- Inability to maintain analgesia despite reasonable dose escalation
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- Intolerable adverse effects at dose that produces effective analgesia with unsuccessful attempts to use alternate opioids
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- Deterioration in physical, emotional, or social functioning attributed to opioid therapy
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- Persistent noncompliance with patient treatment agreement
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- Taking doses larger than those prescribed
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- Increasing dose without consulting the clinician
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- Misusing alcohol or illicit drugs
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- Injecting or inhaling oral, transdermal, topical, or sublingual formulations
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- Obtaining medications illegally or inappropriately (illegal opioid dealers, forged prescriptions, family members, the internet, multiple clinicians, multiple pharmacies)
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- Selling prescription medications or illegal drugs
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- Not adhering to nonpharmacologic components of treatment or refusing monitoring (eg, pill counts, urine drug testing, or opioid use contract)
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- Behaving in a manner that is intimidating or threatening to care providers
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- The pain has resolved
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- Any patient who is taking greater than 90 MME or concurrently using additional sedative medications
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