Study Points

Responsible and Effective Opioid Prescribing

Course #55151 • 3 Hours/Credits

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    • 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

    SCOPE OF THE PROBLEM

    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].

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  2. When opioids are used for acute pain, clinicians should prescribe

    PAIN MANAGEMENT APPROACHES

    Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids in a quantity no greater than that needed for the expected duration of severe pain. In most cases, three days or less will be sufficient; more than seven days will rarely be needed [10]. However, it is important to note that this guideline is based on emergency department prescribing guidelines for non-traumatic non-surgical pain [12]. It may be necessary to prescribe for longer periods in patients with acute severe pain.

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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?

    CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK

    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
    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)

    CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK

    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 [18,19].

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

    CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK

    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" [1,23]:

    • 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

    CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK

    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 statements regarding the disposal of opioids is TRUE?

    CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK

    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 [49]. 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 [50]. 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 [31,50]. The FDA provides a free toolkit of materials (e.g., social media images, fact sheets, posters) to raise awareness of the serious dangers of keeping unused opioid pain medicines in the home and with information about safe disposal of these medicines. The Remove the Risk Outreach toolkit is updated regularly and can be found at https://www.fda.gov/drugs/ensuring-safe-use-medicine/safe-opioid-disposal-remove-risk-outreach-toolkit [31]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so.

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  8. The most common source of nonmedical use of prescribed opioids is from

    IDENTIFICATION OF DRUG DIVERSION/SEEKING BEHAVIORS

    Research 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 2019 National Survey on Drug Use and Health asked non-medical users of prescription opioids how they obtained their most recently used drugs [51]. Among persons 12 years of age or older, 38.6% obtained their prescription opioids from a friend or relative for free, 34.7% got them through a prescription from one doctor (vs. 17.3% in 2009–2010), 9.5% bought them from a friend or relative, and 3.2% took them from a friend or relative without asking [51]. Less frequent sources included a drug dealer or other stranger (6.5%); multiple doctors (2.0%); and theft from a doctor's office, clinic, hospital, or pharmacy (0.9%) (vs. 0.2% in 2009–2010) [51].

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  9. 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 [48,54,55]:

    • 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 [48,54,55]:

    • 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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  10. 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 [60].

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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.