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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. 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 [3]. Payers and health systems should not use the 2022 guideline to set rigid standards related to dosage or duration of opioid therapy. The guideline is not a replacement for clinical judgment or individualized, patient-centered care [19].
| A) | Low | ||
| B) | Medium | ||
| C) | High | ||
| D) | Severe |
RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
| Low Risk | |||||||||
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| Medium Risk | |||||||||
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| High Risk | |||||||||
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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, 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 [36,37].
| 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" [1,40]:
Analgesia
Activities of daily living
Adverse or side effects
Aberrant drug-related behaviors
Affect (i.e., patient mood)
| A) | 6 to 12 weeks. | ||
| B) | 3 to 6 months. | ||
| C) | 6 to 12 months. | ||
| D) | 1 to 2 years. |
| 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 of 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 [51]. 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 [52]. 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 [52,53]. 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 [53]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so. In April 2023, the FDA issued a letter requiring all manufacturers of opioid analgesics dispensed in outpatient settings to submit a proposed modification to the Opioid Analgesic REMS. The modification requires manufacturers to make available prepaid mail-back envelopes to outpatient pharmacies and other opioid dispensers as an opioid analgesic disposal option for patients. The FDA expects to take action on this modification in 2024 [50].
| 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 2021 National Survey on Drug Use and Health asked non-medical users of prescription opioids how they obtained their most recently used drugs [54]. Among persons 12 years of age or older, 33.9% obtained their prescription opioids from a friend or relative for free, 39.3% got them through a prescription from one doctor (vs. 34.7% in 2019), 7.3% bought them from a friend or relative, and 3.7% took them from a friend or relative without asking [54]. Other sources included a drug dealer or other stranger (7.9%); multiple doctors (3.2%); and theft from a doctor's office, clinic, hospital, or pharmacy (0.7%) (vs. 0.9% in 2019) [54].
| 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 |
In addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [48,57,58]:
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 [48,57,58]:
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 [62].