lecture 79

Question 1

what do recommendations 1 and 2 cover?

Answer 1

determining whether or not to initiate opioids for pain

Question 2

what do recommendations 3,4, and 5 cover?

Answer 2

selecting opioids and determining opioid dosages

Question 3

what do recommendations 6 and 7 cover?

Answer 3

deciding duration of initial opioid prescription and conducting follow-up

Question 4

what do recommendations 8-12 cover?

Answer 4

assessing risk and addressing potential harms of opioid use

Question 5

what does recommendation 1 say?

Answer 5

non-opioids therapies are at least as effective as opioids for many common types of acute pain (maximize nonpharm and nonopioid pain)

Question 6

what does recommendation 2 say?

Answer 6

non-opioid therapies are preferred for subacute and chronic pain

Question 7

what does recommendation 3 say?

Answer 7

clinician should prescribe IR opioids for acute, subacute, or chronic pain when starting

Question 8

what does recommendation 4 say?

Answer 8

clinician should prescribe the lowest effective dosage

Question 9

what does recommendation 5 say?

Answer 9

carefully weigh benefits and risks and exercise care when changing opioid dosage
if benefits outweigh risks, work closely with pts to optimize nonopioid therapy while continuing opioid therapy
if risks outweight benefits, gradually taper to lower dosages

Question 10

what does recommendation 6 say?

Answer 10

prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids
acute pain

Question 11

what does recommendation 7 say?

Answer 11

evaluate benefits and risks with pts within 1-4 weeks of starting
clinicians should regularly reevaluate benefits and risks of continued opioid therapy

Question 12

what does recommendation 8 say?

Answer 12

work with pts to incorporate management plan strategies to migrate risk

Question 13

what does recommendation 9 say?

Answer 13

review the pts history of controlled substance prescriptions using PDMP to determine whether the pt is receiving opioid dosages or combos that put the pt at high risk for OD

Question 14

what does recommendation 10 say?

Answer 14

consider the benefits and risk of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances

Question 15

what does recommendation 11 say?

Answer 15

use caution when prescribing opioid pain medication and benzos concurrently

Question 16

what does recommendation 12 say?

Answer 16

clinician should offer or arrange treatment with evidence-based medications
detoxifications on its own is not recommended

Question 17

when should opioids be reduced or tapered?

Answer 17

requests dosage reduction
does not have clinically meaningful improvement in pain and function (30% )
on dosages over 50 MME without benefit or opioids are combined with benzos
shows signs of SUD
experiences OD or other serious AE
shows early warning signs for overdose risk such as confusion, sedation, or slurred speech

Question 18

how should opioids be reduced/tapered?

Answer 18

avoid abrupt tapering or sudden d/c
once lowest available dose is reached, the interval between doses can be extended
if d/c opioids, they may be stopped when taken less than once a day

Question 19

how much should be decreased based on time taking opioids?

Answer 19

if more than a year, decrease by 10% per MONTH
if taking weeks to months, decrease by 10% per WEEK

Question 20

who does the 2014 chronic pain law apply to?

Answer 20

any pt
- taking over 60 pills per month for over 3 mo
- taking an opioid over 15 MME for over 3 mo
- using a transdermal opioid patch for over 3 mo
- taking tramadol (if over 300 mg/day) for over 3 mo
- taking any dose of an ER controlled med

Question 21

what are the exemptions to the 2014 chronic pain law?

Answer 21

terminal condition
palliative care
hospice
nursing home

Question 22

according to the 2014 chronic pain law, what are practitioners required to do?

Answer 22

perform your own evaluation
assess mental health
assess risk for substance misuse
check INSPECT (with each rx or q90d if on pain contract)
sign and discuss treatment agreement/functional goals
reasses and document risk discussion if greater than 60 MED

Question 23

what did the 2017 opioid 7 day prescribing limit do?

Answer 23

physicians issuing initial opioid RX for a pt may not prescribe more than a 7 day supply

Question 24

what are the exceptions to the 7 day limit?

Answer 24

cancer
medication assisted treatment (MAT) for substance-abuse disorder
palliative care
professional judgement (must document that a non-opiate not appropriate and physician is using their professional judgement to go over 7 days)

Question 25

what did the 2019 INSPECT requirement do?

Answer 25

requires checking INSPECT each time before prescribing an opioid or benzo to any pt no exceptions pt on paint management contract must still be checked via inspect every 90 days

Question 26

what is a pain contract?

Answer 26

a written agreement between pt and prescriber does not legally prevent another provider from prescribing opioids or a pharmacy from filling opioids prescribed by a different provider but does make it so that the pt will no longer receive opioid RXs from the original provider

Question 27

what is OPEN?

Answer 27

michigan opioid prescribing engagement network shows opioid recommendations for specific procedures to curb over prescribing of post-operative opioids

Question 28

what is the pt education associated with OPEN?

Answer 28

expect to have pain after surgery because its part of the healing process and is normal typically worse the day after surgery but will get better the goal is to manage your pain so you can do the things you need to care for yourself and heal (eat, breathe deeply, walk, sleep)

Question 29

how should orders be dealt with in hospital setting?

Answer 29

pts can have multiple orders for pain medication but only one order for each severity of pain example: if pain ranks between a 7-10 use fentanyl but if its between a 4-6 use oxy

Question 30

what is a PCA?

Answer 30

pt controlled analgesia allows pt to decide when they will get a dose of pain medicine computerized pump attached to IV line allows pt to release medicine when pressing the button

Question 31

when are PCAs used?

Answer 31

for severe acute non-malignant pain --> post-operative, pancreatitis, sickle cell crisis

Question 32

what are the recommended treatments for low back pain?

Answer 32

self-care and education (remain active and limit bedrest) non-pharm treatments (exercise, CBT, interdisciplinary rehab) medications

Question 33

what medications are recommended for low back pain?

Answer 33

first line --> tylenol, NSAIDs second line --> SNRIs, TCAs

Question 34

what is non pharm treatments for OA?

Answer 34

exercise, weight loss, pt education

Question 35

what medications are used for OA?

Answer 35

first line --> tylenol, oral/topical NSAIDs second line --> intra-articular hyaluronic acid, capsaicin

Question 36

what are the non-pharm treatments for fibromyalgia?

Answer 36

low-impact aerobic exercise (brisk walking, swimming, water aerobics, or bicycling) CBT biofeedback interdisciplinary rehab

Question 37

what medications are used for fibromyalgia?

Answer 37

FDA approved --> pregabalin, duloxetine other options --> TCAs, gabapentin, venlafaxine

Question 38

what medications are used for neuropathic pain?

Answer 38

first line --> SNRIs, gabapentin/pregabalin second line --> topical lidocaine, TCAs

Question 39

what is the purpose of hospice?

Answer 39

provide comfort to pt in pain decrease respiratory drive to aid in natural end of life processes

Question 40

what route of admin is preferred in hospice?

Answer 40

buccal/SL parenteral (usually a continuous infusion) transdermal

Question 41

how should a hospice pt be monitored?

Answer 41

pt comfort (pain assessment to see how well pain controlled) less concerned with SE unless making pt uncomfortable

Question 42

how should symptoms of hospice pts be treated?

Answer 42

pain relief/air hunger --> morphine IV or solution (20 mg/mL) under tongue (could also use fentanyl or hydromorphone) anxiety/agitation --> lorazepam IV/SL PRN NV --> zofran ODT secretions --> atropine ophtalmic drops under tongue, glycopyrrolate IV PRN, scopolamine patch