Study Points
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Study Points
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- Apply epidemiologic trends in opioid use and misuse to current practice so at-risk patient populations can be more easily identified, assessed, and treated.
- Create comprehensive treatment plans for patients with pain that address patient needs as well as drug diversion prevention.
- Evaluate behaviors that may indicate drug seeking or diverting as well as approaches for patients suspected of misusing opioids.
- Identify state and federal laws governing the proper prescription and monitoring of controlled substances.
- Describe the available treatment modalities for opioid use disorder.
Inappropriate opioid analgesic prescribing for pain is defined as
Click to ReviewInappropriate opioid analgesic prescribing for pain is defined as the non-prescribing, inadequate prescribing, excessive prescribing, or continued prescribing despite evidence of ineffectiveness of opioids. Appropriate opioid prescribing is essential to achieve pain control; to minimize patient risk of abuse, addiction, and fatal toxicity; and to minimize societal harms from diversion. The foundation of appropriate opioid prescribing is thorough patient assessment, treatment planning, and follow-up and monitoring. Essential for proper patient assessment and treatment planning is comprehension of the clinical concepts of opioid abuse and addiction, their behavioral manifestations in pain patients, and how these potentially problematic behavioral responses to opioids both resemble and differ from physical dependence and pseudo-dependence [1,2]. Prescriber knowledge deficit has been identified as a key obstacle to appropriate opioid prescribing and, along with gaps in policy, treatment, attitudes, and research, contributes to widespread inadequate treatment of pain [1,3].
When opioids are used for acute pain, clinicians should prescribe
Click to ReviewCDC RECOMMENDATIONS FOR PRESCRIBING OPIOIDS FOR PAIN, EXCLUDING SICKLE CELL DISEASE OR CANCER, PALLIATIVE, OR END-OF-LIFE CARE
Determining Whether or Not to Initiate Opioids for Pain Recommendation 1: Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies. Opioid therapy should only be considered for acute pain if expected benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy. Recommendation 2: Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies. Opioid therapy for subacute and chronic pain should only be used if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Recommendation 3: When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. Selecting Opioids and Determining Opioid Dosages Recommendation 4: When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients. Recommendation 5: For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages. Deciding Duration of Initial Opioid Prescription and Conducting Follow-Up Recommendation 6: When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Recommendation 7: Clinicians should evaluate benefits and risks with patients within one to four weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly re-evaluate benefits and risks of continued opioid therapy with patients. Assessing Risk and Addressing Harms of Opioid Use Recommendation 8: Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone. Recommendation 9: When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose. Recommendation 10: When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances. Recommendation 11: Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants. Recommendation 12: Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death. A patient prescribed opioids for chronic pain who is 65 years of age and displays high levels of pain acceptance and active coping strategies is considered at what level of risk for developing problematic opioid behavioral responses?
Click to ReviewRISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
Low Risk Definable physical pathology Objective signs and reliable symptoms Clinical correlation with diagnostic testing, including MRI, physical examination, and interventional diagnostic techniques With or without mild psychologic comorbidity With or without minor medical comorbidity No or well-defined and controlled personal or family history of alcohol or substance use disorder Age 45 years or older High levels of pain acceptance and active coping strategies High motivation and willingness to participate in multimodal therapy and attempting to function at normal levels Medium Risk Significant pain problems with objective signs and symptoms confirmed by radiologic evaluation, physical examination, or diagnostic interventions Moderate psychologic problems, well controlled by therapy Moderate coexisting medical disorders that are well controlled by medical therapy and are not affected by chronic opioid therapy (e.g., central sleep apnea) Develops mild tolerance but not hyperalgesia without physical dependence or addiction Past history of personal or family history of alcohol or substance use disorder Pain involving more than three regions of the body Defined pathology with moderate levels of pain acceptance and coping strategies Willing to participate in multimodal therapy, attempting to function in normal daily life High Risk Widespread pain without objective signs and symptoms Pain involving more than three regions of the body Aberrant drug-related behavior History of alcohol or substance use disorder, , diversion, dependency, tolerance, or hyperalgesia Major psychologic disorders Age younger than 45 years HIV-related pain High levels of pain exacerbation and low levels of coping strategies Unwilling to participate in multimodal therapy Not functioning close to a near normal lifestyle HIV = human immunodeficiency syndrome, MRI = magnetic resonance imaging. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)
Click to ReviewThe Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a patient-administered, 24-item screen with questions addressing history of alcohol/substance use, psychologic status, mood, cravings, and stress. Like the ORT, the SOAPP-R helps assess risk level of aberrant drug-related behaviors and the appropriate extent of monitoring [28,29].
Which of the following is NOT one of the 5 A's of monitoring chronic opioid response?
Click to ReviewWhen implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function [1]. This can include input from family members and/or the state PDMP. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. At every visit, chronic opioid response may be monitored according to the "Five A's" [1,32]:
Analgesia
Activities of daily living (e.g., physical, psychological, and social functioning)
Adverse or side effects
Aberrant or abnormal drug-related behaviors
Affect (i.e., patient mood)
Before ordering toxicology testing, including urine drug tests, clinicians should do which of the following?
Click to ReviewBefore ordering toxicology testing, including urine drug tests, clinicians should have a plan for responding to unexpected results and should explain to patients that toxicology testing will not be used punitively but instead is intended to improve their safety. Clinicians should also explain expected results and ask patients about use of prescribed medications and other substances and ask whether there might be unexpected results. This will provide an opportunity for patients to provide information about changes in their use of prescribed opioids or other drugs. Urine test results suggesting opioid misuse should be discussed with the patient using a positive, supportive approach. The test results and the patient discussion should be documented [2].
According to the Office of National Drug Control Policy, most unnecessary or expired medications should be disposed of
Click to ReviewThere are no universal recommendations for the proper disposal of unused opioids, although efforts toward patient education on what to do with unused or expired medications have increased . According to the FDA, the best way to dispose of most types of unused or expired medications (both prescription and over-the-counter) is to immediately use a take-back option, such as a designated "take-back location" or by mailing medications back using a prepaid drug mail-back envelope. As of April 2025, the FDA began requiring OA REMS Program Companies to provide prepaid mail-back envelopes upon request to pharmacies and other dispensers of opioid analgesics to improve proper and equitable disposal of this class of drugs [40].
The most common source of nonmedical use of prescribed opioids is from
Click to ReviewResearch has more closely defined the location of prescribed opioid diversion into illicit use in the supply chain from the manufacturer to the distributor, retailer, and the end user (the pain patient). This information carries with it substantial public policy and regulatory implications. The 2024 National Survey on Drug Use and Health found that 7.6 million individuals misused prescription opioids in the past year. Among persons 12 years of age or older, 42.3% obtained their prescription opioids from a friend or relative. Of this, 31.3% got them through a friend or relative for free, 6.9% bought them from a friend or relative, and 4% took them from a friend or relative without asking. Another 40.5% got their opioids through a prescription from one doctor. Less frequent sources included a drug dealer or other stranger (7.6%) and theft from a doctor's office, clinic, hospital, or pharmacy (1.3%) [49].
Which of the following behaviors is the most suggestive of an emerging opioid use disorder?
Click to ReviewIn addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [53,54]:
Selling medications
Prescription forgery or alteration
Injecting medications meant for oral use
Obtaining medications from nonmedical sources
Resisting medication change despite worsening function or significant negative effects
Loss of control over alcohol use
Using illegal drugs or non-prescribed controlled substances
Recurrent episodes of:
Prescription loss or theft
Obtaining opioids from other providers in violation of a treatment agreement
Unsanctioned dose escalation
Running out of medication and requesting early refills
Behaviors with a lower level of evidence for their association with opioid misuse include [53,54]:
Aggressive demands for more drug
Asking for specific medications
Stockpiling medications during times when pain is less severe
Using pain medications to treat other symptoms
Reluctance to decrease opioid dosing once stable
In the earlier stages of treatment:
Increasing medication dosing without provider permission
Obtaining prescriptions from sources other than the pain provider
Sharing or borrowing similar medications from friends/family
Which government agency is responsible for formulating federal standards for the handling of controlled substances?
Click to ReviewThe U.S. Drug Enforcement Administration (DEA) is responsible for formulating federal standards for the handling of controlled substances. In 2011, the DEA began requiring every state to implement electronic databases that track prescribing habits, referred to as PDMPs. Specific policies regarding controlled substances are administered at the state level [60].
Which of the following drugs is considered the criterion standard in reversing respiratory depression and coma in acute opioid overdose?
Click to ReviewIn response to acute overdose, the short-acting opioid antagonist naloxone is considered the criterion standard, and it remains the most widely used opioid antagonist for the reversal of overdose and opioid-related respiratory depression. It acts by competing with opioids at receptor sites in the brain stem, reversing desensitization to carbon dioxide, and reversing or preventing respiratory failure and coma. There is no evidence that subcutaneous, intramuscular, or nasal inhalation use is inferior to intravenous naloxone. As such, this has prompted naloxone to be available to the general public over-the-counter for administration outside the healthcare setting to treat acute opioid overdose in all 50 states [77].
The opioid agonist most frequently used in opioid withdrawal is
Click to ReviewThe three primary treatment modalities used for detoxification are opioid agonists, non-opioid medications, and rapid and ultra-rapid opioid detoxification. The most frequently employed method of opioid withdrawal is a slow, supervised detoxification during which an opioid agonist, usually methadone, is substituted for the abused opioid. Methadone is the most frequently used opioid agonist due to the convenience of its once-a-day dosing. Methadone is highly bound to plasma proteins and accumulates more readily than heroin in all body tissues. Methadone also has a longer half-life, approximately 22 hours, which makes withdrawal more difficult than from heroin. Substitution therapy with methadone has a high initial dropout rate (30% to 90%) and an early relapse rate. Alternative pharmacologic detoxification choices (all off-label) include clonidine (with or without methadone), midazolam, trazodone, or buprenorphine [32,71,80,81,82].
Twelve-step programs are based on
Click to ReviewTwelve-step programs for opioid abuse and dependence include Narcotics Anonymous (NA) and Methadone Anonymous (MA) and are modeled after Alcoholics Anonymous (AA), an abstinence-based support and self-improvement program that is based on the 12-step model of recovery. AA has helped hundreds of thousands of individuals with alcohol misuse disorder achieve sobriety [93]. The 12-step model emphasizes acceptance of dependence as a chronic, progressive disease that can be arrested through abstinence but not cured. Additional elements include spiritual growth, personal responsibility, and helping other addicted persons. By inducing a shift in the consciousness of the addict, 12-step programs offer a holistic solution and are a resource for emotional support [93]. Although research on efficacy and patient outcomes in NA and MA is very limited, many prominent researchers emphasize the important role that ongoing involvement in 12-step programs plays in recovery from substance abuse [94].
- Back to Course Home
- Participation Instructions
- Review the course material online or in print.
- Complete the course evaluation.
- Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.