Chapter 13 Risk Stratification and Management of Opioids

Question 1

ASSESSING FOR RISK OF MISUSE OR

ADDICTION

Answer 1

minimal prevention
measures are applied that include initial assessment,
an opioid treatment agreement, informed consent, regular urine drug tests (UDTs), regular reassessment of treatment
goals, and thorough documentation

Question 2

Patients are evaluated

for the presence of

Answer 2

opioid-related risk factors that include personal or family history of substance misuse, young age, history of sexual abuse, mental disease, social patterns
of drug use, psychological stress, poor social support, polysubstance misuse, cigarette dependency, and repeated 2rehabilitations for substance misuse

Question 3

The Screener and Opioid Assessment for Patients with Pain, Version 1 (SOAPP 1.0),

Answer 3

a 14-item, self administered
questionnaire that examines such predictors as history of substance misuse, sexual abuse, mood disorders, impulsivity, legal problems, and chaotic social environment

Question 4

Opioid Risk Tool

Answer 4

is a five-item, self-report questionnaire, which provides a gender-specific
score, and can be completed in less than 5 min

Question 5

The Opioid Risk Tool (ORT)

assesses for

Answer 5

personal and family history of substance misuse; age; history of preadolescent sexual
abuse; and the presence of certain mental disorders, and has successfully identified which patients are at lowest and highest risk

Question 6

Diagnosis, Intractability,

Risk, Efficacy (DIRE)

Answer 6

incorporates risk factors for substance misuse in addition to characteristics regarding the patient’s pain

Question 7

Rather than assigning a

patient a risk category, the DIRE purports to determine

Answer 7

whether the patient is a good candidate for long-term opioid therapy

Question 8

Which of the three tools is sensitive for detecting high-risk patients?

Answer 8

SOAPP is the most sensitive of the three tools at detecting high-risk patients, followed by the ORT and then the DIRE

Question 9

At each clinic visit, the patient should be reassessed for the 4As:

Answer 9

aberrant drug-taking behaviors
activities of daily living, adverse effects, and
analgesia,

Question 10

Urine Drug Tests (UDTs

Answer 10

UDTs can help indicate whether illicit or unauthorized prescriptions
are present, and whether the patient is actually taking the prescribed medication.

Question 11

Signs of aberrant

behavior should trigger a UDT. Two main types of UDT that are available.

Answer 11

Initial screening, usually a radioactive or enzyme mediated immunoassay test, can show whether substances are present but typically cannot isolate specific opioids. Confirmation testing generally requires a gas chromatography/mass spectrometry (GC/MS), which can detect actual
molecular structures of specific drugs and their metabolites. Initial testing may be done in the office, but confirmation testing is most often handled by a lab

Question 12

If Urine Drug Tests (UDTs is positive, the clinician should

Answer 12

document and address with the patient any aberrant behaviors that arise during the course of opioid therapy and should intensify monitoring measures accordingly.

Question 13

Intensified levels of monitoring may involve

Answer 13

limiting the amount or types of medication
prescribed, requiring frequent physician visits and UDTs, bringing in specialists to co-manage the patient, and appointing a third party to dispense medication to the patient

Question 14

long-term consumption of opioids contributes to endocrine deficiencies

Answer 14

that long-term consumption of opioids contributes to hormone deficiencies, in particular those that produce adverse sexual side effects

Question 15

adverse sexual side effects

Answer 15

These effects may include
decreased libido and muscle mass, erectile dysfunction fatigue, depression, hot flashes, menstrual irregularities,
weight gain, and osteoporosis

Question 16

the impact of chronic opioid therapy on the endocrine system in men and women

Answer 16

found extensive hypogonadism in men and women primarily due to central suppression
of hypothalamic secretion of gonadotropin-releasing
hormone (GnRH)

Question 17

Opioid-consuming women compared to nonopioid controls demonstrated

Answer 17

lower values of testosterone, estradiol, dehydroepiandrosterone
sulfate, LH, and follicle-stimulating hormone (FSH)

Question 18

Men taking sustained-release opioids for pain have demonstrated significantly

Answer 18

lower levels of

testosterone, luteinizing hormone (LH), and other hormones than nonopioid controls

Question 19

Patients taking opioids for chronic pain should be screened for

Answer 19

symptoms associated with abnormalities of sex hormones, and those on high-dose opioids (>100-mg morphine equivalent) should be tested for serum hormone levels.

Question 20

Recommended lab tests for patients taking opioids for chronic pain include

Answer 20

those for total testosterone, free testosterone, estradiol, LH, and FSH. Hypogonadism is typically diagnosed at less than 300 ng/dL total (bound and free) testosterone

Question 21

treatment choice in patients with abnormalities of sex hormones

Answer 21

recommend opioid rotation or opioid reduction accompanied by non- pharmacologic treatments for pain. If these measures are unsuccessful, hormone replacement therapy may be considered as follows:
Testosterone: gel, cream, buccal, transdermal
Estrogen
Dehydroepiandrosterone (DHEA), prasteron (INN)
(50 to 100 mg/day)
Thyroxine, Growth hormone
l Hydrocortisone

Question 22

sleep-disordered breathing associated with

Answer 22

opioid consumption.

Question 23

Complicating risk factors for apnea

Answer 23

benzodiazepine use, chronic pain, and high body mass index (BMI) (an apparent factor
for obstructive but not central sleep apnea)

Question 24

sleep studies are advisable for patients

taking

Answer 24

methadone more than 40 mg per day and other

opioids at approximately 100 to 150 mg morphine equivalent per day

Question 25

The conservative prescribing guidelines are

recommended for initiating or converting to methadone in patient at risk of sleep-disordered

Answer 25

Do not use conversion tables to determine the initial dose. Consider the patient to be opioid-naive for initiating methadone, regardless of prior opioid dose.
l Start with a ceiling dose of no more than 20 mg/day (10 mg/day for elderly or infirm patients).
l Adjust other medications down slowly while concurrently titrating methadone up slowly.
l Adjust doses no more often than weekly to allow
steady-state blood levels of methadone to develop and for the maximum respiratory-depressant effects to become clear.
l The starting dose and speed of methadone titration may need to be adjusted downward if patients are taking
concomitant benzodiazepines

Question 26

Risk Stratification after Sleep Study Screening

Answer 26

Level 3 (highest risk)
Around-the-clock opioids with CAI. >5 events/hr
Around-the-clock opioids with AHI. >30 events/hr
Level 2 (moderate risk)
Around-the-clock opioids with AHI. >5 events/hr
Level 1 (lowest risk)
Patients with AHI , 5 events/hr
AHI apnea-hypopnea index;
CAI, central apnea index.

Question 27

Opioid-induced hyperalgesia (OIH)

Answer 27

s a paradoxical response in which sensitivity to painful stimuli increases following opioid administration to treat pain

Question 28

Opioid-induced hyperalgesia (OIH) mechanism of action

Answer 28

neuroplastic changes in the peripheral and central nervous systems that lead to sensitization
of pronociceptive pathways

Question 29

What is the difference between OIH and tolerance?

Answer 29

Tolerance is a neurophysiologic adaptation of decreased analgesic effectiveness in response to desensitization of antinociceptive pathways, may be overcome by increasing doses.In contrast, OIH is characterized by lessened analgesic effectiveness coupled with an enhanced sensitivity to pain in which increasing doses may
worsen pain. OIH is also a hallmark of opioid withdrawal

Question 30

To assess for the presence of OIH, other possible causes for

failure of opioid analgesia must be ruled out as follows:

Answer 30

Worsening pain pathology
Opioid tolerance
Physical withdrawal
Inadequate analgesia
Addiction

Question 31

Means to minimize OIH or possibly to resolve it, include the following:

Answer 31

The lowest clinically effective opioid dose
Adjuvant medications to enhance opioid sparing
Long-acting opioids
Opioid rotation
Opioids that incorporate low-dose opioid antagonists

Question 32

opioids come with

significant risks and will prove more harmful than helpful for some patients. Warning signs to look for include

Answer 32

no benefit from opioids despite dose adjustments, side-effect management, and/or opioid rotation; poor tolerance at
analgesic doses; persistent adherence problems despite
appropriate limits and monitoring; or the presence of a
complicating comorbid condition that renders opioid therapy
ineffective or harmful