|
| A) | Patient preference | ||
| B) | Trials of opioid monotherapy only | ||
| C) | Diagnosis with an appropriate differential | ||
| D) | A single assessment of substance abuse risk |
All patients with pain have a level of risk that can only be roughly estimated initially and modified over time as more information is obtained. There are ten essential steps of opioid prescribing for chronic pain to help mitigate any potential problems [5]:
Diagnosis with an appropriate differential
Psychological assessment, including risk of substance use disorders
Informed consent
Treatment agreement
Pre- and post-treatment assessments of pain level and function
Appropriate trial of opioid therapy with or without adjunctive medication
Reassessment of patient levels of pain and functioning
Regular assessment with the 5 A's (i.e., analgesia, activity, adverse effects, aberrant behaviors, and affect)
Periodically review pain diagnosis and comorbid conditions, including substance use disorders
Documentation
| 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 [4]. This can include input from family members and/or the state prescription drug monitoring program. Prescription drug monitoring programs are one of the most effective measures for reducing opioid analgesic diversion and abuse, but their efficacy is undermined by inconsistent use [6]. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. Decisions regarding the continuation, modification, or termination of opioid therapy for pain should be based on evaluation of the patient's progress and the absence of substantial risks or adverse events [4]. At every visit, chronic opioid response may be monitored according to the 5 A's [8]:
Analgesia
Affect (i.e., patient mood)
Activities of daily living
Adverse or side effects
Aberrant drug-related behaviors
| A) | 5 items. | ||
| B) | 17 items. | ||
| C) | 25 items. | ||
| D) | 40 items. |
The Current Opioid Misuse Measure (COMM) is a 17-item patient self-report assessment designed to help clinicians identify misuse or abuse in patients with chronic pain. Unlike the ORT and the SOAPP-R, the COMM identifies aberrant behaviors associated with opioid misuse in patients already receiving long-term opioid therapy [11]. Sample questions include: In the past 30 days, how often have you had to take more of your medication than prescribed? In the past 30 days, how much of your time was spent thinking about opioid medications (e.g., having enough, taking them, dosing schedule)?
| A) | Suboptimal physician-patient communication | ||
| B) | Inappropriate and/or excessive opioid prescriptions | ||
| C) | Deficits in chart notes and progress documentation | ||
| D) | Lack of knowledge regarding mutual responsibilities and expectations |
Guidelines by the FSMB and the Joint Commission stress the importance of documentation from both a healthcare quality and medicolegal perspective. Research has found widespread deficits in chart notes and progress documentation with patients with chronic pain receiving opioid therapy, and the Pain Assessment and Documentation Tool (PADT) was designed to address these shortcomings [12]. The PADT is a clinician-directed interview, with most sections (e.g., analgesia, activities of daily living, adverse events) consisting of questions asked of the patient. However, the potential aberrant drug-related behavior section must be completed by the physician based on his or her observations of the patient.
| A) | reporting whether a patient's mood is worsening (e.g., depression) while on opioid therapy. | ||
| B) | observing whether a patient is losing control of his or her life during the course of opioid therapy. | ||
| C) | providing input regarding positive or negative changes in patient function, attitude, and level of comfort. | ||
| D) | All of the above |
Family members of the patient can provide valuable information that better informs decision making regarding continuing opioid therapy. Family members can observe whether a patient is losing control of his or her life or becoming less functional or more depressed during the course of opioid therapy. They can also provide input regarding positive or negative changes in patient function, attitude, and level of comfort. The following questions can be asked of family members or a spouse to help clarify whether the patient's response to opioid therapy is favorable or unfavorable [8]:
Is the person's day centered around taking the opioid medication? Response can help clarify long-term risks and benefits of the medication and identify other treatment options.
Does the person take pain medication only on occasion, perhaps three or four times per week? If yes, the likelihood of addiction is low.
Have there been any other substance (alcohol, tobacco, or drug) abuse problems in the person's life? An affirmative response should be taken into consideration when prescribing.
Does the person in pain spend most of the day resting, avoiding activity, or feeling depressed? If so, this suggests the pain medication is failing to promote rehabilitation. Daily activity is essential, and the patient may be considered for enrollment in a graduated exercise program
Is the person in pain able to function (e.g., work, do household chores, play) with pain medication in a way that is clearly better than without? If yes, this suggests the pain medication is contributing to wellness.
Does this patient smoke? Smoking increases pain and reduces the effectiveness of opioids.
| A) | 6 to 12 weeks. | ||
| B) | 3 to 6 months. | ||
| C) | 6 to 12 months. | ||
| D) | 1 to 2 years. |
| A) | understand the limitations. | ||
| B) | always use manufacturer recommended testing frequency. | ||
| C) | use immunoassay point-of-care results as the basis of important clinical decisions. | ||
| D) | aggressively confront patients with results suggesting non-use of a prescribed opioid. |
Initially, testing involves the use of class-specific immunoassay drug panels [4]. If necessary, this may be followed with gas chromatography/mass spectrometry for specific drug or metabolite detection. It is important that testing identifies the specific drug rather than the drug class, and the prescribed opioid should be included in the screen. Any abnormalities should be confirmed with a laboratory toxicologist or clinical pathologist. Immunoassay may be used point-of-care for "on-the-spot" therapy changes, but the high error rate prevents its use in major clinical decisions unless liquid chromatography is coupled with mass spectrometry confirmation.
Urine test results suggesting opioid misuse should be discussed with the patient using a positive, supportive approach. The test results and the patient discussion should be documented.
It is important to appreciate the limitations of UDTs. Healthcare providers are increasingly relying on UDTs as a means to reduce abuse and diversion of prescribed opioids. This has led to a proliferation in diagnostic laboratories that offer urine testing. With this increase have come questions of whether these business interests benefit or hinder patient care, what prescribers should do with the information they obtain, the accuracy of urine screens, and whether some companies and clinicians are financially exploiting the UDT boom [18]. Despite wide endorsement and making intuitive sense, there is little empirical confirmation that UDTs reduce prescription opioid abuse [1,6].
| A) | immediately halt an opioid if the side effects are unacceptable. | ||
| B) | never break or chew/crush tablets or cut or tear patches prior to use. | ||
| C) | share opioids with friends and relatives that cannot afford their own prescriptions. | ||
| D) | take other central nervous system depressants to manage opioid side effects. |
When prescribing opioids, clinicians should provide patients with the following information and instructions [7,26]:
Product-specific information
Taking the opioid as prescribed
Importance of dosing regimen adherence, managing missed doses, and prescriber contact if pain is not controlled
Warning and rationale to never break or chew/crush tablets or cut or tear patches prior to use
Warning and rationale to avoid other central nervous system depressants, such as sedative-hypnotics, anxiolytics, alcohol, or illicit drugs
Warning not to abruptly halt or reduce the opioid without physician oversight of safe tapering when discontinuing
The potential of serious side effects or death
Risk factors, signs, and symptoms of overdose and opioid-induced respiratory depression, gastrointestinal obstruction, and allergic reactions
The risks of falls, using heavy machinery, and driving
Warning and rationale to never share an opioid analgesic
Rationale for secure opioid storage
Warning to protect opioids from theft
Instructions for disposal of unneeded opioids, based on product-specific disposal information
| A) | burning. | ||
| B) | flushing down the toilet. | ||
| C) | throwing in the garbage in a sealed container. | ||
| D) | sharing with a friend or relative 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. 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 [27]. The FDA recommends that most opioid 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 [27]. Disposal by flushing down the toilet provides immediate and definitive elimination of safety hazards from intentional use or accidental exposure involving opioid products. All transdermal patch opioid products should be flushed down the toilet after folding in half by adhesive side against adhesive side [28]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so. Flushing unused medications has been the subject of controversy, with some state governments and boards recommending against the practice due to pollution concerns and effects on waterways and wildlife [29].
| A) | inadequate analgesia. | ||
| B) | resolution of the pain syndrome. | ||
| C) | significant aberrant medication use. | ||
| D) | All of the above |
The decision to continue or end opioid prescribing should be based on a joint discussion of the anticipated benefits and risks. An opioid should be discontinued with resolution of the pain condition, intolerable side effects, inadequate analgesia, lack of improvement in quality of life despite dose titration, deteriorating function, or significant aberrant medication use [4].