Opioid Taper Decision Tool

Pain Management

A VA Clinician's Guide

VA PBM Academic Detailing Service

Real Provider Resources

Real Patient Results

Your Partner in Enhancing Veteran Health Outcomes

VA PBM Academic Detailing Service Email Group:

PharmacyAcademicDetailingProgr[email protected]

VA PBM Academic Detailing Service SharePoint Site:

https://vaww.portal2.va.gov/sites/ad/SitePages/Home.aspx

VA PBM Academic Detailing Public WebSite:

http://www.pbm.va.gov/PBM/academicdetailingservicehome.asp

The Opioid Taper Decision Tool is designed to assist Primary

Care providers in determining if an opioid taper is necessary

for a specic patient, in performing the taper, and in

providing follow-up and support during the taper.

Opioid prescribing recommendations: summary of 2016 CDC Guidelines

Determining when to

initiate or continue

opioids for chronic pain

• Opioids are not rst-line

or r

outine therapy

• Establish treatment goals

before starting opioid

therapy and a plan if

therapy is discontinued

• Only continue opioid

if there is clinically

meaningful improvement

in pain and function

• Discuss risks, benets

and responsibilities for

managing therapy before

starting and during

treatment

Opioid selection, dosage,

duration, follow-up and

discontinuation

• Use immediate-release

(IR) opioids when star

ting

therapy

• Prescribe the lowest

eective dose

• When using opioids for

acute pain, provide no

more than needed for the

condition

• Follow up and review

benets and risks before

starting and during therapy

• If benets do not outweigh

harms, consider tapering

opioids to lower doses or

taper and discontinue

Assessing risk and

addressing harms of

opioid use

• Oer risk mitigation

str

ategies, including

naloxone for patients at

risk for overdose

• Review PDMP

data at

least every 3 months and

perform UDT

at least

annually

***

• Avoid prescribing opioid

and benzodiazepines

concurrently when

possible

• Clinicians should oer or

arrange MAT

****

for patients

with OUD

†

Prescription drug monitoring program

Urine drug testing

***

Some VA facilities may require more frequent testing

****

Medication-assisted treatment

†

Opioid use disorder

Possible reasons to re-evaluate the risks and benets of continuing

opioid therapy:

Opioids are associated with many risks and it may be determined that they are not indicated for pain

management for a particular Veteran.

• No pain reduction, no

improvement in function

or patient requests to

discontinue therapy

• Severe unmanageable

adverse eects (e.g.,

drowsiness, constipation,

cognitive impairment)

• Dosage indicates high risk

of adverse events (e.g.,

doses of 90 MEDD* and

higher)

• Non-adherence to the

treatment plan or unsafe

behaviors

(e.g., early rells,

lost/stolen prescription,

buying or borrowing

opioids, failure to obtain or

aberrant UDT

***

)

• Concerns related to an

increased risk of SUD

****

(e.g., behaviors, age < 30,

family history, personal

history of SUD

†

)

• Overdose event involving

opioids

• Medical comorbidities that

can increase risk (e.g., lung

disease, sleep apnea, liver

disease, renal disease, fall

risk, advanced age)

• Concomitant use of

medications that increase

risk (e.g., benzodiazepines)

• Mental health

comorbidities that can

worsen with opioid therapy

(e.g., PTSD, depression,

anxiety)

Consider Tapering Opioid

Prior to any changes in therapy, discuss the risks of continued use, along with

possible benets, with the Veteran. Establish a plan to consider dose reduction,

consultation with specialists, or consider alternative pain management strategies.

Morphine equivalent daily dose

Consider assessment for opioid use disorder (OUD)

***

Urine drug test

****

Substance use disorder

†

Personal history of SUD includes alcohol use disorder (AUD), opioid use disorder (OUD), and/or a use disorder involving other substances

When considering an opioid taper, monitor for conditions that may

warrant evaluation and arrange primary care and/or emergency

department follow-up when indicated:

Disorders that may need urgent evaluation

If a patient is taking more than their prescribed dosage of opioids or showing signs of aberrant

behavior, before deciding to change therapy, look for the following “red ags”:

Progressive numbness or weakness

Progressive changes in bowel or bladder

function

Unexplained weight loss

History of internal malignancy that has not

been re-staged

Signs of/risk factors for infection

(fever, recent skin or urinary infection,

immunosuppression, IV drug use)

Ensure screening and treatment is oered for conditions that

can complicate pain management before initiating opioid taper:

1, 3, 4

Mental health disorders (e.g., PTSD, anxiety disorders, depressive disorders)

• If suicidal, then activate suicide prevention plan.

• If high suicide risk or actively suicidal, consult with mental health provider before beginning taper.

Opioid use disorder (OUD) and other substance use disorders (SUD)

• The lifetime prevalence for OUD among patients receiving long-term opioid therapy is estimated

to be about 41%: approximately 28% for mild symptoms, 10% for moderate symptoms and 3.5%

for severe symptoms of OUD.

• Patients with chronic pain who develop OUD from opioid analgesic therapy need to have BOTH

pain and OUD addressed. Either tapering the opioid analgesic or continuing to prescribe the

opioid without providing OUD treatment may increase the risk of overdose and other adverse

events. Refer to DSM 5 criteria for OUD.

• Use a shared decision-making approach to discuss options for OUD treatment:

– First-line: Medication Assisted Therapy (MAT)

— PREFERRED: Opioid Agonist Therapy (OAT)—buprenorphine/naloxone (Suboxone®)

or methadone maintenance

— ALTERNATIVE: Extended Release (ER) Injectable Naltrexone (Vivitrol®)

– MAT can be provided in a variety of treatment settings including: residential SUD treatment,

intensive outpatient SUD treatment, regular SUD specialty care clinic, primary care or general

mental health clinic, or federally regulated opioid treatment program.

Methadone must be provided through a federally regulated opioid treatment program for OUD therapy.

“Moral injury” (inner conict)

• An act of transgression that leads to serious inner conict typically brought on by:

– Betrayal, disproportionate violence, incidents involving civilians, within-rank violence

• Treatment via psychologists or chaplains is available

Central sensitization (e .g., bromyalgia, chronic headaches, and likely many other types of complex

chronic pain)

Medical complications (e.g., lung disease, hepatic disease, renal disease, or fall risk)

Sleep disorders including sleep apnea

When a decision is made to taper, special attention must be given to ensure that the Veteran does

not f

eel abandoned

. P

rior t

o an

y changes being made in opioid pr

escribing

, a discussion should

cur bet

een the

eteran, family members/caregivers, and the provider either during a face-to-

face appointment or on the telephone.

Using all the following strategies will help in the transition:

Discussion Ask about goals Educate the Veteran

• Listen to the Veteran’s

story

• Let the Veteran know

that you believe that

their pain is real

• Include family

members or other

supporters in the

discussion

• Acknowledge the

Veteran’s fears

about tapering

[use Motivational

Interviewing (MI)

techniques]

• Draw out their goals for life

(not just being pain-free)

• Have the Veteran ll out the

Personal Health Inventory

(PHI)

• Ask how we can support

them during the taper

• Use Bio-Psycho-Social Model

– e.g., PHI’s “Whole Health”

approach

• Oer Veterans pain education groups

[especially Cognitive Behavioral

Therapy (CBT) or Acceptance and

Commitment Therapy (ACT) for Pain,

if available]

• Oer physical therapy and

Complementary and Integrative

Health (CIH) interventions such as:

– acupuncture, meditation, yoga

• Slowly tapering opioids to reduce

opioid risks while not “cutting o” the

Veteran

• Oer non-opioid pain medications

when appropriate

• Commit to working with the Veteran

on other options for improved

function and some decrease in pain

PHI’s Whole Health Approach: http://www.va.gov/PATIENTCENTEREDCARE/explore/about-whole-health.asp

Pain Management Opioid Safety VA Education Guide 2014, pages 5-6: https://vaww.portal2.va.gov/sites/ad/SitePages/Pain%20Management.aspx

Considerations when formulating an opioid taper plan:

• Determine if the initial goal is a dose reduction or complete discontinuation. If initial goal is

determined to be a dose reduction, subsequent regular reassessment may indicate that complete

discontinuation is more suitable.

• Several factors go into the speed of taper selected:

– Slower, more gradual tapers are often the most tolerable and can be completed over several

months to years based on the opioid dose.

– The longer the duration of previous opioid therapy, the longer the taper may take.

Most commonly, tapering will involve dose

reduction of 5% to 20% every 4 weeks.

• More rapid tapers may be required in certain instances like drug diversion, illegal activities, or

situations where the risks of continuing the opioid outweigh the risks of a rapid taper.

• Document the rationale for the opioid taper and the opioid taper schedule in the Veteran’s

medical record.

 Provide opioid overdose education and prescribe naloxone to patients at increased

risk of overdose.

 Strongly caution patients that it takes as little as a week to lose their tolerance and

that they are at risk of an overdose if they resume their original dose.

 Patients are at an increased risk of overdose during this process secondary

to reduced tolerance to opioids and the availability of opioids and heroin in

the community.

Example Tapers for Opioids

5-9

Slowest Taper

(over years)

Reduce by 2 to 10%

every 4 to 8 weeks

with pauses in taper

as needed

Consider for patients

taking high doses of

long-acting opioids for

many years

Slower Taper (over

months or years)

Reduce by 5 to 20%

every 4 weeks with

pauses in taper as

needed

MOST COMMON

TAPER

Faster Taper

(over weeks)

****

Reduce by 10 to 20%

every week

Rapid Taper

(over days)

****

Reduce by 20 to 50%

of rst dose if

needed, then reduce

by 10 to 20% every

day

Ex: morphine SR 90 mg

Q8h = 270 MEDD

Month 1: 90 mg SR

qam, 75 mg noon,

90 mg qpm [5%

reduction]

Month 2: 75 mg SR

qam, 75 mg noon,

90 mg qpm

Month 3: 75 mg SR

(60 mg+15 mg) Q8h

Month 4: 75 mg SR

qam, 60 mg noon,

75 mg qpm

Month 5: 60 mg SR

qam, 60 mg noon,

75 mg qpm

Month 6: 60 mg SR

Q8h

Month 7: 60 mg SR

qam, 45 mg noon,

60 mg qpm

Month 8: 45 mg SR

qam, 45 mg noon,

60 mg qpm

Month 9: 45 mg SR

Q8h

Ex: morphine SR 90 mg

Q8h = 270 MEDD

Month 1:

75 mg (60 mg+15

mg)SR Q8h [16%

reduction]

Month 2:

60 mg SR Q8h

Month 3:

45 mg SR Q8h

Month 4:

30 mg SR Q8h

Month 5:

15 mg SR Q8h

Month 6:

15 mg SR Q12h

Month 7:

15mg SR QHS,

then stop

***

Ex: morphine SR 90 mg

Q8h = 270 MEDD

Week 1:

75 mg SR Q8h

[16% reduction]

Week 2:

60 mg SR (15 mg x 4)

Q8h

Week 3:

45 mg SR (15 mg x 3)

Q8h

Week 4:

30 mg SR (15 mg x 2)

Q8h

Week 5:

15 mg SR Q8h

Week 6:

15 mg SR Q12h

Week 7:

15 mg SR QHS x 7

days, then stop

***

Ex: morphine SR 90 mg

Q8h = 270 MEDD

Day 1:

60 mg SR (15 mg x 4)

Q8h [33% reduction]

Day 2:

45 mg SR (15 mg x 3)

Q8h

Day 3:

30 mg SR (15 mg x 2)

Q8h

Day 4:

15 mg SR Q8h

Days 5-7:

15 mg SR Q12h

Days 8-11:

15 mg SR QHS, then

stop

***

Continue the taper based on Veteran response. Pauses in the taper may allow the patient time to acquire new skills for management of pain and emotional distress

while allowing for neurobiological equilibration.

Continue following this rate of taper until o the morphine or the desired dose of opioid is reached.

***

May consider morphine IR 15 mg ½ tablet (7.5 mg) twice daily.

****

Rapid tapers can cause withdrawal eects and patients should be treated with adjunctive medications to minimize these eects; may need to consider admitting

the patient for inpatient care. If patients are prescribed both long-acting and short-acting opioids, the decision about which formulation to be tapered rst should be

individualized based on medical history, mental health diagnoses, and patient preference. Data shows that overdose risk is greater with long-acting preparations.

Communicate the opioid taper plan to the Veteran

Example: Veteran is currently taking morphine SR 60 mg, 1 tablet every 8 hours. Goal is to reduce dose

of morphine to SR 30 mg every 8 hours using a slow taper. Dose will be reduced by 15 mg every 10 days.

Using morphine SR 15 mg tablets, follow the schedule below:

Morning Afternoon Evening

Days 1 to 10 4 tablets = 60 mg 3 tablets = 45 mg 4 tablets = 60 mg

Days 11 to 20 3 tablets = 45 mg 3 tablets = 45 mg 4 tablets = 60 mg

Days 21 to 30 3 tablets = 45 mg 3 tablets = 45 mg 3 tablets = 45 mg

Scenario 1: Veteran is tolerating the taper

Scenario 2: Veteran is resisting further reduction

*If the Veteran is resisting further dose reductions, explore the reason for the reluctance: medical (increased pain), mental health (worsening depression, anxiety,

etc.), and substance use disorder (SUD)/opioid use disorder (OUD). Refer to OUD Provider Education Guide on VA PBM Academic Detailing SharePoint for more

information. https://vaww.portal2.va.gov/sites/ad/SitePages/OUD.aspx

**If possible, the Veteran should be actively involved in skills training and/or have a comprehensive pain care plan.

Follow up with the Veteran during the taper:

Follow Up Slowest Taper

(over years)

Slower Taper

(over months)

Faster Taper

(over weeks)

Rapid Taper

(over days)

When 1 to 4 weeks

after starting

taper then

monthly before

each reduction

1 to 4 weeks

after starting

taper then

monthly before

each reduction

Weekly before

each dose

reduction

Daily before each

dose reduction or

if available oer

inpatient admission

Who PACT Team

How Clinic and/or

telephone

Clinic and/or

telephone

Clinic and/or

telephone

Hospital, clinic or

telephone

What Patient function,

***

pain intensity, sleep, physical activity, personal goals, and stress level

Follow-up for tapering is recommended to be a team function with various team members taking on roles in which they have demonstrated specic competencies.

Mental health practitioners may need to be included in the follow-up plan.

Providers will need to determine whether a telephone or in-clinic appointment is appropriate based on the risk category of the Veteran. A Veteran with high risk due

to a medical condition may have decompensation during the taper and may require a clinic visit over telephone follow-up. If there are issues with the Veteran obtaining

outside prescriptions or they are displaying other aberrant behaviors during the taper, providing follow-up in a clinic visit may be more optimal than a telephone visit.

***

Quality of Life Scale for patients with pain: https://www.theacpa.org/uploads/documents/Quality_of_Life_Scale.pdf

Manage withdrawal symptoms during the taper:

Short-term oral medications can be utilized to assist with managing the withdrawal

symptoms, especially when prescribing fast tapers. Do not treat withdrawal symptoms with

an opioid or benzodiazepine.

Early Symptoms

(hours to days)

Late Symptoms

(days to weeks)

Prolonged Symptoms

(weeks to months)

• Anxiety/restlessness

• Rapid short respirations

• Runny nose, tearing eyes,

sweating

• Insomnia

• Dilated reactive pupils

• Runny nose, tearing eyes

• Rapid breathing, yawning

• Tremor, diuse muscle

spasms/aches

• Piloerection

• Nausea, vomiting, and

diarrhea

• Abdominal pain

• Fever, chills

• Increased white blood cells

if sudden withdrawal

• Irritability, fatigue

• Bradycardia

• Decreased body temperature

• Craving

• Insomnia

Consider use of adjuvant medications during the taper to reduce

withdrawal symptoms:

6-9, 11-19

Short-term oral medications can be utilized to assist with managing the withdrawal symptoms,

especially during fast tapers.

Indication Treatment Options

Autonomic symptoms

(sweating, tachycardia,

myoclonus)

First line

• Clonidine 0.1 to 0.2 mg oral every 6 to 8 hours; hold dose if blood pressure

<90/60 mmHg (0.1 to 0.2 mg 2 to 4 times daily is commonly used in the

outpatient setting)

– Recommend test dose (0.1 mg oral) with blood pressure check

1 hour post dose; obtain daily blood pressure checks; increasing dose

requires additional blood pressure checks

– Re-evaluate in 3 to 7 days; taper to stop; average duration 15 days

Alternatives

• Baclofen 5 mg 3 times daily may increase to 40 mg total daily dose

– Re-evaluate in 3 to 7 days; average duration 15 days

– May continue after acute withdrawal to help decrease cravings

– Should be tapered when it is discontinued

• Gabapentin start at 100 to 300 mg and titrate to 1800 to 2100 mg divided in

2 to 3 daily doses

– Can help reduce withdrawal symptoms and help with pain, anxiety,

and sleep

• Tizanidine 4 mg three times daily, can increase to 8 mg three times daily

Anxiety, dysphoria,

lacrimation, rhinorrhea

• Hydroxyzine 25 to 50 mg three times a day as needed

• Diphenhydramine 25 mg every 6 hours as needed

Myalgias • NSAIDs (e.g., naproxen 375 to 500 mg twice daily or ibuprofen 400 to 600

mg four times daily)

***

• Acetaminophen 650 mg every 6 hours as needed

• Topical medications like menthol/methylsalicylate cream, lidocaine

cream/ointment

Sleep disturbance • Trazodone 25 to 300 mg orally at bedtime

Nausea • Prochlorperazine 5 to 10 mg every 4 hours as needed

• Promethazine 25 mg orally or rectally every 6 hours as needed

• Ondansetron 4 mg every 6 hours as needed

Abdominal cramping • Dicyclomine 20 mg every 6 to 8 hours as needed

Diarrhea • Loperamide 4 mg orally initially, then 2 mg with each loose stool, not to

exceed 16 mg daily

• Bismuth subsalicylate 524 mg every 0.5 to 1 hour orally, not to exceed

4192 mg/day

adjust dose if renal impairment;

avoid in Veterans > 65 years old;

***

caution in patients with risk GI bleed, renal compromise, cardiac disease

Online Resources Available:

Brainman & Understanding Pain (2-3 min):

• http://www.dvcipm.org/clinical-resources/joint-pain-education-project-jpep

Videos for Veterans to understand their own role in healing from the American Chronic Pain Association (ACPA):

• Four at tires: http://www.theacpa.org/a-car-with-four-at-tires

• Veterans in Pain: http://www.theacpa.org/video/veteransinpain

Videos Instructing on Self-paced Exercise:

• Exercise Guidelines: http://www.youtube.com/watch?v=gN-WwxfPIZo

Other web-based Education for Back Pain, Neck Pain, and Headaches:

• http://www.knowyourback.org/Pages/BackPainPrevention/Exercise/ExerciseVideo.aspx

• http://www.knowyourback.org/Documents/Cervical_Exercise.pdf

Deep Breathing Exercises:

• http://www.youtube.com/watch?v=YdsipKCACac

• http://www.t2.health.mil/apps/breathe2relax (Phone app)

Progressive Muscle Relaxation Techniques:

• http://www.militaryonesource.mil/deployment?content_id=269532

Opioid Overdose Education and Naloxone Distribution (OEND) Implementation SharePoint:

• https://vaww.portal2.va.gov/sites/mentalhealth/OEND/default.aspx

VA Dashboards That Can Identify High-Risk Veterans on Opioid Therapy:

• OTRR (VSSC Opioid Therapy Risk Report)

https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/PC/Almanac/PAIN_ProviderWEB&rs:Command=Render

• OSI (Opioid Safety Initiative) Dashboard

http://vhacmnreport08t.vha.med.va.gov/Reports/Pages/Folder.aspx?ItemPath=/External/PBM/

Opioid+Safety+Initiative+Dashboard&ViewMode=List

• STORM tool

https://spsites.cdw.va.gov/sites/OMHO_PsychPharm/Pages/Real-Time-STORM-Dashboard.aspx

This discussion tool was written by:

Julianne Himstreet, Pharm.D., BCPS

Sarah Popish, Pharm.D., BCPP

Ilene Robeck, MD

Michael Saenger, MD

Special thanks to our expert reviewers:

Michael Chaman, Pharm.D., BCPS

Friedhelm Sandbrink, MD

Steven Mudra, MD

Aram Mardian, MD

References:

1. Dowell D, Haegerich TM, Chou R; CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR 2016;65(1-49).

2. Atlas SJ, Deyo RA; Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001 Feb; 16(2):

120–131. doi: 0.1111/j.1525-1497.2001.91141.x

3. DSM-5 Criteria for Opioid Use Disorder: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders Fifth

Edition. 2013.

4. J. A. Boscarino, S. N. Homan, and J. J. Han, “Opioid-use disorder among patients on long-term opioid therapy: impact of nal DSM-5

diagnostic criteria on prevalence and correlates.,” Subst. Abuse Rehabil., vol. 6, pp. 83–91, Jan. 2015.

5. Canadian Guideline for Safe and Eective Use of Opioids for Chronic Non‐Cancer Pain — Part B: Recommendations for Practice, Version

5.5. April 30, 2010. [NOUGG] Accessed at: http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf

6. Berna C, Kulich RJ, Rathmell JP. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for

Everyday Practice. Mayo Clin Proc. 2015:90(6):828-842.

7. Kral, LA; Jackson K, Uritsky TJ. A practical guide to tapering opioids. Ment Health Clin (internet). 2015;5(3):102-108. DOI: 10.9740/

mhc.2015.05.102.

8. Chou R, Fanciullo GJ, Fine PG, Adler JA, et al. Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. J Pain.

2009;10(2):113-30. DOI: 10.1016/j.jpain.2008.10.008.

9. Kahan M, Wilson L, Mailis-Gagnon A, Srivastava A, National Opioid Use Guideline G. Canadian guideline for safe and eective use

of opioids for chronic non-cancer pain: clinical summary for family physicians. Part 2: special populations. Can Fam Physician.

2011;57(11):1269-76, e419-28.

10. American Society of Addiction Medicine (ASAM) National practice guideline for the use of medications in the treatment of addiction

involving opioid use. 2015. Available from: http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-

docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24

11. Micromedex Drugdex Evaluations. Thomson Micromedex. Greenwood Village, CO. Available at: http://www.thomsonhc.com. Accessed

March 19, 2012.

12. Charney DS, Sternberg DE, Kleber HD, et. al. The clinical use of clonidine in abrupt withdrawal from methadone. Eects on blood

pressure and specic signs and symptoms. Arch Gen Psychiatry. 1981 Nov;38(11):1273-7.

13. Mattick RP, Hall W. Are detoxication programmes eective? Lancet. 1996 Jan 13;347(8994):97-100.

14. Boscarino JA, Homan SN, Han JJ. Opioid-use disorder among patients on long-term opioid therapy: impact of nal DSM-5 diagnostic

criteria on prevalence and correlates. Substance Abuse and Rehabilitation 2015:6 83–91

15. Canadian Guideline for Safe and Eective Use of Opioids for Chronic Non‐Cancer Pain Part B: Recommendations for Practice, Version

5.5 April 30, 2010. [NOUGG] Accessed at: http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf

16. Ahmadi-Abhari SA, Akhondzadeh S, Assadi SM, Shabestari OL, Farzanehan SM, Kamlipour A. Baclofen versus clonidine in the

treatment of opiates withdrawal, side-eects aspect: a double-blind randomized controlled trial. Journal of Clinical Pharmacy and

Therapeutics 2001;26:67-71

17. Akhondzadeh S, Ahmadi-Abhari SA, Assadi SM, Shabestari OL, Kashani AR, Farzanehgan SM. Double-blind randomized controlled trial

of baclofen in the treatment of opiates wit Journal of Clinical Pharmacy and Therapeutics 2000; 25:347-353.

18. Assadi SM, Radgoodarzi R, Ahmadi-Abhari SA. BMC Psychi atry. Baclofen for maintenance treatment of opioid dependence: A

randomized double-blind placebo-controlled clinical trial. 2003;3:16-26.

19. de Beaurepaire, R. Suppression of alcohol dependence using baclofen: a 2 year observational study of 100 patients. Frontiers in

Psychiatry. 2012;103: 1-7.

Notes

U.S. Department of Veterans Affairs

This reference guide was created to be used as a tool for VA providers and is available

to use from the Academic Detailing SharePoint.

These are general recommendations only; specic clinical decisions should be made

by the treating provider based on an individual patient’s clinical condition.

VA PBM Academic Detailing Service Email Group:

PharmacyAcademicDetailingPro[email protected]

VA PBM Academic Detailing Service SharePoint Site:

https://vaww.portal2.va.gov/sites/ad/SitePages/Home.aspx

VA PBM Academic Detailing Public Website:

http://www.pbm.va.gov/PBM/academicdetailingservicehome.asp

October 2016 IB 10-939 P96820