Study Points

Prescribing Opioids, Providing Naloxone, and Preventing Drug Diversion: The West Virginia Requirement

Course #91603 - $18 -

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  • 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.
  1. Inappropriate opioid analgesic prescribing for pain is defined as

    DEFINITIONS

    Inappropriate opioid analgesic prescribing for pain is defined as the non-prescribing, inadequate prescribing, excessive prescribing, or continued prescribing despite evidence of ineffectiveness of opioids [1]. 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. 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 [2]. For example, a survey of 1,000 internists, family physicians, and general practitioners found that while 100% believed that prescription drug abuse was a problem in their communities, their knowledge of the specifics of the epidemic were lacking [77]. Only 66% correctly identified swallowing pills whole as the most common route of abuse, and 46% supported the false claim that abuse-deterrent formulations were less addictive than other formulations. Perhaps most troubling, only 25% of participants reported being "not at all" or "only slightly" concerned about the diversion of opioids to the illicit market, a common practice at all levels of the pharmaceutical supply chain [77].

    Another survey measuring more than 200 primary care physicians' and medical students' understanding of opioids and addiction found that [3]:

    • Only 25% of students and 14% of physicians correctly identified the highest risk patient for opioid-related overdose.

    • About half of students and physicians selected the best treatment practice for opioid use disorder.

    • 31% of medical students and 22% of physicians did not believe sustained recovery from opioid use disorder is possible.

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  2. What proportion of adults in the United States is prescribed an opioid such as oxycodone or hydrocodone for chronic pain?

    EPIDEMIOLOGY OF CHRONIC PAIN AND OPIOID MISUSE

    The current extent of opioid analgesic use in the United States is unprecedented in the country's history and unparalleled anywhere in the world. Before 1990, physicians in the United States were skeptical of prescribing opioids for chronic noncancer pain. But, according to 2017 CDC data, 20% of adults are prescribed an opioid such as oxycodone and hydrocodone for chronic pain, and sales of opioid analgesics totals approximately $7 billion annually [65,71].

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  3. 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?

    INITIATION AND MANAGEMENT OF THE PATIENT WITH CHRONIC PAIN

    RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS

    Low Risk
    Definable physical pathology with 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 alcoholism or substance abuse
    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 alcoholism or substance abuse
    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 alcoholism or drug misuse, abuse, addiction, 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.
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  4. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)

    INITIATION AND MANAGEMENT OF THE PATIENT WITH CHRONIC PAIN

    The 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 [23].

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  5. Which of the following is NOT one of the 5 A's of monitoring chronic opioid response?

    INITIATION AND MANAGEMENT OF THE PATIENT WITH CHRONIC PAIN

    When 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 "5 A's" [1,28]:

    • Analgesia

    • Activities of daily living

    • Adverse or side effects

    • Aberrant drug-related behaviors

    • Affect (i.e., patient mood)

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  6. For patients considered at medium risk for misuse of prescription opioids, urine drug testing should be completed every

    INITIATION AND MANAGEMENT OF THE PATIENT WITH CHRONIC PAIN

    PATIENT RISK LEVEL AND FREQUENCY OF MONITORING

    Monitoring ToolPatient Risk Level
    LowMediumHigh
    Urine drug testEvery 1 to 2 yearsEvery 6 to 12 monthsEvery 3 to 6 months
    State prescription drug monitoring programTwice per yearThree times per yearFour times per year
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  7. Which of the following is a universal recommendation for the proper disposal of unused opioids?

    INITIATION AND MANAGEMENT OF THE PATIENT WITH CHRONIC PAIN

    There are no universal recommendations for the proper disposal of unused opioids, and patients are rarely advised of what to do with unused or expired medications [34]. According to the FDA, most medications that are no longer necessary or have expired should be removed from their containers, mixed with undesirable substances (e.g., cat litter, used coffee grounds), and put into an impermeable, nondescript container (e.g., disposable container with a lid or a sealed bag) before throwing in the trash [35]. Any personal information should be obscured or destroyed. The FDA recommends that certain medications, including oxycodone/acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl (Duragesic Transdermal System), be flushed down the toilet instead of thrown in the trash [35]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so and no other safe disposal method is available. In addition, beginning in 2023, manufacturers of opioid analgesics dispensed in outpatient settings must make prepaid mail-back envelopes available to outpatient pharmacies and other dispensers as an additional opioid analgesic disposal option for patients [80].

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  8. Which government agency is responsible for formulating federal standards for the handling of controlled substances?

    COMPLIANCE WITH STATE AND FEDERAL LAWS

    The 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[37].

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  9. In West Virginia, which of the following groups must provide dispensing information to the West Virginia Board of Pharmacy each 24-hour period through the Controlled Substances Automated Prescription Program (CSAPP)?

    COMPLIANCE WITH STATE AND FEDERAL LAWS

    In West Virginia, all licensees who dispense Schedule II, III, IV, and V controlled substances to residents of West Virginia must provide the dispensing information to the West Virginia Board of Pharmacy each 24-hour period through the Controlled Substances Automated Prescription Program (CSAPP) [42]. This includes:

    • Physicians

    • Dentists

    • Veterinarians

    • Physician assistants

    • Advanced practice nurses

    • Other prescribers and dispensers

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  10. Which of the following behaviors is the most suggestive of an emerging opioid use disorder?

    IDENTIFICATION OF DRUG DIVERSION/SEEKING BEHAVIORS

    In addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [33,46,47]:

    • 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 [33,46,47]:

    • 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

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  • 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.