AMDG - Opioid Dosing Guideline for Chronic Non-Cancer Pain CME Activity

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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.

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.

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.

	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.

	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)

TRUE OR FALSE:

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

	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 www.agencymeddirectors.wa.gov.

	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 www.microsoft.com. You may also answer this question by referring to Table 5, on page 17 of the Opioid Dosing Guideline.

	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.

The Opioid Risk Tool (ORT) to screen for risk of opioid addiction
The CAGE-AID to screen for alcohol or drug problems
The PHQ-9 to screen for depression severity
The SF36 Health Survey
A baseline urine drug test
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

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

	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.

	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 â€œred flagâ€ 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).

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

	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.

	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.

	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.

	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.

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

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.

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

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

	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-naíve patients for the sustained release formulation is 10mg q 12 hours.

	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.

True

False

True

False

True

False

Question 23: (Answer found on page 30)

TRUE OR FALSE:

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

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

Morphine

Methadone

Hydrocodone

Codeine

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.

	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.

	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.

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

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).

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.

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.

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.

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.

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

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

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.

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.

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.

	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.

	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.

True

False

	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.

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

True

False

True

False

	a) Twice the patientâ€™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.

	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.

	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.

Activity Version 2, July 2011