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Opioid Dosing Guideline and DOH Pain Management Rules Online CME Activity

Select the item that best answers each question. Select only one item per question.

If you have not already done so, you may find it helpful to open the guideline in a new browser window, or print the guideline for reference, as you will be referring to it throughout.

PDF Opioid Dosing Guideline for Chronic Non-cancer Pain (209 KB PDF)


If you have not already done so, please be sure to watch the DOH Pain Management Rules Video (20 minutes). Clicking on the video icon below will take you to an external site in a new browser window. This video is housed on the GoToWebinar server and is viewable on demand, 24 hours a day, at no charge.

DOH Pain Rule Video

In this activity you might be asked to click on external link(s) to be able to answer the corresponding question. These links will open in a new browser window, and will not close you out of the activity by doing so.

Question 1: (Answer found on page 1)

In response to the increasing morbidity and mortality associated with the increasing use of opioids, the Centers for Disease Control and Prevention (CDC) has released several recommendations for how health care providers can help. The recommendations include ALL of the following EXCEPT:

a)  Use opioid medications for acute or chronic pain only after determining that alternative therapies do not deliver adequate pain relief. The lowest effective dose of opioids should be used.
b)  In addition to behavioral screening and use of patient agreements, consider random, periodic, targeted urine testing for opioids and other drugs for any patient less than 65 years old with non-cancer pain who has been treated with opioids for more than six weeks.
c)  If a patient's dosage has increased to 120 mg MED per day or more without substantial improvement in function and pain, seek a consult from a pain specialist.
d)  It is generally appropriate to prescribe long-acting or controlled-release opioids (e.g., OxyContin®, fentanyl patches, and methadone) for acute pain.

Question 2: (Answer found on page 1) 

Recent studies indicate a dramatic increase nationally in accidental deaths associated with the use of prescription opioids. Data collected in Washington state show ALL of the following EXCEPT:

a)  During 2004—2007, over 1,600 WA residents had confirmed unintentional poisoning deaths due to prescription opioid-related overdoses.
b)  Unintentional opioid-related overdose deaths increased substantially during 1995—2008.
c)  Hospitalizations for opioid-related overdoses increased substantially during 1995—2007.
d)  Addiction treatment admissions, where prescription opioids were the primary drug of abuse, increased substantially between 2000 and 2009.
e)  Non-prescription opioid-related overdose deaths now exceed prescription opioid-related overdose deaths.
f)  The death rate from unintentional poisoning exceeded the death rate from motor vehicle crashes in 2006.

Question 3: (Answer found on page 3)


The hallmark of this guideline is a recommendation to not prescribe more than an average daily MED of 120mg without either the patient demonstrating improvement in function and pain or first obtaining a consultation from a pain management expert. A recent cohort study supports the 120mg MED dosing threshold. Patients receiving 100mg or more per day MED had a 9-fold increase in overdose risk. Most overdoses were medically serious, and 12% were fatal.

True   False

Question 4: (Answer found on pages 4 and 16-17)

For patients taking more than one opioid, the morphine equivalent doses (MEDs) of the different opioids must be added together to determine the cumulative dose. Which ONE of the following statements about MED is CORRECT?

a)  40 mg per day of oxycodone is equal to 80 mg morphine equivalents.
b)  30 mg per day of hydrocodone is equal to 60 mg morphine equivalents.
c)  An electronic opioid dose calculator can be downloaded, free of charge, at

Question 5: (Answer found on page 4) 

Using the Opioid Dose Calculator (click here *), the morphine equivalent dose for 60 mg per day of hydrocodone and 60 mg per day of oxycodone is which of the following:

a)  60 mg oral morphine equivalents
b)  100 mg oral morphine equivalents
c)  150 mg oral morphine equivalents
d)  160 mg oral morphine equivalents

* To answer this question, Microsoft Excel Version 97 or newer is required to view the Opioid Dosing
   Calculator.  If you do not have Microsoft Excel, a free viewer is available for download from  You may also answer this question by referring to Table 5, on page 17 of the Opioid
   Dosing Guideline.

Question 6: (Answer found on pages 3-6) 

Mrs. Smith has chronic pain from degenerative disk disease and has been taking several opioids for six months with a total daily morphine equivalent dose of 90 mg per day. According to these guidelines, which ONE of the following statements is CORRECT:

a)  A pain management consultation is required to address potential alternative treatments to opioids.
b)  It is inappropriate for the patient and prescriber to sign an opioid agreement.
c)  It is not necessary for the prescriber to monitor Mrs. Smith’s pain and function because the opioid dose is relatively low.
d)  No pain management consultation is needed if the prescriber is documenting sustained improvement in both function and pain.
e)  It is rare for opioids to cause depression or anxiety disorders, so it is not necessary for the prescriber to assess Mrs. Smith for psychological conditions.

Question 7: (Answer found on page 5)

If substantial risk is identified through screening, extreme caution should be used and a specialty consultation (e.g. addiction or mental health specialist) is strongly encouraged. A number of tools are available which can easily be used in the primary care setting to perform a baseline risk assessment. Which of the following tools should be used and documented in the record?

  1. The Opioid Risk Tool (ORT) to screen for risk of opioid addiction
  2. The CAGE-AID to screen for alcohol or drug problems
  3. The PHQ-9 to screen for depression severity
  4. The SF36 Health Survey
  5. A baseline urine drug test
  6. A baseline assessment of function and pain with the 2-item Graded Chronic Pain Scale
a)   #1 and #3
b)  #2 and #4

c)  #3 and #5
d)  #1, 2, 3, 5 and 6
e)  #2, 3, 4, 5 and 6
f)  All of the above.

Question 8: (Answer found on pages 6-7)

According to the Opioid Guideline, the key to effective opioid therapy for chronic non-cancer pain is to achieve sustained improvement in pain and physical function. Assessing the effectiveness of opioid treatment should entail tracking and documenting both functional improvement and pain relief.

While there is no universally accepted tool to assess opioid therapy's impact on function and pain, which of the following is the ONE tool which the AMDG recommends as an ongoing and rapid method to easily track function and pain?

a)  The Neck Disability Index
b)  The Short Musculoskeletal Function Assessment
c)  The two-item Graded Chronic Pain Scale
d)  The “Pain Faces Scale”
e)  The QuickDash, for musculoskeletal disorders of the upper extremities
f)  The Oswestry Disability Index

Question 9: (Answer found on page 7)

Increasing opioid doses may not improve function and pain control and may cause complications. Chronic opioid therapy may be associated with which of the following?

a)  Development of tolerance to its analgesic effects
b)  Hyperalgesia
c)  Allodynia
d)  All of the above

Question 10: (Answer found on pages 8-9)

Regarding urine drug testing (UDT), which ONE of the following statements is FALSE:

a)  Baseline UDT should be performed on all transferring patients who are already using opioids and for those patients who you are considering for chronic opioid therapy (for example, 3rd opioid prescription or >6 weeks after an acute injury). 
b)  After opioid therapy has been initiated, the prescriber should randomly repeat testing at the approximate frequency determined by the patient’s risk category based on the ORT or similar screening tools.
c)  For patients at moderate risk of opioid addiction by ORT, the recommended frequency of UDT is "regular" (e.g., up to 2/year).
d)  Chromatography/mass spectrometry is the most common method of screening and can be performed either in a laboratory or at the point-of-care.
e)  Immunoassays can concurrently test for multiple drug classes, provide rapid results and guide appropriate utilization of confirmatory testing.
f)   Immunoassays can cross-react with other drugs and vary in sensitivity and specificity. Thus, unexpected immunoassay results should be interpreted with caution and verified by confirmatory testing.

Question 11: (Answer found on page 9)

Regarding interpretation of urine drug testing (UDT), which ONE of the following statements is FALSE:

a)  When the immunoassay result is unexpected and the patient does not acknowledge or credibly explain the result, a confirmatory test using either GC/MS or LC/MS/MS should be ordered.
b)  If the patient tested negative for prescribed opioids and if confirmatory testing substantiates a “red flag” result, the prescriber should consider a controlled taper or stop prescribing opioids immediately.
c)  The NIDA 5 tests for many commonly prescribed or abused drugs such as benzodiazepines and semi-synthethic or synthetic opioids.
d)  Positive testing for alcohol is one of the "red flag" results.
e)  For help with drug testing or results, you may contact your local laboratory director, toxicologist or certified Medical Review Officer (MRO).

Question 12: (Answer found on pages 9 and 33)

The NIDA 5 (National Institute on Drug Abuse) is the most commonly used basic urine drug test. The NIDA 5 does NOT screen for which of the following:

a)   Benzodiazepines
b)  Codeine
c)  Oxycodone
d)  A and B
e)  A and C

Question 13: (Answer found on page 10)

Mr. Jones has chronic pain from arthritis and has been taking several opioids for nine months with a total daily morphine equivalent dose of 90 mg per day. Mr. Jones continues to have considerable pain, and his prescribing provider is considering increasing the dose of opioids to exceed 120 mg per day total daily morphine equivalent dose. According to this guideline, before increasing the dose, the prescriber should:

a)  Ensure that there are no significant psychological issues or evidence of drug-seeking behaviors.
b)  Ensure that the patient has demonstrated improvement in function and pain previously at a lower dose.
c)  Consider seeking an opioid management consultation.
d)  All of the above.

Question 14: (Answer found on page 10) 

Regarding consultative assistance for opioid management, which ONE of the following statements is FALSE:

a)  Consultative assistance for opioid management and prudent prescribing of opioids should be with a pain management expert who is familiar with and endorses this guideline.
b)  Prescribers should seek consultative assistance for patients on > 120mg MED/day.
c)  Consultation with a specialist does not necessitate transfer of the patient for care or ongoing opioid prescribing.
d)  The consultant should advise the prescribing provider on a pain management plan and may include: alternative treatments to reduce or discontinue use of opioids, explanation of the risks and benefits of a possible trial with opioids above 120mg/day MED, and the need for ongoing documentation of improvement in function and pain.
e)  Consultations must be done face-to-face with the patient.

Question 15: (Answer found on page 10)

To find a specialist who can help with opioid management, which of the following resources are provided in the guideline?

a)  A list of consultants at the AMDG web site.
b)  A list of organizations that offer credentialing or certification in pain medicine, such as the American Board of Pain Medicine and others.
c)  The University of Washington School of Medicine toll-free MEDCON consultation and referral service available 24 hours per day, 7 days per week.
d)  All of the above.

Question 16: (Answer found on pages 10-11) 

Not all patients benefit from opioids, and prescribers frequently face the challenge of reducing the opioid dose or discontinuing the opioid altogether. Which ONE of the following statements about weaning opioids is INCORRECT?

a)  A decrease by 10% of the original dose per week is usually well tolerated with minimal physiological adverse effects. Some patients can be tapered more rapidly without problems (over 6 to 8 weeks).
b)  Symptoms of an abstinence syndrome can be managed with clonidine 0.1-0.2 mg orally every 6 hours while monitoring often for significant hypotension and anticholinergic side effects.
c)  Providers should not treat withdrawal symptoms with opioids or benzodiazepines after discontinuing opioids.
d)  Referral for counseling or other support during this period is recommended if there are significant behavioral issues.
e)  Symptoms of opioid withdrawal may resolve within 2 weeks after opioids have been discontinued.

Question 17: (Answer found on pages 12-13)

Patients who exhibit overt signs of alcohol or substance abuse disorder should be referred to an addiction specialist for appropriate treatment. Which of the following statements about addiction management is/are correct?

  1. Prognosis is poor for patients with a DSM diagnosis of opioid dependence or opioid abuse who do not receive treatment.

  2. Reasons to refer for addiction management include drug-seeking behaviors such as frequently losing prescriptions, aggressive demand for opioids, unsanctioned dose escalation, and getting opioids from multiple prescribers.

  3. Patients with a comorbid psychiatric condition or addiction are at higher risk of opioid misuse despite their attempts to follow the treatment plan.

  4. Prescribers should intensify monitoring and scrutiny and seek a consultation with an addiction specialist if there is past or active substance dependence or abuse.

a)  #1 and #3
b)  #2 and #4
c)  #1, 2 and 4
d)  #1, 2, 3 and 4

Question 18: (Answer found on page 16)

The guideline provides dosing thresholds and recommendations for selected opioids. According to the guideline, which ONE of the following statements about dosing is FALSE?

a)  Oxymorphone should be used with extreme caution due to potential fatal interaction with alcohol or medications containing alcohol.
b)  Meperidine should not be prescribed for chronic non-cancer pain.
c)  Methadone may take a long time to reach a stable level in the body. So methadone doses may be increased as frequently as every 3 days.
d)  You should not prescribe methadone as PRN or combine with other long-acting opioids.
e)  For oxycodone, the recommended dose threshold for pain consult is 80mg per 24 hours, while the recommended starting dose for opioid-nave patients for the sustained release formulation is 10mg q 12 hours.

Question 19: (Answer found on page 18)

Regarding the many screening tools described in the guideline, which ONE of the following statements is FALSE?

a)  The recommended tool to screen for risk of opioid addiction is the ORT.
b)  The recommended tool to screen for current or past substance abuse is CAGE-AID.
c)  recommended tool to screen for mental health conditions is the PHQ-9.
d)  Each of the three recommended screening tools takes about 20 minutes to complete.
e)  All three of the recommended screening tools are available for public use at no cost.

Question 20: (Answer found on page 19)


Mr. Smith has just finished answering the five questions on the Opioid Risk Tool (ORT). His total score is 6. This indicates he is at moderate risk of opioid addiction.

True   False

Question 21: (Answer found on page 20)


Ms. Johnson has just finished answering the four questions on the CAGE-AID Questionnaire. She answered "no" to all of the questions, except that she said "yes" that people have annoyed her by criticizing her drug use. These responses are considered a negative screen.

True   False

Question 22: (Answer found on pages 21-23)


Mr. Adams has just finished answering the ten questions on the PHQ-9. His total score is 15. These answers suggest Mr. Adams is a candidate for treatment for depression.

True   False

Question 23: (Answer found on page 30)


You started treating Ms. Jefferson several months ago for low back pain. She had been in treatment for five years and had undergone several surgical procedures. When you began treating her, she was taking a variety of medications, including opioids.

Two months ago you began assessing her pain and function using the Two Item Graded Chronic Pain Scale. When you first assessed her "average/usual pain intensity" and "pain-related interference with activities" her ratings were 8 (severe) and 9 (severe), respectively. When you assessed her again today, her ratings were 6 (moderate) and 7 (severe), respectively.

Ms. Jefferson's ratings are considered moderate but clinically significant improvement.

True   False

Question 24: (Answer found on pages 32-33)

If you are prescribing morphine to your patient, which ONE of the following results might you get from a confirmatory UDT?

a)  Codeine
b)  Hydrocodone
c)  Oxymorphone
d)  Hydromorphone

Question 25: (Answer found on pages 32-33)

Which of the following drugs cannot be detected by an “opiates” immunoassay?

  1. Morphine

  2. Methadone

  3. Hydrocodone

  4. Codeine

  5. Meperidine

a)  #1 and #3
b)  #2 and #4
c)  #2 and #5
d)  All of the above.
e)  None of the above.

Question 26: (Answer found on pages 35-36)

A 47-year-old male with rotator cuff tendonitis has chronic shoulder pain managed with morphine SR 30mg TID and oxycodone/acetaminophen 5/325mg 1 tab Q4H PRN (MED = 135mg/day). He reports no other drug therapy. A treatment agreement has been signed by you and the patient recently. You perform a random UDT using a point-of-care testing kit. The immunoassays are positive for opiates but also positive for benzodiazepines. You have discussed the unexpected results with the patient. Which of the following should you NOT do?

a)  If explanation is credible (e.g. receiving treatment for anxiety from another provider), I may want to send the urine sample to laboratory to confirm his story.
b)  If explanation is not accepted (e.g. patient admits benzodiazepine use that is not prescribed for the patient), I should stop prescribing opioids and consider a referral to an addiction specialist or drug treatment program.
c)  If result cannot be explained, I should send the original urine sample to laboratory for confirmatory testing.

Question 27: (Answer found on pages 37-38)

What language can you use to explain to patients why drug screening doesn't mean you don't trust them?

a)  “It ensures my capacity to provide treatment for your pain while balancing the need for safety.”
b)  “It provides critical information needed to assess the success of your therapy.”
c)  “Prescription medications are a common form of treatment for chronic pain. However, each person reacts differently to them. UDT enables us to identify individual risks related to your medications and avoid problems.”
d)  “Our clinic uses ‘universal precautions’ in opioid prescribing, which includes UDT. This is the same as wearing gloves on all patients when drawing blood.”
e)  Any of the above.

Question 28: (Answer found on pages 39-40)

Regarding reimbursement by Washington State public payers for consultations, as recommended in this guideline, which of the following statements is/are TRUE?

a)  Reimbursement does NOT always require face-to-face consultation.
b)  Reimbursement does NOT require transfer of care in most situations.
c)  Reimbursement is available for consultations done using video conferencing or webinar.
d)  Telephone consultations with specialists, non face-to-face, can be billed using codes 99441-99443 (physicians), or 98966-98968 (non-physician health care professional- ARNPs, PAs, psychologists).
e)  Email or online consultations with specialists can be billed using code 99444 (physician only) or 98969 (non-physician health care professional- ARNPs, PAs, psychologists).
f)  All of the above.

Question 29: (Answer found on pages 41-46)

Regarding additional resources for you and your patients, which of the following statements is/are correct?

  1. The Department of Social and Health Services (DSHS) provides an online Tool Kit to help address drug and alcohol issues in Medicaid patients.

  2. The DSHS Division of Alcohol and Substance Abuse can be reached at 877-301-4557, where a referral for treatment may be made to opioid therapy programs (OTPs).

  3. The Physician Clinical Support System has mentors available to help you, by phone or email, with questions on methadone or buprenorphine. In addition, helpful tools can be downloaded from the web site. There is no cost for this service. A mentor will be assigned to you within 2 days.

  4. The "takeasdirected" web site created by DOH provides information for patients and health care providers, including information on opioid safety and warning signs of drug abuse.

  5. The Collaborative Opioid Prescribing Education (COPE) is an online training to improve doctor-patient communications and collaborative goal-setting. COPE is available through the University of Washington.

  6. CDEMS is the Chronic Disease Electronic Management System, a free Microsoft Access database application designed to assist medical practices in tracking the care of patients with chronic health conditions.

a)  #1 and #3
b)  #2 and #4
c)  #3 and #6
d)  All of the above.
e)  None of the above.

Question 30: (Answer found on page 47)

The emergency department is a significant source of prescription opioids, yet there has been little guidance on how to treat pain in the ED while minimizing the potential for abuse.

In Washington state a promising approach has been started to deter patients who visit EDs from obtaining prescription opioids for misuse. Which of the following statements correctly describe this program?

  1. The Emergency Department Information Exchange (EDIE) is a low-cost, HIPAA compliant system of sharing patient information between EDs.

  2. When a patient visits the ED, the EDIE instantly and automatically checks for other ED visits at participating hospitals across Washington.

  3. The EDIE notifies the ED immediately by fax when a patient is found to have a suspicious pattern of visiting the ED. The fax contains a history of the patient's ED visits for the ED physician to review prior to seeing the patient.

  4. Information such as the patient's primary care physician and instructions on how to treat the patient's chronic pain is included in the fax if the patient is enrolled in an Emergency Department Care Coordination program.

  5. After a patient is enrolled in an Emergency Department Care Coordination program, a multidisciplinary team creates a set of ED care guidelines, including specific recommendations for opioid prescribing, for each patient.

a)  #1 and #3
b)  #2 and #4
c)  #3 and #6
d)  All of the above.
e)  None of the above.

Questions 31-40 are based on the video on the Rules for the Treatment of Chronic Non-Cancer Pain promulgated by the Washington State Department of Health. (See test instructions for details.)

Question 31: (Answer found in the video on the DOH rules)

ESHB 2876 was passed to:

a)  Reduce the number of opioid prescriptions in the state of Washington.
b)  Legislate the practice of medicine.
c)  Address the rising death rate from unintended opioid deaths.
d)  Reduce the prescribing of long-acting opioids.

Question 32: (Answer found in the video on the DOH rules)

Exceptional circumstances to the rule include:

a)  Hospice care.
b)  Palliative care or other end of life care.
c)  Management of a new medical problem that involves acute pain.
d)  All of the above.

Question 33: (Answer found in the video on the DOH rules)

Informed consent shall be a part of every treatment plan:

True   False

Question 34: (Answer found in the video on the DOH rules)

Written agreements for treatment must be obtained for:

a)  All patients receiving opioids.
b)  Patient determined to be a high risk.
c)  Anyone under the age of 18 years.
d)  For long-acting opioids only.

Question 35: (Answer found in the video on the DOH rules)

Periodic review of the treatment plan shall occur:

a)  On a regular basis.
b)  Generally every six months.
c)  Whenever it seems necessary.
d)  Yearly.

Question 36: (Answer found in the video on the DOH rules)

Prescribers of long-acting opioids should have a one-time (lifetime) completion of at least four hours of CME:

True   False

Question 37: (Answer found in the video on the DOH rules)

Episodic care practitioners may NEVER prescribe long-acting opioids:

True   False

Question 38: (Answer found in the video on the DOH rules)

The mandatory consultation threshold for adults is:

a)  Twice the patient’s weight in kilograms.
b)  120 mg of morphine equivalent dose (MED).
c)  When the treatment is not working.
d)  After six months of treatment.

Question 39: (Answer found in the video on the DOH rules)

To be an exempt provider the practitioner must:

a)  Have practiced for three years or more.
b)  Have over 50 chronic pain patients.
c)  Have completed in the previous two years, 12 hours of chronic pain CME with at least two hours dedicated to long-acting opioids.
d)  Work in a pain clinic.

Question 40: (Answer found in the video on the DOH rules)

If a provider cannot find a pain specialist to refer to for whatever reason he/she must:

a)  Stop prescribing opioids.
b)  Use only short acting opioids.
c)  Document in the health record the reason why.
d)  Use any opioid but Methadone.

    Please review your information carefully before clicking the "Submit" button.

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Activity Version 2, July 2011