Study Points

Strategies for Appropriate Opioid Prescribing: The Florida Requirement

Course #45121 - $15 • 2 Hours/Credits

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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 patients with pain, and how these potentially problematic behavioral responses to opioids both resemble and differ from physical dependence and pseudo-addiction. 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 2013 survey measuring 200 primary care physicians' understanding of opioids and addiction found that [3]:

    • 35% admitted knowing little about opioid addiction.

    • 66% and 57% viewed low levels of education and income, respectively, as causal or highly contributory to opioid addiction.

    • 30% believed opioid addiction "is more of a psychologic problem," akin to poor lifestyle choices rather than a chronic illness or disease.

    • 92% associated prescription analgesics with opioid addiction, but only 69% associated heroin with opioid addiction.

    • 43% regarded opioid dependence and addiction as synonymous.

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  2. Data indicate that opioid analgesic prescribing and overdose peaked in

    EPIDEMIOLOGY OF CHRONIC PAIN AND OPIOID MISUSE

    There is a widespread misperception that opioid analgesic prescribing and overdose continues to grow, fueling an opioid epidemic [13,14,15,16,17]. This is refuted by the following data showing that national opioid analgesic prescribing and overdose peaked in 2011 and are in multiyear decline.

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  3. A patient prescribed opioids for chronic pain who has no personal or family history of alcohol or substance abuse is considered at what level of risk for developing problematic opioid behavioral responses?

    INITIATION AND MANAGEMENT OF THE PATIENT WITH PAIN

    RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS

    Low Risk
    No or well-defined and controlled personal or family history of alcohol/substance use disorder
    No or minimal co-occurring psychiatric disorders or medical comorbidities
    Age 45 years or older
    High levels of pain acceptance and active coping strategies
    High motivation and willingness to participate in multimodal therapy, attempting to function at normal levels
    Medium Risk
    Moderate concomitant psychiatric disorders, well controlled by therapy
    Moderate coexisting medical disorders well-controlled by medical therapy and not affected by chronic opioid therapy (e.g., central sleep apnea)
    History of personal or family alcoholism/substance abuse/addiction
    Willing to participate in multimodal therapy, attempting to function in normal daily life
    Pain involving more than three regions of the body
    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
    Unwilling to participate in multimodal therapy, not functioning close to a near normal lifestyle
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  4. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)

    INITIATION AND MANAGEMENT OF THE PATIENT WITH 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 [67,68].

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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 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" [1,75]:

    • 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 PAIN

    PATIENT RISK LEVEL AND FREQUENCY OF MONITORING

    Monitoring ToolPatient Risk Level
    LowMediumHigh
    Urine drug testEvery one to two yearsEvery 6 to 12 monthsEvery three to six months
    State prescription drug monitoring programTwice per yearThree times per yearFour times per year
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  7. The U.S. Food and Drug Administration recommends that unused OxyContin tablets be disposed of by

    INITIATION AND MANAGEMENT OF THE PATIENT WITH 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 [84]. According to the Office of National Drug Control Policy, 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 [85]. 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 [85]. 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 [86]. 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 disposal method is appropriate.

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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 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 [95].

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  9. All clinicians who dispense controlled substances are required to report the action to the Electronic Florida Online Reporting of Controlled Substances Evaluation (E-FORCSE) within

    COMPLIANCE WITH STATE AND FEDERAL LAWS

    All clinicians who dispense controlled substances are required to report the action to E-FORCSE as soon as possible, but no later than the close of the next business day [99]. This should be repeated each time the substance is dispensed. This reporting requirement is waived in certain circumstances, including for [99]:

    • The dispensing of a controlled substance in the healthcare system of the Department of Corrections

    • The dispensing of a controlled substance to a person younger than 16 years of age

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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 [82,103,104]:

    • 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 less association with opioid misuse include [82,103,104]:

    • 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.