Responsible Opioid Prescribing: Decreasing the Risks of Misuse, Abuse & Diversion

Transcription

1 Responsible Opioid Prescribing: Decreasing the Risks of Misuse, Abuse and Diversion Clinical Updates for Nurse Practitioners and Physician Assistants: Faculty Carol P. Curtiss, MSN, RN-BC Clinical Nurse Specialist Consultant Curtiss Consulting, Greenfield, MA Adjunct Faculty Tufts University School of Medicine Master of Science in Pain Research, Education and Policy Program 2 Assistants: 2013 Opioid Analgesics - 1

2 Faculty Disclosure Advisory Board Teva Pharmaceuticals Consultant and Speakers Bureau: Non-branded Oncology & Palliative Care Programs Genentech Pharmaceuticals 3 Objectives 1. Discuss current guideline-based principles for assessing and managing pain 2. Describe the problems of misuse, abuse and diversion of opioid analgesics in the community 3. Identify strategies for responsible prescribing of opioid analgesics to diminish risks of misuse, abuse and diversion 4 Assistants: 2013 Opioid Analgesics - 2

3 ON A SCALE OF 1 TO 5, PLEASE RATE HOW CONFIDENT YOU ARE EVALUATING PATIENTS FOR RISK OF OPIOID MISUSE, ABUSE AND DIVERSION. 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 5 Pre-test question #1 Which of the following statements regarding published evidence-based pain management guidelines is FALSE? 1. Self report from the person with pain is the most reliable indicator of pain and pain relief 2. Vital signs are poor indicators for the presence of persistent pain 3. Multi-modal pain management plans include both medications and non-drug interventions selected for each individual patient 4. If one opioid is ineffective to relieve pain, other opioids are not likely to work either 6 Assistants: 2013 Opioid Analgesics - 3

4 Pre-test question #2 Which of the following describes current published recommendations for the use of opioids in the treatment of moderate to severe chronic pain? 1. Consider opioids only if the person is not at risk for misuse, abuse or addiction and other strategies have not worked 2. Opioids are contraindicated for all chronic pain conditions 3. Consider a trial of opioids if the person has pain-related functional impairment or decreased quality of life when other strategies have not worked 4. Consider opioids for all patients with unrelieved moderate to severe chronic pain 7 Pre-test question #3 When using a State s Prescription Monitoring Program (PMP), which of the following is TRUE? 1. Access is limited only to those patients under your care 2. Anyone can access the PMP for information about misuse and abuse 3. PMPs are only appropriate for use by law enforcement 4. All PMPs in the United States interact with one another 8 Assistants: 2013 Opioid Analgesics - 4

5 Pre-test question #4 Your patient s recent urine drug test indicates the unexpected presence of a drug you have not prescribed for this patient. According to current recommendations, which of the following is an appropriate initial response? 1. Dismiss the patient from your practice for violating the written agreement 2. Discuss the results with the patient, asking for a possible explanation 3. Tell the patient you can no longer prescribe opioids but will continue other treatments 4. Remind the patient about the written agreement and give them one more chance 9 Unrelieved Pain: A Public Health Problem Major public health problem 100 million in U.S. live with chronic pain Greater than diabetes, heart disease and cancer combined Costs U.S. > $600 billion each year Under-treatment occurs in every clinical setting and for all types of pain Institute of Medicine Committee on Advancing Pain Research, Care and Education. Relieving Pain in America: A Blueprint for transforming Prevention, Care, Education & Research. Washington, D.C.: National Academies Press, Assistants: 2013 Opioid Analgesics - 5

6 Pain Management EBP Guidelines: All have similar principles: Person with pain is the expert Self report is the gold standard Screen everyone routinely at each contact Complete a comprehensive pain assessment Combine medications with nondrug interventions in a way that manages pain effectively (multi-modal) Individualize care based on documented goals Adjust medications to individual responses Reassess at specific planned intervals to evaluate the effect of interventions Communicate the plan to others Identify and deal with barriers Continue to improve via QI/PI 11 Individual responses to Pain Individual pain medications, even within the same family Genetic differences, age, health frailty, metabolism etc. Doses of medication, even with the same clinical problem 12 Assistants: 2013 Opioid Analgesics - 6

7 13 Opioids: Achieving a Balance Effective and timely pain management Prevention of misuse, abuse, and diversion 14 Assistants: 2013 Opioid Analgesics - 7

8 Prevalence of Substance Use Disorders in the U.S. General population 8.7% aged > 12 classified with substance use disorder Alcohol: 15 million Illicit drugs: 4.2 million Non-medical use of prescription pain meds, Those 12 or older =4.6%. Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH, 2012.; SAMHSA NSDUH Report, 1/8/13 Persons with pain Rates vary depending on definition & population studied 0-39% with tobacco included Does not appear greater than the general population except with current/past hx. of substance abuse or psychiatric co-morbidities Fleming MF et al. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007; 8(7): Addiction Definitions Primary chronic disease of brain reward, motivation, memory and circuitry Inability to Abstain Impaired control over Behavior Craving Diminished recognition of problems Dysfunctional Emotional response Physical dependence Expected biologic response to medication withdrawal syndrome will occur. Taper medication to manage. By itself, this is NOT addiction. American Society of Addiction Medicine, Assistants: 2013 Opioid Analgesics - 8

9 Unintentional Deaths, CDC Public Health Grand Rounds ; National Vital Statistics System. multiple cause dataset 17 Prescription analgesic overdose deaths among women Overdose of Opioids & Benzodiazepines 18 Assistants: 2013 Opioid Analgesics - 9

10 Sources Where User Obtained Drugs for Non-medical Use, Misuse by Prescribers Prescribing without adequate assessment knowledge of each drug s characteristics, dosing, strengths, relative potency to morphine, adverse events, & cautions written goals for treatment outcomes reassessment before renewals integrating multimodal plans Prescribing controlled-release/long acting to opioid naïve persons Self misuse/abuse/diversion 20 Assistants: 2013 Opioid Analgesics - 10

11 Case #1 Your patient is a 69 year old retired postal worker with severe osteoarthritis of the right hip. She has experienced hip pain on a daily basis for 5 years. Pain has progressively worsened over the past few months. Her orthopedist recommended scheduled acetaminophen and P.T. and prefers to delay joint replacement. Clinical question #1 What is your next step with this patient? 1. Refer the patient for a second opinion 2. Conduct a comprehensive pain assessment 3. Continue physical therapy and acetaminophen 4. Refer her to a support group for people with persistent pain 21 Pain Assessment: Ask Detailed Questions About Pain Pain Relief Effects of pain on the person ADLs, Function, Psychosocial factors The person Bio-psycho-social factors, support systems, risks, etoh, drugs, smoke, comorbidities, watch in action Response to treatment History & P/E, diagnostics/labs as needed Establish & periodically review written goals of care 22 Curtiss CP. Oncology Nursing Forum (5): S7-S16. Assistants: 2013 Opioid Analgesics - 11

12 Hierarchy of Assessment: Cognitively Impaired/Non-verbal 1. Self report is the gold standard Anything else is a guess 2. Diagnoses/procedures that usually cause pain 3. Observation/behavioral assessment tools Vital signs changes least predictable 4. Surrogate reporting 5. Attempt an analgesic trial Herr et al. Pain Management Nursing (4): McGill Pain Questionnaire Assessment Tools Brief Pain Inventory Edmonton Symptom Assessment Toolrevised Pain Assessment & Documentation Tool Psychosocial Pain Assessment Form These tools and others available at: Checklist of Nonverbal Pain Indicators (CNPI) Pain Assessment in Advanced Dementia Scale (PAINAD) MOBID-2 Pain Scale Assessment of Discomfort in Dementia Protocol (ADD) 24 Assistants: 2013 Opioid Analgesics - 12

13 Case #1 (cont d): :Assessment Reports pain at 8 (0-10) in right hip Present most all of the time, worse on movement (10/10) No relief from APAP, heat, cold or P.T. History of peptic ulcer disease Physical exam indicates limited ROM in right hip, Height 5 4, Weight 165 Imaging indicates severe osteoarthritis of the right hip Pain interferes with walking & climbing stairs, slightly relieved (6/10) with inactivity, interferes with sleep, prevents full participation in P.T. Patient says she is discouraged, but not depressed. Has supportive family who agree with information provided by patient 25 Clinical Question #2 Based on current published guidelines, is this patient a candidate for opioid therapy for her pain? 1. No, because she has chronic pain 2. No, because she is elderly 3. Yes, because her pain interferes with quality of life 4. Yes, because she participates in P.T. 26 Assistants: 2013 Opioid Analgesics - 13

14 Guidelines: Chronic Opioid Therapy All patients with moderate-to-severe pain, pain-related functional impairment, or diminished QOL due to pain should be considered for opioid therapy Acetaminophen as first-line NSAIDs only after risk/benefit analysis: lowest dose/shortest period of time. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009; 57: American Geriatrics Society Guideline Safe & effective opioid therapy for chronic non-cancer pain requires skills & knowledge in both principles of opioid prescribing & assessment & management of risks of opioid abuse, addiction & diversion consider a trial for moderate to severe pain when pain has adverse effects on QOL & where benefits outweigh risks Chou et al, Clinical guideline for the use of chronic opioid therapy in non-cancer pain. 2009; J Pain 10(2): ; FDA & NIH Pain Consortium Assessment of analgesic treatment of chronic pain: A Scientific Workshop. May, Opioid REMS: FDA Mandate Long acting/extended release opioids (LA/ER), March 2013 Prescriber education based on FDA Blueprint Voluntary now but may be linked to DEA registration later Medication guides and patient education Assessment & auditing to monitor & evaluate REMs Transmucosal immediate release fentanyl Mandatory education for prescriber, dispenser & distributor 100% on knowledge assessment Written enrollment for all, including pt./prescriber signed agreement Patient selection & counseling InformationbyDrugClass/ucm htm TirfUI/rems/home.action 28 Assistants: 2013 Opioid Analgesics - 14

15 Case #1 (cont d): Planning Written goals of treatment Multi-modal plan Optimum weight, exercise, assistive devices Non-pharmacologic interventions Medications Topical agents If no benefit from topicals, consider a trial of oral opioids Risk assessment for misuse and abuse Initiate a trial with an exit plan 29 It s a Journey, not a Race 30 Assistants: 2013 Opioid Analgesics - 15

16 Persistent Pain: Are Opioids the Right Choice? Are other interventions as effective? Are opioids appropriate for this condition & patient? Is the patient at risk to abuse opioids? Are opioids a part of a multi-modal plan? Balance the risk v. benefit Are there written individual goals? Initiate a trial with an exit plan Does the patient improve with opioids? 31 Initiating Opioid Therapy: Evidence-based Recommendations History & P/E History of pain and substance use disorders obtained, evaluated and documented Written treatment plan Goals to determine efficacy Informed consent and agreement to treat Periodic review Consultation Accurate & complete medical records Compliance with laws & regulations Federation of State Medical Boards of the U.S. Model Policy for the Use of Controlled Substances for the Treatment of Pain, Assistants: 2013 Opioid Analgesics - 16

17 Universal Precautions in Pain Management 1. Patient evaluation, diagnostics as needed History (smoke, ETOH, drugs), physical & diagnosis Psychological assessment & risk evaluation 2. Risks, benefits, informed consent 3. Written treatment agreement with clear goals 4. Assessment of pain intensity & function pre and post intervention 5. Appropriate trial of medications & exit strategy Fed. of State Medical Boards Model Policy: Use of Controlled Substances in the Treatment of Pain, 2004; Gourley D & Heit H. Universal precautions: a matter of mutual trust and responsibility. Pain Medicine (2): Universal Precautions (cont d) 7. Scheduled reassessment Analgesia, ADLs, aberrant behavior, adverse effects Progress toward specific goals 8. Periodic review of diagnosis, including addictive disorders 9. Referral and/or consultation as needed 10. Documentation 11. Compliance with laws and regulations 34 Assistants: 2013 Opioid Analgesics - 17

18 Opioids & Persistent Pain: Risk Management Evaluate risk for substance abuse, misuse before starting opioid trial Screening tools & comprehensive assessment Stratify risk high, medium, low Structure treatment commensurate with risk High risk = > structure Assess drug-related behaviors over time Respond to aberrant behaviors Communicate and educate Adapted from: Portenoy RK : June 25, Selecting an Opioid Individualize the plan Opioid Starting dose Titration Side effect management Consider: Health status & co-morbidities Exposure to opioids (naïve or tolerant) Other prescribed medications The treatment plan 36 Fishman S. Responsible Opioid Prescribing: A clinician s guide. 2 nd Ed Assistants: 2013 Opioid Analgesics - 18

19 Patient & Family Education Risks of unrelieved pain Importance of taking medications as instructed What to report and to whom Risks of opioid therapy Self and others Safe storage Total possession of medication at all times Locked boxes/safes Safe disposal Household strategies Take-back programs 37 Opioid Therapy & Persistent Pain: Risk Management Tools PMP* Written Agreements Patient/Provider Relationship & Universal Precautions Risk Screening Tools Conversation Ongoing Assessment Documentation Urine Drug Testing *PMP: Prescription Drug Monitoring Programs: also known as PMP 38 Assistants: 2013 Opioid Analgesics - 19

20 Screening Tool: CAGE AID Brown & Rounds. Wisconsin Medical Journal. 1995;94(3): Screener & Opioid Assessment for Patients with Pain, revised (SOAPP -R) 24 item, paper/pencil survey for those considering opioid therapy Used to determine level of monitoring for longterm opioid therapy High risk > 22 Moderate risk Low risk < 9 Not intended to screen out patients for therapy May over-identify risk in low risk patients Accessed July 9, 2013 at: 40 Assistants: 2013 Opioid Analgesics - 20

21 Screening Tool: Opioid Risk Tool (ORT) Low risk 0-3 points Moderate risk 4-7 points High risk > 8 points Webster et al. Pain Med. 2005;6: DIRE Score: Selection for chronic opioid therapy Miles Belgade, Assessment & Management of Chronic Pain. Institute for Clinical Systems Improvement. Score Factor Explanation Diagnosis Intractability Risk psychological chemical health reliability 1=benign chronic condition/minimal objective findings/no definite dx; 2=slowly progressive condition concordant with moderate pain/fixed condition with moderate objective findings; 3= advanced condition with severe pain with objective findings 1= few therapies tried/patient takes passive role; 2= most customary treatments tried/patient not fully engaged/barriers; 3= fully engaged with inadequate response (r= total of each p,c,r,s below) 1=serious mental health illness; 2= moderate mental health illness; 3=good communication with clinic/no mental illness 1= active/recent use; 2= chemical coper or in remission for chemical dependency; 3= no CD history, not drug focused 1=Hx numerous problems; 2= occasional nonadherence; 3= highly reliable social support 1= life in chaos little family support; 2= reduction in some relations; 3= supportive close family, involved, no isolation Efficacy score 1= poor function/minimal relief despite titration; 2= moderate benefit with improved function in multiple ways; 3= good improvement in pain & function with stable doses over time Score of 7-13: not a suitable candidate Score of 14-21: may be a good candidate for long term opioids 42 Assistants: 2013 Opioid Analgesics - 21

22 Stratify Risk: Opioids & Persistent Pain Low Risk Moderate Risk High Risk Primary care No history of substance abuse or untreated psychopathology Minimal risk factors Primary Care with Specialist Support Past history of substance abuse (not prescription opioid abuse) Significant risk factors such as current/past psych disorder Specialty Care Active substance abuse problem, active untreated psychopathology History of opioid substance abuse Gourlay & Heit. Universal Precautions in Pain Medicine: A rational approach to the treatment of chronic pain. Pain Medicine. 2005:6(2); Katz. Patient level opioid risk management. Suppl. to PainEDU.org Manual, Case #1 (cont d) Continued Assessment Low risk for misuse and abuse Opioid Risk Tool (ORT) score of 1 PMP review: No opioids prescribed No hx. of psychopathology, substance abuse Written goals for treatment 1. Sleep through the night 2. Participate fully in P.T. 3. Walk down the driveway twice daily 4. Be able to dance at least one dance at upcoming family wedding ( 2 months away) 44 Assistants: 2013 Opioid Analgesics - 22

23 Current Opioid Misuse Measure (COMM) For those currently on long term opioid therapy 17 item patient self-assessment S/S intoxication, emotional volatility, poor response to medications, addiction, healthcare use patterns, problematic medication behavior NOT used prior to therapy Meltzer et al. Pain. 2011;152: Prescription Drug Monitoring Programs (PDMPs or PMPs) Statewide electronic databases Collect prescribing & dispensing data on controlled substances dispensed in the state Access open to only those authorized by state law health care providers, pharmacists, regulatory bodies & law enforcement Can access the prescriptions YOUR patients are receiving in the state Use at start of therapy & periodically Be aware of errors in data entry 46 Assistants: 2013 Opioid Analgesics - 23

24 State PMP Status August 1, 2013 No PMP PMP Pending PMP Operating PMP Interconnect Status July 9, 2013 MOU Pending MOU Executed PMPI Operating Assistants: 2013 Opioid Analgesics - 24

25 Treatment Agreements: Common Elements Obtain informed consent to treat Partnership between patient and provider Agreement common elements: Risks and benefits of therapy Clear written goals of care Expectations for participation in other therapies Ongoing evaluation plan Toxicology screening & random testing Heit HA. Creating and Implementing Opioid Agreements. CareManagement: Disease Management Digest. 2003;7(1): Common Elements of Treatment Agreements (cont d) Medication taken as prescribed One prescriber, one pharmacy for pain meds No escalation of dose (includes change in frequency of dosing), sharing, altering medications (chewing) No early refills, on weekends/off hours No illicit substances Pill/patch counts as requested Heit HA. Creating and Implementing Opioid Agreements. CareManagement: Disease Management Digest. 2003;7(1): Assistants: 2013 Opioid Analgesics - 25

26 Urine Drug Testing (UDT) Assesses current adherence to pharmacotherapy, tests for illicit substances Identifies potential drug-drug interactions Helps guide future treatment plans Frequency At initiation of therapy Ongoing & randomly for all patients More frequently for higher risk/concerns Must know what to order and how to interpret results 51 Urine Drug Testing (UDT) Screening UDT - Immunoassay High rate of false-positive or false-negative results Confirmatory UDT Gas chromatography-mass spectrometry (GC-MS) High performance liquid chromatography (HPLC) Advantages Relative ease of sampling; screening UDT low cost, simple testing Longer detection period for parent drug and/or its metabolite(s) than serum testing Disadvantages Clinicians must understand what to order (thresholds, tests) Must know drugs and metabolites to interpret Clinicians may be unprepared to address unanticipated results Heit HA, Gourlay D. J Pain Sympt Manage. 2004:27(3): Assistants: 2013 Opioid Analgesics - 26

27 Case #2 Your patient has been taking hydrocodone with acetaminophen for three months to treat recurrent back pain with significant improvement. He s returned to work as a licensed plumber and reports his quality of life has improved as well. You order a random urine drug test (immunoassay) and the results of the test are positive for hydrocodone and for amphetamines. What is your next step? 1. Discuss the results with him and tell him you will no longer prescribe hydrocodone/acetaminophen 2. Discuss the results with him and ask about other medications he is taking 3. Reorder the immunoassay urine test to confirm results 4. Dismiss him from your practice for violating the medication agreement 53 Immunoassay: Examples of False + Ibuprofen Synthetic PCN OTC nasal decongestants Amitriptyline Quinine OTC nighttime cold/ sleep meds Dextromethorphan Diphenhydramine Hemp seed, oil, flour, ale False + marijuana, barbiturate False + cocaine False + amphetamines False + opiates False + opiates False + methadone False + PCP False + PCP False + marijuana Clinical Drug Testing in Primary Care. Technical Assistance Publication 32. U. S. Department of Substance Abuse and Mental Health Services Administration (SAMHSA), 2012; Vincent et al. J. Family Practice (10): Assistants: 2013 Opioid Analgesics - 27

28 Case #3 Your patient has been taking oral methadone for persistent pain due to an old traumatic injury. You obtain an opiate screen immunoassay for his random urine test. The results are negative for methadone. What is your next step? 1. Dismiss the patient from your practice for violating his agreement 2. Taper him off the opioid and continue to treat his pain with non-opioid interventions 3. Interview the patient regarding possible aberrant behaviors 4. None of the above 55 Common Opioid Metabolites Heroin 6- acetylmorphine Fentanyl Methadone Morphine containing drugs & poppy seeds Morphine Codeine Hydromorphone Hydrocodone Oxycodone Chou, 2012 Oxymorphone 56 Assistants: 2013 Opioid Analgesics - 28

29 Follow-up & Open Communication Pain assessment, physical, mental health Analgesia, Activities of daily living (function), Aberrant behavior, Adverse events Passik SD, Kirsh KL. Pain Med. 2003;4(2): Progress toward goals of care What is the benefit of this treatment? What are you able to do now that you weren't doing before? Medication review with the patient Benefits and adverse effects PDMP review, random UDT Revisions to plan, if needed 57 Case #4 Your patient calls during regular office hours requesting an early refill of her opioid medication because she ran out. This is the first time the patient has made this request. What is your response to the patient? 1. Refuse and taper her off of opioid therapy because she violated the opioid agreement. 2. Dismiss her from your practice 3. Refer her to an addiction specialist 4. Schedule an appointment to see her today 58 Assistants: 2013 Opioid Analgesics - 29

30 Chronic Pain or Addiction? Chronic Pain Medication use Not out of control Improves QOL Desire to decrease meds with adverse affects Concerned about physical problem Follows agreements Frequently has meds leftover Addiction Medication use Out of control Impairs QOL Continues despite A/Es Unaware/in denial of any problems Doesn t follow agreement Doesn t have leftover meds Loses prescriptions Always has a story Fishman S. Responsible Opioid Prescribing. 2 nd ed. Washington DC, Waterford Life Science, 2012: Evaluating Aberrant Behaviors Vary in seriousness Evaluate seriousness, the cause(s), likelihood of recurrence and clinical context High predictor is > 3 episodes & sense of losing control Serious include diversion, injecting oral meds Response Range from education and increased monitoring to referral to addiction treatment Chou, et al. Clinical Guideline for the use of chronic opioid therapy in chronic noncancer pain. J of Pain (2): Assistants: 2013 Opioid Analgesics - 30

31 Summary Assess, assess, assess, assess Individualize written treatment plans Identify treatment goals in writing Adjust doses for each patient Use multi-modal approaches Monitor analgesia, ADLs, A/Es, aberrant behaviors, achievement of goals Document, document, document 61 Resources Download or hard copies for free with standard shipping: United States, Substance Abuse & Mental Health Services Administration (SAMHSA) Download or hard copies free: CME Federation of State Medical Boards, Univ. Nebraska Medical Center, SAMHSA & FSMB Foundation 62 Assistants: 2013 Opioid Analgesics - 31

32 EBP Guidelines: Pain American Pain Society Guidelines Use of analgesics, 2008 Arthritis pain, 2002 Cancer Pain Sickle cell disease pain,1999 Fibromyalgia, American Geriatrics Society Guideline Management of persistent pain in older persons, JAGS, Pharmacologic management of persistent pain in older persons, JAGS, Intern l Assoc.for the Study of Pain (IASP). An interdisciplinary expert consensus statement on assessment of pain in older persons, Clin J Pain 23: S1-S43. American Medical Directors Assoc. Pain in long term care, American Academy of Pain Medicine Use of chronic opioid therapy in chronic non-cancer pain. Chou et al., 2009, J Pain 10: National Comprehensive Cancer Network (NCCN) Palliative care guideline Cancer pain: Adults guideline American Society for Pain Management Nursing Core curriculum, 2010 Position statements American Society of Anesthesiologists & American Society for Regional Anesthesia & Pain Medicine Practice Guidelines for Acute Pain Management in the Perioperative Setting. Anesthesiology Practice Guidelines for Chronic Pain Management, Anesthesiology, Post-test question #1 Which of the following statements regarding published evidence-based pain management guidelines is FALSE? 1. Self report from the person with pain is the most reliable indicator of pain and pain relief 2. Vital signs are poor indicators for the presence of persistent pain 3. Multi-modal pain management plans include both medications and non-drug interventions selected for each individual patient 4. If one opioid is ineffective to relieve pain, other opioids are not likely to work either 64 Assistants: 2013 Opioid Analgesics - 32

33 Post-test question #2 Which of the following describes current published recommendations for the use of opioids in the treatment of moderate to severe chronic pain? 1. Consider opioids only if the person is not at risk for misuse, abuse or addiction and other strategies have not worked 2. Opioids are contraindicated for all chronic pain conditions 3. Consider a trial of opioids if the person has pain-related functional impairment or decreased quality of life when other strategies have not worked 4. Consider opioids for all patients with unrelieved moderate to severe chronic pain 65 Post-test question #3 When using a State s Prescription Monitoring Program (PMP), which of the following is TRUE? 1. Access is limited only to those patients under your care 2. Anyone can access the PMP for information about misuse and abuse 3. PMPs are only appropriate for use by law enforcement 4. All PMPs in the United States interact with one another 66 Assistants: 2013 Opioid Analgesics - 33

34 Post-test question #4 Your patient s recent urine drug test indicates the unexpected presence of a drug you have not prescribed for this patient. According to current recommendations, which of the following is an appropriate initial response? 1. Dismiss the patient from your practice for violating the written agreement 2. Discuss the results with the patient, asking for a possible explanation 3. Tell the patient you can no longer prescribe opioids but will continue other treatments 4. Remind the patient about the written agreement and give them one more chance 67 ON A SCALE OF 1 TO 5, PLEASE RATE HOW CONFIDENT YOU ARE EVALUATING PATIENTS FOR RISK OF OPIOID MISUSE, ABUSE AND DIVERSION. 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 68 Assistants: 2013 Opioid Analgesics - 34

35 WHICH OF THE FOLLOWING STATEMENTS BEST DESCRIBES YOUR PRACTICE IN TREATING PATIENTS WITH OPIOD ANALGESICS? 1. I do not treat patients with opioid analgesics, nor do I plan to this year. 2. I did not treat patients with opioid analgesics before this course, but as a result of attending this course I m thinking of treating them now. 3. I do treat patients with opioid analgesics and this course helped me change my treatment methods. 4. I do treat patients with opioid analgesics and this course confirmed my current practice Assistants: 2013 Opioid Analgesics - 35