Attachment 1 VA DoD Opioids CPG Pocket Card Print Ready.pdf

Ma y 2

M od ul e

A:

D et er m in at io n of

A pp ro pr ia te ne ss fo r O pi oi ds fo r C hr on ic

P ai n *O the r V

A/ Do

D

CP

Gs ar e a va ila ble he re

: h ttp s:/ /w ww .he alt hq ua lity

.va .go v/

A cc es s to th e fu ll gu id el in e an d ad di tio na l r es ou rc es ar e av ai la bl e at

: h ttp s:

//w w w

.h ea lth qu al ity

.v a.

go v/

Si de ba r A

: C om po ne nt s o f P ai n/ Bi op sy ch os oc ia l As se ss m en t

Co nd uc t a pa in as se ss me nt (e

.g.

, in for ma tio n a bo ut the on se t o f p ain loc ati on

, d ur ati on

, e xa ce rb ati ng fa cto rs, re lie vin g f ac tor s, wh eth er th er e is ra dia tio n [ loc ati on of th e r ad iat ion an d w ha t tr igg er s t he ra dia tio n], ho ur pa in pa tte rn

, q ua lity of pa in)

As se ss hi sto ry of pr ev iou s t re atm en ts an d e ffe ct on in ss im pa ct of pa in on da ily fu nc tio nin g a nd qu ali ty of life (e

.g.

, p ain int er fer en ce

, fa mi ly, ed uc ati on , w or k, co mm un ity

, s oc ial ac tiv itie s, sle ep qu ali ty) ss pa tie nt’ s f un cti on al go als

Ev alu ate ps yc ho log ica l/b eh av ior al fac tor s, inc lud ing su ici de ris k, a t ha t ma y a ffe ct tre atm en t (e

.g.

, p ain av oid an ce , p ain ca tas tro ph izi ng

Ev alu ate so cia l fa cto rs tha t m ay af fec t tr ea tm en t (e .g.

, e mp loy me nt, ho me les sn s) ss cu rre nt an d p as t c o-o cc ur rin g c on dit ion s ( me dic al an d be ha vio ra l h ea lth co mo rb idi tie uc t p hy sic al ex am nfi rm di ag no sis

(r ev iew pr ev iou s d iag no sti c s tud ies ns ide r c on su lta tio ns an d r efe rra ls

Pa nt be lie fs an d u nd er sta nd ing of

Th e c au se of th eir

Th eir tre atm en t p re fer en ce s

Th e p er ce ive d e ffic ac y o f v ar iou s t re atm en t o pti on s Fo r p ati en ts alr ea dy on pr es cri be d o pio ids , s ee M od ul e C a Se e t he

V A/

Do D

CP

G for th e A ss es sm en t a nd M an ag em en t o f P ati en ts at

Ri sk for

S uic ide , a va ila ble at

: h ttp s:

//w w w

.h ea lth qu al ity

.v a.

go v/

Si de ba r B

: N on

-o pi oi d

Tr ea tm en ts fo r C hr on ic

Re ha bil ita tio n a nd m an ipu lat ive th er ap ies (e

.g.

, p ro vid ed by ph ys ica l the ra pis ts, oc cu pa tio na l th er ap ist s, ch iro pr ac tor

Ph ma co log ic the ra py

(e .g.

, o ve r-t he

-co un ter m ed ica tio ns

, n on

-o pio id pr es cri pti on pa in me dic ati on

Int er ve nti on al pr oc ed ur es (e

.g.

, tr igg er po int in jec tio ns

, jo int in jec tio ns ac up un ctu re

Ps yc ho log ica l a nd be ha vio ra l in ter ve nti on s ( e.g

., m oti va tio na l int er vie wi ng , C

BT

mp lem en tar y a nd in teg ra tiv e t re atm en ts (e

.g.

, y og a, tai ch i)

Si de ba r F

: C on sid er at io ns fo r T ap er in g, D os ag e Re du ct io n, an d Di sc on tin ua tio n nt pr efe re nc nt ch ar ac ter ist ics an d n ee ds

La ck of cl ini ca lly m ea nin gfu l im pr ov em en t in fu nc tio na l g oa ls

(re vie w tre atm en t g oa ls at on se t o f tr ea tm t) om ita nt us e o f m ed ica tio ns th at inc re as e r isk of ov er do

- o cc ur rin g m ed ica l o r b eh av ior al he alt h c on dit ion s, inc lud ing

S

UD

tha t in cre as e r isk nt no n-co mp lia nc e w ith op ioi d s afe ty me as ur es an d o pio id ris k mi tig ati on st ra teg ies nt no n-pa rtic ipa tio n i n a co mp re he ns ive pa in ca re pl

Hi gh er do sa ge w hic h i nc re as es ris k o f a dv er se ev en ts (se e S ide ba r L co nd itio n n ot eff ec tiv ely tr ea ted w ith op ioi ds (e

.g.

, b ac k p ain w ith no rm al

MR

I; f ibr om ya lgi a)

Im pr ov em en t in th e u nd er lyi ng pa in co nd itio n b ein g t re ate

Si gn ific an t s ide ef fec ts

Ex pe rie nc es ov er do se or ot he r s er iou s a dv er se ev

Di ve rsi on

No

Do p ot en tia l b en ef its o ut w ei gh ri s?

id er st re ng th a nd n um be r o f r isk fa ct or s an d pa tie nt p re fe re nc e (s ee S id eb ar C

Pa tie nt w ith c hr on ic pa in

O bt ai n pa in a nd b io ps yc ho so cia l a ss es sm en t ( se e Si de ba r A

Re fe r/ co ns ul t f or a pp ro pr ia te in te rd isc ip lin ar y tr ea tm en ts

Ed uc at e/ re -e du ca te o n, im pl em en t, an d op tim ize n on -o pi oi d tr ea tm en ts fo r ch ro ni c pa in

(s ee

S id eb ar

B in clu di

Se lf-m an ag em en t t o pr om ot e he al th a nd w el ln s

No n-op io id p ha rm ac ol og ic m an ag em ph ar m ac ol og ic pa in tr ea tm en

Be vi or al th er ap ie s ( e.

g.

, c og ni tiv e be ha vi or al th er ap y)

Ph ys ica l/m ov em en t-b as ed th er ap ie s ( e.

g.

, p hy sic al th er ap y)

M ip ul at iv e th er ap ie s ( e.

g.

, c hi ro pr ac tic c e) m pl em en ta ry a nd in te gr at iv e he al th tr ea tm en ts (e

.g ac up un ct ur e)

In te rv en tio na l p ai n ca re

(e .g jo in t i nj ec tio n, ra di of re qu en cy a bl at n) al ist ic ex pe ct at io ns a nd li m ita tio ns o f m ed ica l t re at m fe r t o th e

LB

P, O

A, a nd H ea da ch e

CP

Gs a s a pp ro pr ia te fo r f ur th er c on di tio n-sp ec ifi c gu id an ce

No Ye s

No Ye s

Ye s No No

Pr oc ee to od ul e

C

Ye s

Co m pl et e op io id ri sk a ss es sm en t;

re fe r f or in te rd isc ip lin ar y pa in a nd sp ec ia lty co ul ta tio ns , a s a pp ro pr ia te

(s ee

S id eb ar

C

Ed uc at e pa tie nt a nd fa m ily a bo ut tr ea tm en t o pt io ns , i nc lu di ed uc at io n on

Kn ow n ris ks a nd u nk no w n lo ng -te rm b en ef its o f o pi oi

Ri s o f S

UD

a nd o ve rd os

Ne fo r r isk m iti ga tio n st ra te gi

Na lo xo ne re sc ue

Di sc us s a nd c om pl et e w rit te n in fo rm ed c on nt w ith p at ie nt a nd fa ily od ify a nd d oc um en t c om pr eh en siv e ag em en t p la n in clu di ng o pi oi ds

Pr oc ee d to M od ul e B

Ye s

Ye s

No 12 13

14 15

Ex it al go rit hm

; m an ag e w ith no op io id m od al iti es

Is th e pa tie nt c ur re nt ly o n op io id s f or ch ro ni c pa in

Af te r r eg ul ar fo llo w -u p an d tr ea tm en t op tim iza tio n, h as th e tr ea tm en t p la n be ef ct iv e in m an ag in g pa in a nd o pt im izi fu tio n?

Is th e pa tie nt a bl e an d w ill in g to e ng ag e a pr eh en siv e pa in c ar e pl an

Is ad di ng o pi oi pr eh en siv e pa in th er ap y in di ca te d at th is tim e?

(s

S id eb ar

D

Is pa tie nt p re pa re d to a cc ep t re sp on sib ili tie s of a nd is p ro vi de r pr ep ar ed to im pl em en t r isk iti ga tio n st ra te gi es

Ab br ev iat io ns

: C

BT

: c og nit ive be ha vio ra l th er ap y;

CP

Gs

: V A/

Do D

Cl ini ca l

Pr ac tic e G uid eli ne s;

LB

P:

lo w ba ck pa in;

M

AT

: m ed ica tio n a ss ist ed tr ea tm en t;

ME

DD

: m or ph ine e qu iva len t d ail y d os e;

mg : m illi gr am (s)

; M

OU

D:

m ed ica tio n f op ioi d u se di so rd er

; M

RI

: m ag ne tic re so na nc e im ag ing

; O A:

os teo ar thr itis

OE

ND

: O ve rd os e Ed uc ati on an d N alo xo ne

D ist rib uti on ; O

UD

: o pio id us e dis or de r;

PD

MP

: P re sc rip tio n D ru g

Mo nit or ing

P ro gr am

; S

UD

: s ub sta nc e us e dis or de rs;

U

DT

: u rin e d ru g tes tin g;

VA

/D oD

S

UD

C

PG

: V A/

Do D

Cl ini ca l P ra cti ce

Gu ide lin e f or th e M an ag em en t o f S ub sta nc e Us e D iso rd er s

A dd iti on al S id eb ar s re fe re nc ed th ro ug ho ut th e al go rit hm c an b e fo un d in th e fu ll gu id el in e (o n pa ge s

-3 2)

Th e

U se o f O pi oi ds in th ag em en t o f C hr on ic P ai n

VA

/D oD C

LI

NI

CA

L

PR

AC

TI

CE

G

UI

DE

LI

NE

S

VA

/D oD C

LI

NI

CA

L

PR

AC

TI

CE

G

UI

DE

LI

NE

S

Ma y 2

M od ul e

C : M ai nt ai ni ng , T ap er in g, D is co nt in ui ng , o r S w itc hi ng fr om F ul l A go ni st O pi oi ds

No

Ar e on e of th e fo llo w in g pr es t?

nt re sis ta nc e to ta r

Hi gh ri sk o r d an ge ro us b eh av rs

(in clu di ng e le va te d ris k of su ici de cr ea se in p at ie nt d ist re ss

No

Re pe at c om pr eh en siv e bi op sy ch os oc ia l as se ss m en t ( se e

Si de ba rs

A a nd C

In di ca tio n to d isc on tin ue , c on tin ue , t ap er

, o r r ed uc e tr ea tm en t w ith o pi oi ds (s ee S id eb ar s H a

I)

Ad dr es s s af et y an d m isu ss fo r e le va te d su ici de ri ss fo r w ith dr aw al sy m pt om s a nd o ffe r e xp ed ite d ta pe r, im m ed ia sc on tin ua tio n, o r m ed ica lly -a ss ist ed w ith dr aw al a s i nd ica in ue to m on ito r f or S

UD

a nd b eh av io ra l h ea lth c om or bi di tie s a r t re at m en t a s i nd ica te d (s ee V

A/ Do

D

SU

D

CP

G* a nd A ca de m ic

De ta ili ng

T ap er in g Do cu m t) id er sw itc h to p ar tia l a go ni st o pi oi ds o r t ap er o pi oi on tin ua tio n (s ee S id eb

J) ag e w ith n on -o pi oi d m od al iti es

(s ee

S id eb ar

B it al go rit hm

De ve lo p in di vi du al ize d tr ea tm en t p la n

(in clu di ng p ac ta rin g if ap pl ica bl e an d se tt in g of c ar

e) b as ed o n pa tie nt a nd tr ea tm en t c ha ra ct er ist ics

(s ee

S id eb ar

J an d Re co m m en da tio ns an d

Ye at e or re fe r t o

SU

D tr ea tm en t w ith a pp ro pr ia te m on ito rin g an d fo llo w up

(e .g

M

O

UD

, t re at m en t f or co m or bi di tie s)

(s ee

V A/

Do D

SU

D

CP

G* id er sw itc h to p ar tia l a go ni st o pi oi ds o r t ap er o pi oi on tin ua tio n

(s ee

S id eb

J) ag e w ith n on

-o pi oi d m od al iti es (s ee S id eb ar B it al go rit hm

Ye s

No

34 36

Ye

Fo llo w

-u p as cl in ica lly in di ca te d af te r e ac h ch an ge in d os ag e an d af te r di sc on tin ua tio n, c on sid er in g pa tie nt a nd tr ea tm en t c ha ra ct er ist ics id er th e fo llo w in g at e ac h in te ra ct io n w ith p at ie

Ed uc at e on se lf-m an ag em en t a nd ri sk s o f o pi oi ds

(s ee

S id eb ar

K

O pt im ize w ho le p er so n ap pr oa ch to p ai n ca im ize tr ea tm en t o f c o-oc cu rr in g be ha vi or al h ea lth c on di im ize n on

-o pi oi d pa in tr ea tm en t m od al as se ss fo r O

UD

a nd re ad in es s f or O

UD

tr ea tm en t a s i nd ica

If nt in ui ng tr ea tm en t w ith o pi oi ds

, u se th e fo llo w in g ap pr oa

Sh te st d ur at

Us lo w es t e ffe ct iv e do se (r ec og ni zin g th at n o do se is c om pl et el y sa ov er do se ri sk in cr ea se s a t d os es

-5 m g M

ED

D)

(s ee

S id eb

L) in ua l a ss es sm en t o f i m pr ov em en t i n pa in a nd fu nc tio na l s ta tu s a ad rs e ef fe ct s

Ye s

Do es th e pa tie nt d em on st ra sig o r s ym pt om s o f S

UD

(s ee V

A/ Do

D

SU

D

CP

G*

Is th er e ev id en ce o f d iv er sio n?

Is th er e hi gh ri sk o r d an ge ro us vi or (e

.g ov er do se e ve nt ac cid en ts

, t hr ea te ni ng p ro vi de r)?

**A cc or din g t o t he C

DC

, d ru g d ive rsi on is w he n p re sc rip tio n m ed ici ne s a re ob tai ne d or us ed ille ga lly

*V A/

Do D

SU

D

CP

G is av ail ab le he re : h ttp s:

//w w w .h ea lth qu al ity .v a.

go v/

Ye s

Ye s

Ye s

Do es th e pa tie nt w an t t o co nt ue op id th er ap y?

Ca nd id at e fo r o pi oi ds w ith co ns en t ( be gi n a tr ia l i n co nj un ct io n w ith c om pr eh en siv e pa in c ar e pl an

In iti at e op io id s u sin g th e fo llo w in g ap pr oa sh or t d ur at io n

(e .g

1-w ee k in iti al p re sc rip n)

Pl to re ev al ua te a t 3 da ys o r f ew lo w es t e ffe ct iv e do se

, r ec og ni zin g th at n o do se is c om pl et el y sa

A st ra te gy o f e sc al at in g do se to a ch ie ve b en ef it in cr ea se s r isk (s ee Si de ba r L an d ha s n ot b ee n sh ow n to im pr ov e fu nc

Lo

-a ct in g op io id s s ho ul d no t b e pr es cr ib ed fo r o pi oi d-na ïv e in di vi du al s

(s m m en da tio n a nd

A pp en di x D) id er a lte rn at iv es to m et ha do ne a nd tr an sd er m al fe nt an yl (s ee A pp en di x

D) ss im pr ov em en t i n pa in a nd fu nc tio na l s ta tu s a nd a dv er se e ffe ct pl et e ris k m iti ga tio n st ra te gi es (s ee S id eb ar E

Pr ov id e m ed ica tio n an d ov er do se e du ca tio n, o ffe r n al ox on e pr es cr ip tio n

Re ev al ua tio n as n ee de d cli ni ca lly a nd b as ed o n pa tie nt ri sk fa ct or s (e

.g

1-w ee ks a fte r i ni tia tio n of o pi oi ds , n ot la te r t ha n d ay ss

Fu tio n, p la n, ri sk s, an d be ne fit s o f o pi rs e ef fe ct he re nc e to tr ea tm en t p la pl ica tio ns o r c o-oc cu rr in g co nd iti on s (e

.g m ed ica l, be ha vi he th , a nd /o r S

UD

nt p re fe re pl et e ris k m iti ga tio n st ra te gi es (s ee S id eb ar vi ew a nd o pt im ize c om pr eh en siv e pa in c ar e pl an (e

.g no n-op id tr ea tm en ts , s el f-m an ag em en t s tr at eg ie

Ta r t o di sc on tin ua tio n

(c on su lt

M od ul e

C if ne ed ag e w ith n on -o pi oi d m od al iti es

Is th er e cli ni ca lly m ea ni ng fu l i m pr ov em en t i n fu nc tio n an d pa in th at o ut w ei gh s r isk s?

Pr ov id e m ed ica l a nd /o r b eh av io ra l h ea lth tr ea tm en t t o st ab ili ze a s i nd ica te d;

c on sid er ta pe rin g op io id s t o di sc on tin ua tio n

(c on su lt

M od ul e

C)

Is th e pa tie nt su ffi cie nt ly m ed ica lly a vi or al ly s ta bl e to co nt in ue o pi oi d m ed ica tio n?

Co ns id er o ne o r m or e of th e fo llo w g:

Sh te ni ng p re sc rib in g in te rv ns ify in g ris k m iti ga tio n st ra te gi es

(s ee

S id eb ar rr in g to in te rd isc ip lin ar y ca ul tin g w ith o r r ef er rin g to sp ec ia lty c

Sw itc hi ng to p ar tia l a go ni st o pi

Se

VA

/D oD S

UD

C

PG

if th er e ar e in di ca tio ns o f O

UD

Re as se ss in

-3 m on th s o r m or e fre qu en tly a s d et er m by p at ie nt ri sk fa ct or s ( se e Si de ba r G

Ta pe r t o re du ce d do se o r t ap on tin ua tio n;

p ro ce ed to

M od ul e

C

Ar e th er e fa ct or s t ha t i nc re as e ris ks o f o pi

(e

.g no n-ad he re nc e, c o-oc cu rr in g co nd iti on s, in di ca tio ns o f O

UD

Ar e th er e in di ca tio ns to d isc on tin ue ta pe r?

(s ee S id eb ar F

Ye s

No

Ye s

No

No

No No

M od ul e

B : I ni tia tio n of T re at m en t w ith

O pi

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/HRV (Za stvaranje Adobe PDF dokumenata najpogodnijih za visokokvalitetni ispis prije tiskanja koristite ove postavke. Stvoreni PDF dokumenti mogu se otvoriti Acrobat i Adobe Reader 5.0 i kasnijim verzijama.)

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Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.)

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