Box 3: Basic principles LTOT initiation, reevaluation, and treatment of LTOT ineffectiveness based on the perspective that LTOT is a therapeutic induction of physiological opioid dependence.
  1. In LTOT initiation, the patient and providers together must carefully evaluate the chances of LTOT induced physiological opioid dependence being maintained in an adaptive form with improved function and medical stability and not progressing to a maladaptive form with LTOT ineffectiveness, using predetermined clinical benchmarks to monitor it. The benchmarks of improvement in function and medical stability must be collaboratively defined by the patient and provider considering the individual characteristics of the patient.
  2. In LTOT reevaluation, the patient and provider together must determine if the physiological opioid dependence from LTOT is in an adaptive form with maintenance of improved function and medical instability or in a maladaptive form with poor function and/or medical instability. LTOT continuation and modification decisions should be made based on such a determination.
  3. In treatment of LTOT ineffectiveness, i.e., poor function, medical instability, or unacceptable risks on LTOT, the shared goal of treatment for providers and patients is to transform a maladaptive physiological opioid dependence into an adaptive form and perhaps into a non-dependent state through modification of LTOT regimen while maintaining good function, medical stability, and low risks.
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