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| A) | non-prescribing. | ||
| B) | inadequate prescribing. | ||
| C) | continued prescribing despite evidence of ineffectiveness of opioids. | ||
| D) | All of the above |
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-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].
| A) | the highest safe dose. | ||
| B) | extended-release opioids. | ||
| C) | a quantity no greater than that needed for the expected duration of severe pain. | ||
| D) | All of the above |
Long-term opioid use often begins with treatment of acute pain. Many acute pain conditions can be managed most effectively with nonopioid medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been found to be more effective than opioids for surgical dental pain, and the American Dental Association recommends NSAIDs as first-line treatment for acute dental pain management [5].
| A) | Low | ||
| B) | Medium | ||
| C) | High | ||
| D) | Severe |
RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
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| HIV = human immunodeficiency syndrome, MRI = magnetic resonance imaging. |
| A) | consists of 5 items. | ||
| B) | is patient administered. | ||
| C) | diagnoses depression in the past month. | ||
| D) | assesses the likelihood of current substance abuse. |
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, psychological 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].
| A) | Analgesia | ||
| B) | Acceptance | ||
| C) | Affect (i.e., patient mood) | ||
| D) | Aberrant drug-related behaviors |
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)
| A) | it can increase respiratory drive. | ||
| B) | patients will not understand the differences between the two drug classes. | ||
| C) | both classes of drug cause central nervous system depression and sedation. | ||
| D) | All of the above |
Patients who are unable to undergo dental treatment due to excessive fear, anxiety, or phobias and who do not respond to dental behavior modification techniques require pharmacotherapy. In many cases, this involves the use of benzodiazepines, such as diazepam, triazolam, and lorazepam. However, in patients who are also prescribed opioids, there are risks. In 2019, 16% of persons who died of an opioid overdose also tested positive for benzodiazepines [44]. Combining benzodiazepines with opioids is unsafe because both classes of drug cause central nervous system depression and sedation and can decrease respiratory drive—the usual cause of overdose fatality. Both classes have the potential for drug dependence and addiction. The CDC recommends that dentists avoid prescribing benzodiazepines concurrently with opioids whenever possible [10].
| A) | Patients are almost always advised of what to do with unused or expired medications. | ||
| B) | There are no universal recommendations for the proper disposal of unused opioids. | ||
| C) | According to the FDA, most medications should be flushed down the toilet instead f thrown in the trash. | ||
| D) | All of the above |
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.
| A) | a friend or relative for free. | ||
| B) | a prescription from one doctor. | ||
| C) | purchase from a drug dealer or other stranger. | ||
| D) | theft from a doctor's office, clinic, hospital, or pharmacy. |
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].
| A) | Asking for specific medications | ||
| B) | Injecting medications meant for oral use | ||
| C) | Reluctance to decrease opioid dosing once stable | ||
| D) | Stockpiling medications during times when pain is less severe |
There are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [45,47,48]:
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 [45,47,48]:
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
| A) | Institutes of Medicine | ||
| B) | U.S. Drug Enforcement Administration | ||
| C) | Office of National Drug Control Policy | ||
| D) | U.S. Department of Health and Human Services |
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 [36].