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Course #95060 - $15-
| A) | Add a benzodiazepine at bedtime to reduce opioid requirements. | ||
| B) | Adjust pregabalin dosing to the patient's creatinine clearance. | ||
| C) | Make no changes unless confusion, dizziness, or dyspnea develop. | ||
| D) | Maintain standard pregabalin dosing because it is primarily hepatically cleared. |
Screen all patients receiving opioids for concurrent gabapentinoid use.
When combination therapy is necessary, use the lowest effective doses and titrate slowly.
Monitor for confusion, dizziness, and difficulty breathing—particularly in patients older than 65 years of age.
Adjust gabapentinoid dosing based on creatinine clearance.
Educate patients about signs of respiratory depression and when to seek emergency care.
| A) | 10-fold. | ||
| B) | 1.5-fold. | ||
| C) | 3- to 5-fold. | ||
| D) | No significant increase |
For patients with anxiety disorders, insomnia, or alcohol use disorder (conditions frequently comorbid with chronic pain) the temptation to prescribe benzodiazepines alongside opioids is substantial. However, research consistently demonstrates that this combination increases overdose risk by 3- to 5-fold [9].
| A) | Tramadol | ||
| B) | Morphine | ||
| C) | Meperidine | ||
| D) | Tapentadol |
Assess depression and anxiety in all patients with chronic pain, as these conditions are highly comorbid.
Avoid tramadol, meperidine, and tapentadol in patients on SSRIs or SNRIs.
When serotonergic agents are necessary, choose opioids without serotonergic activity (e.g., morphine, hydromorphone, oxycodone).
Monitor for serotonin syndrome symptoms (e.g., agitation, confusion, rapid heart rate, dilated pupils, tremor, muscle rigidity)
Educate patients about over-the-counter medications with serotonergic properties (e.g., dextromethorphan, St. John's wort)
| A) | 1 gram/day | ||
| B) | 2 grams/day | ||
| C) | 3 grams/day | ||
| D) | 4 grams/day |
Acetaminophen remains a first-line analgesic for musculoskeletal pain, with good safety profiles in most multimorbid patients. Maximum daily dosing should be reduced to 3 grams (rather than 4 grams) in older adults, those with hepatic impairment, or chronic alcohol use [16]. For patients on multiple medications, verify that acetaminophen is not duplicated in combination products.
| A) | Immediate-release oxycodone | ||
| B) | Oral NSAIDs such as naproxen | ||
| C) | Scheduled systemic corticosteroids | ||
| D) | Topical agents (e.g., diclofenac gel or lidocaine patches) |
Topical NSAIDs such as diclofenac gel and lidocaine patches offer localized pain relief with minimal systemic absorption, making them ideal for patients with cardiovascular or renal disease where oral NSAIDs pose risks [17]. Topical agents avoid most drug-drug interactions while providing efficacy comparable to oral analgesics for focal joint pain.
| A) | Opioid dose escalation to target zero pain | ||
| B) | Adding gabapentinoids to existing opioid therapy | ||
| C) | Initiating long-term benzodiazepines for insomnia | ||
| D) | Physical therapy focused on strengthening and gait |
Evidence increasingly supports multimodal approaches incorporating physical therapy, cognitive behavioral therapy, exercise, acupuncture, and mindfulness-based stress reduction [20]. For multimorbid patients, these interventions offer pain relief without adding to polypharmacy burdens. Physical therapy improves both pain and function—a dual benefit particularly relevant when functional goals supersede pain elimination. Cognitive-behavioral therapy for pain reduces pain catastrophizing and improves coping strategies, with effects sustained long-term [21].
| A) | They are prohibited by the CDC guideline. | ||
| B) | They replace the need to check PDMPs during therapy. | ||
| C) | They reliably overestimate risk in older adults with polypharmacy. | ||
| D) | They may underestimate risk in patients with cognitive impairment, polypharmacy, or multiple prescribers. |
Validated instruments like the Opioid Risk Tool (ORT) or the SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised) help stratify patients by risk for opioid misuse [23]. However, these tools were developed in relatively healthy populations; multimorbid patients with cognitive impairment, polypharmacy, or multiple prescribers may be systematically underestimated.
| A) | Reserve naloxone solely for patients who are also prescribed benzodiazepines. | ||
| B) | Wait to prescribe naloxone until the daily opioid dose reaches at least 90 MME/day. | ||
| C) | Provide naloxone only with a documented prior overdose; otherwise defer at this dose. | ||
| D) | Offer naloxone now; multimorbidity and gabapentinoid co-use warrant a lower threshold to reduce overdose risk. |
Current guidelines recommend offering naloxone to any patient on chronic opioid therapy, particularly those on doses ≥50 morphine milligram equivalents (MME) daily, with concurrent benzodiazepine or gabapentinoid use, or with substance use history [25]. For multimorbid patients, this threshold should be lower given enhanced respiratory depression risk.
| A) | Conduct comprehensive medication reviews, recommend renal/hepatic dose adjustments, coordinate deprescribing, and provide medication education. | ||
| B) | Order and interpret imaging for back pain and manage structural findings as the lead clinician. | ||
| C) | Provide psychotherapy as the primary behavioral health provider and bill independently for counseling. | ||
| D) | Independently prescribe and titrate opioids without collaboration or oversight from a prescriber. |
Clinical pharmacists uniquely positioned to optimize medication regimens in multimorbid patients can:
Conduct comprehensive medication reviews, identifying all potential drug-drug interactions, not just opioid-related ones
Recommend dose adjustments based on renal and hepatic function, preventing accumulation toxicity
Suggest therapeutic alternatives when interaction risks are excessive
Coordinate deprescribing strategies, safely discontinuing medications no longer necessary
Provide patient education about proper medication use, storage, and disposal
| A) | Add a benzodiazepine nightly for insomnia to enhance function and reduce anxiety. | ||
| B) | Increase the opioid dose to target minimal pain scores in hopes of improving mood and sleep. | ||
| C) | Switch to meperidine to avoid tolerance and use it as a long-term maintenance analgesic. | ||
| D) | Behavioral health integration offering CBT for pain, motivational interviewing, substance use assessment, and sleep hygiene counseling. |
Integrated behavioral health models that embed psychologists, social workers, or psychiatric nurse practitioners in primary care enable:
Screening and treatment of comorbid mental health conditions
Cognitive-behavioral therapy for chronic pain, addressing maladaptive pain beliefs
Motivational interviewing for patients resistant to tapering or non-opioid alternatives
Substance use disorder assessment and treatment when opioid misuse emerges
Sleep hygiene counseling, as insomnia worsens both pain and mental health