauma are associated with a higher incidence of PTSD symptoms. For treatment of PTSD, there is evidence of lack of efficacy from small clinical trials and evidence of harm from observational studies of benzodiazepines for PTSD. Although anxiety may initially improve with benzodiazepines, the improvement is short-lived and may result in tolerance to increasing doses and eventual failure of the treatment. Even gradual benzodiazepine taper may result in exacerbation of severe PTSD symptoms. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.
|
Recommendations
| 831 |
In addition to benzodiazepines, what to do with caution?
|
the addition of other psychoactive medications to LOT
| 32 |
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we suggest not prescribing Z-drugs to patients who are on LOT, as moderate quality evidence demonstrates that the combination of zolpidem and opioids increases the AOR of overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose) with the combined use of antidepressants and opioids in patients who do not have depression.[66] This particular study did not differentiate between classes of antidepressants, limiting the ability of the Work Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such, there is no recommendation in this guideline with respect to using specific classes of antidepressants and LOT.
|
Recommendations
| 832 |
What is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines?
|
the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone)
| 120 |
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we suggest not prescribing Z-drugs to patients who are on LOT, as moderate quality evidence demonstrates that the combination of zolpidem and opioids increases the AOR of overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose) with the combined use of antidepressants and opioids in patients who do not have depression.[66] This particular study did not differentiate between classes of antidepressants, limiting the ability of the Work Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such, there is no recommendation in this guideline with respect to using specific classes of antidepressants and LOT.
|
Recommendations
| 833 |
What does increase the AOR of overdose?
|
the combination of zolpidem and opioids
| 446 |
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we suggest not prescribing Z-drugs to patients who are on LOT, as moderate quality evidence demonstrates that the combination of zolpidem and opioids increases the AOR of overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose) with the combined use of antidepressants and opioids in patients who do not have depression.[66] This particular study did not differentiate between classes of antidepressants, limiting the ability of the Work Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such, there is no recommendation in this guideline with respect to using specific classes of antidepressants and LOT.
|
Recommendations
| 834 |
The combination of zolpidem and opioids increases what?
|
the AOR of overdose
| 496 |
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we suggest not prescribing Z-drugs to patients who are on LOT, as moderate quality evidence demonstrates that the combination of zolpidem and opioids increases the AOR of overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose) with the combined use of antidepressants and opioids in patients who do not have depression.[66] This particular study did not differentiate between classes of antidepressants, limiting the ability of the Work Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such, there is no recommendation in this guideline with respect to using specific classes of antidepressants and LOT.
|
Recommendations
| 835 |
What can happen with the combined use of antidepressants and opioids in patients who do not have depression?
|
potential adverse outcomes (e.g., risk of overdose)
| 560 |
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we suggest not prescribing Z-drugs to patients who are on LOT, as moderate quality evidence demonstrates that the combination of zolpidem and opioids increases the AOR of overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose) with the combined use of antidepressants and opioids in patients who do not have depression.[66] This particular study did not differentiate between classes of antidepressants, limiting the ability of the Work Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such, there is no recommendation in this guideline with respect to using specific classes of antidepressants and LOT.
|
Recommendations
| 836 |
What can have potential adverse outcomes in patients who do not have depression?
|
the combined use of antidepressants and opioids
| 618 |
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we suggest not prescribing Z-drugs to patients who are on LOT, as moderate quality evidence demonstrates that the combination of zolpidem and opioids increases the AOR of overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose) with the combined use of antidepressants and opioids in patients who do not have depression.[66] This particular study did not differentiate between classes of antidepressants, limiting the ability of the Work Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such, there is no recommendation in this guideline with respect to using specific classes of antidepressants and LOT.
|
Recommendations
| 837 |
Who can have potential adverse outcomes with the combined use of antidepressants and opioids?
|
patients who do not have depression
| 669 |
In addition to benzodiazepines, the addition of other psychoactive medications to LOT must be made with caution. While the evidence for harm associated with the combination of opioids and Z-drugs (e.g., zolpidem, eszopiclone) is not as strong as the evidence for harm associated with the combination of opioids and benzodiazepines, we suggest not prescribing Z-drugs to patients who are on LOT, as moderate quality evidence demonstrates that the combination of zolpidem and opioids increases the AOR of overdose.[66] The evidence reviewed also identifies potential adverse outcomes (e.g., risk of overdose) with the combined use of antidepressants and opioids in patients who do not have depression.[66] This particular study did not differentiate between classes of antidepressants, limiting the ability of the Work Group to recommend for or against prescribing opioids and a specific class of antidepressants. As such, there is no recommendation in this guideline with respect to using specific classes of antidepressants and LOT.
|
Recommendations
| 838 |
What is the stance regarding long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose?
|
recommend against
| 6 |
a) We recommend against long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose. (Strong against) b) For patients less than 30 years of age currently on long-term opioid therapy, we recommend close monitoring and consideration for tapering when risks exceed benefits (see Recommendation 14 and Recommendation 17). (Strong for) (Reviewed, New-replaced)
|
Recommendations
| 839 |
What is recommended for patients less than 30 years of age currently on long-term opioid therapy?
|
close monitoring and consideration for tapering when risks exceed benefits
| 263 |
a) We recommend against long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose. (Strong against) b) For patients less than 30 years of age currently on long-term opioid therapy, we recommend close monitoring and consideration for tapering when risks exceed benefits (see Recommendation 14 and Recommendation 17). (Strong for) (Reviewed, New-replaced)
|
Recommendations
| 840 |
Who are at risk for OUD and overdose?
|
All patients who take opioids chronically
| 0 |
All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are younger than 30 years of age. Seven studies were identified that examined age as a predictor of OUD, respiratory/CNS depression, and/or overdose. Four of the seven studies were rated as fair quality evidence,[59,86,88,92] while three were rated as poor quality evidence.[58,62,87] Six of the seven studies demonstrated that age was inversely associated with the risk of OUD and overdose.[59,62,86-88,92] One of the three low quality studies showed that older subjects had a higher HR of overdose.[58] The Work Group’s overall confidence in the quality of the evidence was moderate.
|
Recommendations
| 841 |
Which patients are especially at risk for OUD and overdose?
|
those who are younger than 30 years of age
| 91 |
All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are younger than 30 years of age. Seven studies were identified that examined age as a predictor of OUD, respiratory/CNS depression, and/or overdose. Four of the seven studies were rated as fair quality evidence,[59,86,88,92] while three were rated as poor quality evidence.[58,62,87] Six of the seven studies demonstrated that age was inversely associated with the risk of OUD and overdose.[59,62,86-88,92] One of the three low quality studies showed that older subjects had a higher HR of overdose.[58] The Work Group’s overall confidence in the quality of the evidence was moderate.
|
Recommendations
| 842 |
All patients who take opioids chronically are at risk for what?
|
OUD and overdose
| 58 |
All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are younger than 30 years of age. Seven studies were identified that examined age as a predictor of OUD, respiratory/CNS depression, and/or overdose. Four of the seven studies were rated as fair quality evidence,[59,86,88,92] while three were rated as poor quality evidence.[58,62,87] Six of the seven studies demonstrated that age was inversely associated with the risk of OUD and overdose.[59,62,86-88,92] One of the three low quality studies showed that older subjects had a higher HR of overdose.[58] The Work Group’s overall confidence in the quality of the evidence was moderate.
|
Recommendations
| 843 |
How many studies examined age as a predictor of OUD, respiratory/CNS depression, and/or overdose?
|
Seven
| 136 |
All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are younger than 30 years of age. Seven studies were identified that examined age as a predictor of OUD, respiratory/CNS depression, and/or overdose. Four of the seven studies were rated as fair quality evidence,[59,86,88,92] while three were rated as poor quality evidence.[58,62,87] Six of the seven studies demonstrated that age was inversely associated with the risk of OUD and overdose.[59,62,86-88,92] One of the three low quality studies showed that older subjects had a higher HR of overdose.[58] The Work Group’s overall confidence in the quality of the evidence was moderate.
|
Recommendations
| 844 |
What should be weighed heavily in the risk-benefit determination for initiating LOT?
|
Similar to other risk factors, age <30 years
| 0 |
Similar to other risk factors, age <30 years should be weighed heavily in the risk-benefit determination for initiating LOT. Age <30 years is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks of OUD and overdose. Hospitalized patients recovering from battlefield injuries, for example, are known to have less chronic pain, depression, and PTSD when their pain is aggressively managed starting soon after injury.[93] In those cases, LOT may be appropriate only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate (see Recommendations 14 and 15).
|
Recommendations
| 845 |
What is not an absolute contraindication to LOT?
|
Age <30 years
| 31 |
Similar to other risk factors, age <30 years should be weighed heavily in the risk-benefit determination for initiating LOT. Age <30 years is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks of OUD and overdose. Hospitalized patients recovering from battlefield injuries, for example, are known to have less chronic pain, depression, and PTSD when their pain is aggressively managed starting soon after injury.[93] In those cases, LOT may be appropriate only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate (see Recommendations 14 and 15).
|
Recommendations
| 846 |
Who are known to have less chronic pain, depression, and PTSD when their pain is aggressively managed starting soon after injury?
|
Hospitalized patients recovering from battlefield injuries
| 288 |
Similar to other risk factors, age <30 years should be weighed heavily in the risk-benefit determination for initiating LOT. Age <30 years is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks of OUD and overdose. Hospitalized patients recovering from battlefield injuries, for example, are known to have less chronic pain, depression, and PTSD when their pain is aggressively managed starting soon after injury.[93] In those cases, LOT may be appropriate only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate (see Recommendations 14 and 15).
|
Recommendations
| 847 |
When may LOT be appropriate?
|
only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate
| 533 |
Similar to other risk factors, age <30 years should be weighed heavily in the risk-benefit determination for initiating LOT. Age <30 years is not an absolute contraindication to LOT. There may be some situations where the benefits of LOT clearly outweigh the risks of OUD and overdose. Hospitalized patients recovering from battlefield injuries, for example, are known to have less chronic pain, depression, and PTSD when their pain is aggressively managed starting soon after injury.[93] In those cases, LOT may be appropriate only if risk mitigation strategies are employed and patients are titrated off LOT as soon as it is appropriate (see Recommendations 14 and 15).
|
Recommendations
| 861 |
Who are at a higher risk of opioid misuse?
|
Younger patients
| 0 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 862 |
Younger patients are at a higher risk of what?
|
opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior)
| 46 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 863 |
Who were significantly less likely to have an aberrant UDT in comparison to patients in the 20-44 age group?
|
patients in the 45-64 year age group
| 168 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 864 |
In comparison to patients in the 20-44 age group, patients in the 45-64 year age group were significantly less likely to have what?
|
an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC])
| 245 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 865 |
Patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to whom?
|
patients in the 20-44 age group
| 394 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 866 |
Who were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid (indicating possible diversion)?
|
Patients in the 45-64 and ≥65 age groups
| 432 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 867 |
Patients in the 45-64 and ≥65 age groups were significantly less likely than whom to have non-detection of a prescribed opioid (indicating possible diversion)?
|
20-44 year olds
| 509 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 868 |
What are significantly less likely in patients in the 45-64 and ≥65 age groups than 20-44 year olds?
|
to have non-detection of a prescribed opioid as well (indicating possible diversion)
| 525 |
Younger patients are also at a higher risk of opioid misuse (as suggested by a UDT indicating high-risk medication-related behavior). Turner et al. (2014) showed that patients in the 45-64 year age group were significantly less likely to have an aberrant UDT (detection of a non-prescribed opioid, non-prescribed benzodiazepine, illicit drug, or tetrahydrocannabinol [THC]) in comparison to patients in the 20-44 age group.[94] Patients in the 45-64 and ≥65 age groups were significantly less likely than 20-44 year olds to have non-detection of a prescribed opioid as well (indicating possible diversion).[94]
|
Recommendations
| 869 |
How was an age of 30 years chosen as a clinically reasonable threshold?
|
An age of 30 years was chosen based on how age was categorized in the six studies that showed an inverse relationship between age and OUD or overdose.
| 0 |
An age of 30 years was chosen based on how age was categorized in the six studies that showed an inverse relationship between age and OUD or overdose. One of those six studies found that patients with OUD were younger than patients without OUD, but did not find a statistically significant relationship.[87] Two of those six studies examined age as a continuous predictor, and neither reported a specific age where the risk of OUD or overdose changed markedly.[62,92] One study examined age as a dichotomous (<65 and ≥65) predictor.[88] In the two remaining studies, the highest risk included ages ranging from 18 to 30 years.[59,86] As such, the Work Group chose 30 years of age as a clinically reasonable threshold.
|
Recommendations
| 870 |
What kind of rationale is there to explain the the relationship between age and OUD and overdose?
|
good neurophysiologic rationale
| 155 |
Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD and overdose. Studies in other areas (e.g., use of different substances) indicate that developing brains (age <30 years) are at increased risk of abnormalities and addiction when exposed to substance use early in life.[95-98]
|
Recommendations
| 871 |
What indicate that developing brains (age <30 years) are at increased risk of abnormalities and addiction when exposed to substance use early in life?
|
Studies in other areas (e.g., use of different substances)
| 250 |
Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD and overdose. Studies in other areas (e.g., use of different substances) indicate that developing brains (age <30 years) are at increased risk of abnormalities and addiction when exposed to substance use early in life.[95-98]
|
Recommendations
| 872 |
What are at increased risk of abnormalities and addiction when exposed to substance use early in life?
|
developing brains (age <30 years)
| 324 |
Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD and overdose. Studies in other areas (e.g., use of different substances) indicate that developing brains (age <30 years) are at increased risk of abnormalities and addiction when exposed to substance use early in life.[95-98]
|
Recommendations
| 873 |
What are the risks of substance use early in life?
|
increased risk of abnormalities and addiction
| 365 |
Some may interpret the recommendation to limit opioid use by age as arbitrary and potentially discriminatory when taken out of context; however, there is good neurophysiologic rationale explaining the relationship between age and OUD and overdose. Studies in other areas (e.g., use of different substances) indicate that developing brains (age <30 years) are at increased risk of abnormalities and addiction when exposed to substance use early in life.[95-98]
|
Recommendations
| 875 |
What is recommended upon initiation of long-term opioid therapy?
|
implementing risk mitigation strategies
| 13 |
We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include: Ongoing, random urine drug testing (including appropriate confirmatory testing), Checking state prescription drug monitoring programs, Monitoring for overdose potential and suicidality, Providing overdose education, Prescribing of naloxone rescue and accompanying education (Strong for | Reviewed, New-replaced)
|
Recommendations
| 876 |
How to implement risk mitigation strategies upon initiation of long-term opioid therapy?
|
starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies
| 99 |
We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include: Ongoing, random urine drug testing (including appropriate confirmatory testing), Checking state prescription drug monitoring programs, Monitoring for overdose potential and suicidality, Providing overdose education, Prescribing of naloxone rescue and accompanying education (Strong for | Reviewed, New-replaced)
|
Recommendations
| 877 |
What should be commensurate with risk factors?
|
The strategies and their frequency
| 231 |
We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include: Ongoing, random urine drug testing (including appropriate confirmatory testing), Checking state prescription drug monitoring programs, Monitoring for overdose potential and suicidality, Providing overdose education, Prescribing of naloxone rescue and accompanying education (Strong for | Reviewed, New-replaced)
|
Recommendations
| 878 |
What should be included in the risk mitigation strategies and their frequency?
|
Ongoing, random urine drug testing (including appropriate confirmatory testing), Checking state prescription drug monitoring programs, Monitoring for overdose potential and suicidality, Providing overdose education, Prescribing of naloxone rescue and accompanying education
| 321 |
We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include: Ongoing, random urine drug testing (including appropriate confirmatory testing), Checking state prescription drug monitoring programs, Monitoring for overdose potential and suicidality, Providing overdose education, Prescribing of naloxone rescue and accompanying education (Strong for | Reviewed, New-replaced)
|
Recommendations
| 879 |
When should risk mitigation for LOT begin?
|
before the opioids are prescribed
| 37 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 880 |
What should be done before the opioids are prescribed?
|
Risk mitigation for LOT should begin
| 0 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 881 |
How should risk mitigation for LOT begin before the opioids are prescribed?
|
through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication
| 72 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 882 |
When should risk mitigation for LOT occur?
|
concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder)
| 283 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 883 |
What was the recommendation in the 2010 OT CPG?
|
use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT
| 492 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 884 |
Is there any study looking at opioid treatment agreements (OTAs)?
|
One identified study was a systematic review of 11 studies
| 834 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 885 |
What kind of evidence is there to support the use of OTAs and UDT?
|
weak
| 1,051 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 886 |
What is OTAs?
|
opioid treatment agreements
| 904 |
Risk mitigation for LOT should begin before the opioids are prescribed, through an informed consent discussion, reviewing the patient’s history, checking state PDMPs, or instructing patients about using drug take back programs to dispose of unused medication. It should also occur concurrently with the therapy (e.g., ongoing UDT, OEND) and in response to adverse events (e.g., needle exchange programs for those who develop an intravenous drug use disorder). The 2010 OT CPG recommended use of an opioid pain care agreement, monitoring for appropriate opioid use, and, with patients’ consent, obtaining a UDT. A literature search was conducted dating back to the original 2010 recommendation to identify studies comparing the effectiveness of different risk mitigation strategies for patients on or being considered for LOT. One identified study was a systematic review of 11 studies looking at opioid treatment agreements (OTAs) and UDT strategies utilizing opioid misuse risk reduction as the main outcome measure.[99] The study revealed weak evidence to support the use of OTAs and UDT. A second study, a retrospective database study, demonstrated decreased risk of suicide attempts in various cohorts with frequent UDT, regular follow-up (including follow-up within four weeks for patients with new opioid prescription), and rehabilitative services are offered.[61] The confidence in the quality of the evidence was moderate for the outcome of attempted suicide risk. The third study was a retrospective cohort study that looked at the intervention of a clinical pharmacist guidance team versus control.[100] Outcome measures included adverse events, pain management, and quality of life. Details of the actual intervention were vague and did not necessarily include OTAs or UDT. Thus, the confidence in the quality of the evidence was very low. The confidence in the quality of the evidence was moderate for UDT and frequent follow-up and was low for OTAs. The frequency of follow-up and monitoring should be based on patient level of risk as determined by an individual risk assessment.
|
Recommendations
| 887 |
What is the relationship between patient values and preferences?
|
There may be some variation
| 0 |
There may be some variation in patient values and preferences. Certain patients may appreciate the use of risk mitigation strategies and others may not. Participants in the patient focus group expressed an understanding of why various risk mitigation strategies were used (see Patient Focus Group Methods and Findings).
|
Recommendations
| 888 |
There may be some variation in what?
|
patient values and preferences
| 31 |
There may be some variation in patient values and preferences. Certain patients may appreciate the use of risk mitigation strategies and others may not. Participants in the patient focus group expressed an understanding of why various risk mitigation strategies were used (see Patient Focus Group Methods and Findings).
|
Recommendations
| 889 |
What does implementing more extensive risk mitigation strategies entail?
|
an investment of resources
| 63 |
Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]
|
Recommendations
| 890 |
Why may primary care providers require more time with patients?
|
to allow for shared decision making and treatment planning
| 151 |
Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]
|
Recommendations
| 891 |
What would happen if there were a more frequent follow-up of patients on LOT?
|
can affect access to care for all empaneled patients
| 254 |
Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]
|
Recommendations
| 892 |
What must VHA providers follow when providing LOT for patients with non-cancer pain?
|
VHA policy regarding education and signature informed consent
| 340 |
Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]
|
Recommendations
| 893 |
When must VHA providers follow VHA policy regarding education and signature informed consent?
|
when providing LOT for patients with non-cancer pain
| 402 |
Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]
|
Recommendations
| 894 |
Who must follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain?
|
VHA providers
| 309 |
Implementing more extensive risk mitigation strategies entails an investment of resources. Primary care providers may require more time with patients to allow for shared decision making and treatment planning. More frequent follow-up of patients on LOT can affect access to care for all empaneled patients. VHA providers must also follow VHA policy regarding education and signature informed consent when providing LOT for patients with non-cancer pain.[101]
|
Recommendations
| 895 |
What did the 2010 OT CPG reflect?
|
prior practice of using opioid treatment (or pain care) agreements
| 198 |
There is a paradigm shift occurring in approaches to ensuring and documenting patient and provider understanding and expectations regarding the risks and benefits of LOT. The 2010 OT CPG reflected prior practice of using opioid treatment (or pain care) agreements. OTAs have been described as coercive rather than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful to the patient-provider relationship.[102-105]
|
Recommendations
| 896 |
How have OTAs been described in the 2010 OT CPG?
|
as coercive rather than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful to the patient-provider relationship
| 292 |
There is a paradigm shift occurring in approaches to ensuring and documenting patient and provider understanding and expectations regarding the risks and benefits of LOT. The 2010 OT CPG reflected prior practice of using opioid treatment (or pain care) agreements. OTAs have been described as coercive rather than therapeutic, lack respect for individual autonomy, can be a barrier to pain care, and may be harmful to the patient-provider relationship.[102-105]
|
Recommendations
| 897 |
Why should an optimal approach to care should include a robust, signature informed consent process?
|
Given the recognized risks of opioid therapy
| 0 |
Given the recognized risks of opioid therapy, an optimal approach to care should include a robust, signature informed consent process that is patient-centered and provides patients with information about known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for signature informed consent, consistent with VA policy for other treatments or procedures with a significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012).
|
Recommendations
| 898 |
Given the recognized risks of opioid therapy, what should be included in an optimal approach to care?
|
a robust, signature informed consent process that is patient-centered and provides patients with information about known benefits and harms of OT and treatment alternatives
| 89 |
Given the recognized risks of opioid therapy, an optimal approach to care should include a robust, signature informed consent process that is patient-centered and provides patients with information about known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for signature informed consent, consistent with VA policy for other treatments or procedures with a significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012).
|
Recommendations
| 899 |
Given the recognized risks of opioid therapy, what should include a robust, signature informed consent process?
|
an optimal approach to care
| 46 |
Given the recognized risks of opioid therapy, an optimal approach to care should include a robust, signature informed consent process that is patient-centered and provides patients with information about known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for signature informed consent, consistent with VA policy for other treatments or procedures with a significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012).
|
Recommendations
| 900 |
What did VA establish in 2014 regarding OT and treatment alternatives?
|
a requirement for signature informed consent, consistent with VA policy for other treatments or procedures with a significant risk of complications or morbidity
| 289 |
Given the recognized risks of opioid therapy, an optimal approach to care should include a robust, signature informed consent process that is patient-centered and provides patients with information about known benefits and harms of OT and treatment alternatives. In 2014, VA established a requirement for signature informed consent, consistent with VA policy for other treatments or procedures with a significant risk of complications or morbidity. See Appendix A, Taking Opioids Responsibly for Your Safety and the Safety of Others: Patient Information Guide on Long-term Opioid Therapy for Chronic Pain (found at http://www.healthquality.va.gov/guidelines/Pain/cot/OpiodTheraphyforChronicPainPatientTool20May20 13print.pdf), and 38 C.F.R. §17.32 (2012).
|
Recommendations
| 901 |
What may patients decline?
|
offered treatments (e.g., OT) and may also decline risk mitigation strategies (e.g., UDT, pill counts) that are recommended in the course of clinical care
| 21 |
Patients may decline offered treatments (e.g., OT) and may also decline risk mitigation strategies (e.g., UDT, pill counts) that are recommended in the course of clinical care. However, providers should discuss this decision with the patient, including the likelihood that their decision may result in the risks of LOT outweighing its potential benefits. This would require a consideration of patient’s safety, and a clinical decision may be made not to initiate OT or to discontinue ongoing OT through tapering (see Recommendation 14 and Recommendation 17).
|
Recommendations
| 902 |
What are used throughout the country for detection of multi-sourcing of controlled substances?
|
State database queries
| 0 |
State database queries for detection of multi-sourcing of controlled substances are used throughout the country. Data comparing states with an implemented state database program to states without one showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly checks of the state database system.[33]
|
Recommendations
| 903 |
For what purpose state database queries are used throughout the country?
|
detection of multi-sourcing of controlled substances
| 27 |
State database queries for detection of multi-sourcing of controlled substances are used throughout the country. Data comparing states with an implemented state database program to states without one showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly checks of the state database system.[33]
|
Recommendations
| 904 |
According to CDC, how often the state database system needs to be checked?
|
at least quarterly
| 281 |
State database queries for detection of multi-sourcing of controlled substances are used throughout the country. Data comparing states with an implemented state database program to states without one showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly checks of the state database system.[33]
|
Recommendations
| 905 |
Who recommends at least quarterly checks of the state database system?
|
The CDC
| 252 |
State database queries for detection of multi-sourcing of controlled substances are used throughout the country. Data comparing states with an implemented state database program to states without one showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly checks of the state database system.[33]
|
Recommendations
| 906 |
According to CDC, what needs to be checked at least quarterly?
|
the state database system
| 311 |
State database queries for detection of multi-sourcing of controlled substances are used throughout the country. Data comparing states with an implemented state database program to states without one showed 1.55 fewer deaths per 100,000 people.[106] The CDC currently recommends at least quarterly checks of the state database system.[33]
|
Recommendations
| 907 |
Why is UDT and confirmatory testing used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen?
|
As substance misuse in patients on LOT is more than 30% in some series
| 0 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 908 |
What do UDTs do when used appropriately?
|
help to address safety, fairness, and trust with OT
| 258 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 909 |
What is critical due to the false positive and negative rates associated with UDTs?
|
Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS])
| 312 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 910 |
Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to what?
|
the false positive and negative rates associated with UDTs
| 441 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 911 |
What does require education and knowledge of the local procedures and clinical scenario?
|
Interpretation of a UDT and confirmatory results
| 505 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 912 |
What is required by the interpretation of a UDT and confirmatory results?
|
education and knowledge of the local procedures and clinical scenario
| 564 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 913 |
What can identify active SUD or possible diversion?
|
UDT results
| 702 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 914 |
What can UDT results do?
|
help identify active SUD or possible diversion
| 734 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 915 |
What should clinicians obtain prior to initiating or continuing LOT and periodically thereafter?
|
UDT
| 77 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 916 |
When should clinicians obtain UDT?
|
prior to initiating or continuing LOT and periodically thereafter
| 824 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 917 |
What should be done when a patient is referred for SUD treatment or is engaged in on-going treatment?
|
close communication between the SUD and pain management providers
| 989 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 918 |
What is the format of the ideal approach to communicate between the SUD and pain management providers when a patient is referred for SUD treatment or is engaged in ongoing treatment?
|
interdisciplinary
| 1,082 |
As substance misuse in patients on LOT is more than 30% in some series,[107] UDT and confirmatory testing is used as an additional method of examining for patient substance misuse and adherence to the prescribed regimen. UDTs, used in the appropriate way, help to address safety, fairness, and trust with OT. Availability of accurate and timely confirmatory testing (e.g., gas chromatography-mass spectrometry [GCMS]) is critical due to the false positive and negative rates associated with UDTs.[53] Interpretation of a UDT and confirmatory results requires education and knowledge of the local procedures and clinical scenario. Local education and access to expert interpretation is necessary. UDT results are helpful and can help identify active SUD or possible diversion. Accordingly, clinicians should obtain UDT prior to initiating or continuing LOT and periodically thereafter. When a patient is referred for SUD treatment or is engaged in on-going treatment there should be close communication between the SUD and pain management providers. The ideal approach is an interdisciplinary format (see Recommendation 16). For more information, see Appendix B on UDT and confirmatory testing.
|
Recommendations
| 919 |
What is a life-saving measure following opioid overdose?
|
Naloxone administration
| 0 |
Naloxone administration has been identified as a life saving measure following opioid overdose. A systematic review of 22 observational studies provided moderate quality evidence that take home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse events.[108] One meta-analysis of nine studies determined that take home naloxone kits were used approximately nine times within the first three months of follow-up for every 100 individuals trained.[109] Further, studies have shown that naloxone administration has been efficacious whether given by medical personnel or lay people, with more than 26,000 reversals documented by the CDC from 1996-2014.[110,111] In addition, prescription of naloxone rescue and accompanying education has also been found to reduce opioid-related emergency department visits.[112] Distribution of naloxone for reversal is supported by SAMHSA, the American Medical Association (AMA), and other medical societies, and is facilitated through the VA via Pharmacy Benefits Management. Clinical efficacy has been established for its use on short-acting opioids, but not for its use on long-acting opioids such as methadone or exceptionally potent opioids.[108]
|
Recommendations
| 920 |
When to administer Naloxone?
|
as a life saving measure following opioid overdose
| 44 |
Naloxone administration has been identified as a life saving measure following opioid overdose. A systematic review of 22 observational studies provided moderate quality evidence that take home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse events.[108] One meta-analysis of nine studies determined that take home naloxone kits were used approximately nine times within the first three months of follow-up for every 100 individuals trained.[109] Further, studies have shown that naloxone administration has been efficacious whether given by medical personnel or lay people, with more than 26,000 reversals documented by the CDC from 1996-2014.[110,111] In addition, prescription of naloxone rescue and accompanying education has also been found to reduce opioid-related emergency department visits.[112] Distribution of naloxone for reversal is supported by SAMHSA, the American Medical Association (AMA), and other medical societies, and is facilitated through the VA via Pharmacy Benefits Management. Clinical efficacy has been established for its use on short-acting opioids, but not for its use on long-acting opioids such as methadone or exceptionally potent opioids.[108]
|
Recommendations
| 921 |
Is there any evidence that take-home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse events?
|
A systematic review of 22 observational studies provided moderate quality evidence
| 96 |
Naloxone administration has been identified as a life saving measure following opioid overdose. A systematic review of 22 observational studies provided moderate quality evidence that take home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse events.[108] One meta-analysis of nine studies determined that take home naloxone kits were used approximately nine times within the first three months of follow-up for every 100 individuals trained.[109] Further, studies have shown that naloxone administration has been efficacious whether given by medical personnel or lay people, with more than 26,000 reversals documented by the CDC from 1996-2014.[110,111] In addition, prescription of naloxone rescue and accompanying education has also been found to reduce opioid-related emergency department visits.[112] Distribution of naloxone for reversal is supported by SAMHSA, the American Medical Association (AMA), and other medical societies, and is facilitated through the VA via Pharmacy Benefits Management. Clinical efficacy has been established for its use on short-acting opioids, but not for its use on long-acting opioids such as methadone or exceptionally potent opioids.[108]
|
Recommendations
| 922 |
What has reduced opioid-related emergency department visits?
|
prescription of naloxone rescue and accompanying education
| 742 |
Naloxone administration has been identified as a life saving measure following opioid overdose. A systematic review of 22 observational studies provided moderate quality evidence that take home naloxone programs are effective in improving overdose survival and decreasing mortality, with a low rate of adverse events.[108] One meta-analysis of nine studies determined that take home naloxone kits were used approximately nine times within the first three months of follow-up for every 100 individuals trained.[109] Further, studies have shown that naloxone administration has been efficacious whether given by medical personnel or lay people, with more than 26,000 reversals documented by the CDC from 1996-2014.[110,111] In addition, prescription of naloxone rescue and accompanying education has also been found to reduce opioid-related emergency department visits.[112] Distribution of naloxone for reversal is supported by SAMHSA, the American Medical Association (AMA), and other medical societies, and is facilitated through the VA via Pharmacy Benefits Management. Clinical efficacy has been established for its use on short-acting opioids, but not for its use on long-acting opioids such as methadone or exceptionally potent opioids.[108]
|
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