opioids rosh quiz
Acetaminophen and morphine patient-controlled analgesia with basal and intermittent dosing Children with uncontrolled pain despite oral opioids require hospital care for intravenous morphine or morphine derivatives. During hospitalization, pain control should use multiple modalities. In this case, the best option is to administer acetaminophen and a morphine patient-controlled analgesia (PCA) with basal and intermittent dosing. Scheduled nonsteroidal anti-inflammatory medications may also be considered if the patient does not have kidney disease.
A 15-year-old girl with sickle cell disease presents to the hospital with 24 hours of severe pain in her right leg. She has otherwise been in her usual state of health and reports no fever or trauma. Radiographs of the right lower extremity show normal findings. In the emergency department, she receives acetaminophen, ketorolac, and intravenous fluids without relief. She requires three doses of morphine before pain improves, and a morphine patient-controlled analgesia is started. She is admitted to the pediatric floor. Which of the following is the most appropriate pain regimen to order upon her arrival? AAcetaminophen BAcetaminophen and morphine patient-controlled analgesia with basal and intermittent dosing CAcetaminophen and morphine patient-controlled analgesia with basal infusion DMorphine patient-controlled analgesia with basal and intermittent dosing
Ethnicity Health equity in pain management is a serious issue in health care today. Studies have shown that different ethnic groups appear to be treated differently in the health care system with respect to pain management and opioid prescribing. Ethnicity is not the only factor that affects pain management. Patients with mental health disorders, cognitive impairment, sickle cell disease, substance use disorders, cancer-related pain, and those of advanced age are at a higher risk of inadequate pain treatment. vs A patient's age (A) can play a role in health equity, especially if cognitive impairment is present. Despite this, it is not as likely to negatively influence referral to a pain specialist as the patient's ethnicity. Diagnosis (B) may contribute to health inequity if there is a certain stigma associated with a diagnosis, but this is not as likely as ethnicity to decrease referrals to a pain specialist
A 19-year-old man with sickle cell disease presents to his primary care physician with increased pain that is preventing him from attending classes. He is an international student from Nigeria. Which factor is most likely to negatively influence his receiving a referral to a pain specialist? AAge BDiagnosis CEthnicity DPain level
Preterm labor and delivery True or false: during pregnancy, a methadone dosage increase may be needed for opioid use disorder treatment. Answer: True. Is pregnancy a contraindication to buprenorphine use? ans: no
A 20-year-old woman presents to her physician for a well-woman checkup. The patient has an intrauterine device and is not planning on becoming pregnant until a few years from now. When asked about substance use, the patient reports using heroin. She states that she tried to stop on her own but has been feeling ill since her last use 2 days ago and does not feel she can quit "cold turkey." The physician counsels the patient about starting opioid agonist therapy. Which of the following effects of opioid use on pregnancy-related outcomes is most likely to be averted if opioid agonist treatment is started as early as possible for this patient? ACongenital anomalies BFetal macrosomia CPlacenta accreta spectrum DPreterm labor and delivery
Diarrhea Classic signs and symptoms of opioid withdrawal include mydriasis, insomnia, yawning, lacrimation, rhinorrhea, piloerection, tachycardia, hypertension, vomiting, and diarrhea. Volume depletionfrom uncontrolled nausea, vomiting, and diarrhea is an important concern with opioid withdrawal syndrome What is piloerection, a characteristic feature of opioid withdrawal? Answer: Piloerection, also known as goosebumps or gooseflesh, is characterized by the skin hairs standing on end as a reflexive response of the sympathetic nervous system.
A 20-year-old woman with a history of opioid use disorder presents to the emergency department. She has had two opioid overdose-related admissions in the past year. Her mother states that her daughter began using substances after a cheerleading injury and a breakup with her partner. She then developed difficulties at school and in her relationships and left college without graduating. The patient says that she initially purchased and used counterfeit oxycodone to cope with her back pain and continued using the drug to feel happy. She states that she has not been able to find more pills since she ran out a couple of days ago. She said she began feeling sick about 12 hours after her last dose and now feels worse about 48 hours later. Which of the following signs and symptoms would you most likely expect to find in this case? ADiarrhea BHypotension CSmall pupils DSomnolence
Clinical Opiate Withdrawal Score of 9 Patients should be in at least mild acute opioid withdrawal before initiating buprenorphine to avoid precipitated withdrawal. The patient should have a Clinical Opiate Withdrawal Score (COWS) score of at least 8. COWS scoring is a standardized assessment tool used to quantify the severity of opioid withdrawal symptoms. The scale evaluates 11 common withdrawal symptoms, including pulse rate, sweating, restlessness, pupil size, bone or joint aches, runny nose or tearing, GI upset, tremor, yawning, anxiety or irritability, and gooseflesh skin. Each symptom is rated on a scale of 0 to 4, with higher scores indicating more severe withdrawal.
A 21-year-old man with a medical history of mild asthma, treated with albuterol as needed, presents to the clinic with concern over his opioid drug use. He states that he has been using various opioids recreationally for approximately 2 years. Lately, he has been spending so much time attempting to obtain opioids and recovering from the effects that he has dropped out of college. His partner also recently ended their relationship due to concerns over how much the drug use has taken over his life. After a long discussion with the patient concerning different options for treatment, he decides he would like to try buprenorphine. A physical exam is performed. Which of the following would be an indication for initiating buprenorphine on the day of this visit? AAlbuterol use in the past 24 hours B Clinical Opiate Withdrawal Score of 9 CFentanyl use 12 hours ago DNo signs and symptoms of opioid withdrawal
Schedule III authority DEA license
A 22-year-old man is successfully treated for an opioid overdose in the emergency department. Upon discharge, he is provided naloxone, harm reduction strategies, and education by the treating clinician. The patient expresses a strong desire to stop using opioids. Which of the following specifically confers a clinician the ability to treat this patient with buprenorphine? AMedical license BPracticing within addiction medicine CSchedule III authority DEA license DX-waiver
Naloxone
A 24-year-old woman presents to the emergency department via ambulance after being found down at her apartment by her friend. Per EMS, the patient has a history of anxiety and chronic leg pain from a sports injury in college. Her friend told EMS that the patient's medications include acetaminophen, escitalopram, and oxycodone. On physical examination, the patient is noted to be lethargic and minimally responsive to commands but is protecting her airway and has a Glasgow Coma Scale score of 10. Her vital signs are a T of 98.2°F, BP of 128/75 mm Hg, HR of 76 bpm, RR of 8/min, and SpO2 of 92%. She has pinpoint pupils and normal breath sounds despite her slowed respiratory rate. Which of the following is the best next step in treatment for this patient? A Atropine B CT of the head without contrast C Flumazenil D Intubation E Naloxone A 22-year-old man with a history of intravenous heroin use presents to the emergency department via private vehicle after a family member found him unresponsive. Vital signs are heart rate of 62 bpm, blood pressure of 104/65 mm Hg, respiratory rate of 6 breaths/minute, oxygen saturation of 89% on room air, and temperature of 98.0°F. On physical examination, he is somnolent and not arousable to sternal rub. Evaluation of his eyes reveals bilateral pinpoint pupils. He is treated and immediately regains consciousness and becomes agitated. Which of the following is the most appropriate choice for his management following discharge from the emergency department?
High-pitched crying True or false: opioid use disorder is associated with an increased risk of placental abruption. Answer: True.
A 25-year-old woman presents to labor and delivery triage at 38 6/7 weeks gestation in spontaneous labor. She precipitously delivers a neonate without anesthesia. Her pregnancy was dated by a first-trimester ultrasound performed at her only obstetric appointment. She reports no medical or surgical history and that she has used heroin throughout the pregnancy. You explain to her that her baby is at risk of neonatal abstinence syndrome. Which of the following is considered a clinical manifestation of this syndrome? ADecreased respiratory rate BExcessive feeding CHigh-pitched crying DHypotonia
Increased sensitivity to pain High-dose or long-term opioid use that results in new or worsening pain (nociceptive sensitization)
A 30-year-old man presents to his primary care office for a routine annual wellness exam. He has been seeing the same family doctor since he was young, and they have a trusting rapport. For the past year, he has been treated by a pain management specialist with opioid therapy for back pain resulting from a serious motor vehicle collision. The patient reports that he has been taking greater amounts of hydrocodone beyond what was prescribed. He says he initially began increasing the amount of the opioid he was taking because his pain persisted on the recommended dose. Later, he began taking extra tablets to feel "high." He notes that he experiences strong cravings and spends considerable time trying to find opioid pills, researching drug dealers and raiding through clients' medicine cabinets. The patient works as a contractor specializing in home remodeling and repair. He recognizes his drug use has negatively impacted his job performance, his relationships with coworkers and friends, and his marriage, and he is neglecting his responsibilities to his child. Nonetheless, he acknowledges that he still uses opioids despite the problems stemming from his usage. He states that he truly wants to stop, but multiple attempts to cut down or quit using opioids have been unsuccessful. Given the patient's history of long-term opioid use, which of the following effects would be most likely? ADecreased heartburn symptoms BIncreased bone density CIncreased libido DIncreased sensitivity to pain
Craving or having a strong desire or urge to use his pain medication
A 31-year-old man with a history of chronic back pain presents to your primary care office requesting a refill of his medication. The patient states that he has been taking a 60 mg extended-release tablet of oxycodone daily for the past 6 months following a motor vehicle collision. The patient says his back pain becomes "unbearable" if he misses a dose. He also says he has recently begun to take two 60 mg tablets daily, as one tablet no longer provides the pain relief it once did. Which of the following symptoms is included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for the suspected diagnosis? ACraving or having a strong desire or urge to use his pain medication BDevoting more time to important social, occupational, or recreational activities CExhibiting unusual aggression toward family and friends DExperiencing a decreased need for sleep ESharing prescription medications amongst family or friends
naloxone in opioid overdose is to reverse the life-threatening respiratory depression caused by an overdose. Opioids include drugs such as heroin, morphine, fentanyl, oxycodone, and hydrocodone. works as an opioid antagonist. Its primary mechanism is to bind to the opioid receptors in the brain, more specifically the mu-opioid receptors, which opioids act upon to produce their effects. The binding of naloxone to these receptors displaces opioids, blocking their effects on the central nervous system and reversing the respiratory depression that can be fatal in an overdose situation. Naloxone does not activate the receptor to produce any effect, and thus it is termed a competitive antagonist.
A 33-year-old man is brought into the emergency department by paramedics after his friend found him unconscious at home. The friend reports that the patient has been taking prescription opioids since he experienced a work-related back injury 4 years ago. The patient's respiration is slow and shallow, with a rate of 6 breaths/minute, and he has pinpoint pupils. His blood pressure is 100/60 mm Hg, heart rate is 55 bpm, and oxygen saturation is 88% on room air. In addition to supportive care, what is the end goal of the primary treatment used in this scenario? ATo help maintain abstinence BTo reverse cardiac toxicity CTo reverse respiratory depression DTo suppress withdrawal symptoms
Answer: True.
True or false: adrenal insufficiency may develop due to long-term opioid use.
Moderate opioid withdrawal COWS Score: 5-12 = mild 13-24 = moderate 25-36 = moderately severe > 36 = severe withdrawal What Clinical Opiate Withdrawal Scale score is ideal for initiating buprenorphine induction treatment? Answer: > 10. Opioid Withdrawal Flu-like illness Abdominal cramps Diarrhea Mydriasis Piloerection Yawning Rx: methadone, buprenorphine, clonidine for iatrogenic withdrawal, other nonopioid adjuncts
A 33-year-old man presents to the emergency department with back pain and generalized body aches. He reports he had previously been treated for back pain by his primary care clinician but ran out of his prescribed medications. He was previously prescribed oxycodone 10 mg every 4 hours. He had been taking the medication more frequently than prescribed and ran out of the medication yesterday. He has developed progressive symptoms, including chills, difficulty sitting still, severe diffuse body aches, and anxiety, since that time. He also reports loose stools, which began this morning. Vital signs include a temperature of 99.4°F, heart rate of 105 bpm, respiratory rate of 22/min, and blood pressure of 108/60 mm Hg. On the physical exam, he appears uncomfortable and is noted to frequently shift positions in bed. He yawns three times during the examination. His pupils are dilated and equal, and he exhibits clear nasal discharge bilaterally. His skin is moist, and the skin on his arms exhibits piloerection on palpation. When asked to stretch out his hands, there is no tremor. Based on his Clinical Opiate Withdrawal Scale score, what degree of opioid withdrawal does this patient exhibit? AMild opioid withdrawal BModerate opioid withdrawal CNo opioid withdrawal DSevere opioid withdrawal
History of depression One significant risk factor is the administration of a high initial total dose and a prolonged course of treatment. Other important risk factors include preoperative pain, history of depression, history of drug, alcohol, or tobacco use, and use of benzodiazepines or antidepressants.
A 34-year-old woman is seen on postoperative day 1 following major surgery. She has never taken opioids for pain management and would like to know the risks and benefits of this class of medication. Which of the following factors increases this patient's risk of chronic opioid use postoperatively? AHistory of depression BLength of the surgical procedure CMultimodal approach to pain management DPrescription of a short-acting opioid for postoperative pain
Opioid tolerance vs
A 35-year-old man (70 kg) with a medical history of general anxiety disorder and depression is admitted to the hospital after a motor vehicle collision. He is immediately taken to the operating room to reduce a dislocated shoulder and reduce and fixate a wrist fracture. His vital signs are stable after the surgery, but he reports 10/10 pain in his right shoulder and wrist. He is prescribed hydromorphone 2 mg orally every 3 hours as needed for moderate pain or 4 mg orally every 3 hours for severe pain as needed. He also has an order for oral acetaminophen 650 mg every 6 hours for mild pain if needed. He has been requiring hydromorphone 4 mg every 3 hours since his operation for severe pain. Initially, the pain was controlled with the 4 mg dose. However, as his hospitalization progresses, he reports less pain control. On postoperative day 4, he is ready to be discharged. He asks the orthopedic surgeon to prescribe him a stronger medication because hydromorphone is no longer fully alleviating his pain. Which of the following best describes what the patient is experiencing? AOpioid addiction BOpioid dependence COpioid tolerance DOpioid withdrawal
Administer an additional 4 mg of sublingual buprenorphine and observe for response A Clinical Opiate Withdrawal Scale (COWS) score of 6-12 corresponds with mild withdrawal and 13-24 with moderate withdrawal. The first dose of 2-4 mg should be administered under clinician supervision to ensure proper technique. After 30-60 minutes, the COWS score should be repeated to assess for changes If the patient's COWS score has decreased but they still have withdrawal symptoms, a second dose of 2-4 mg should be administered. This process can be repeated every hour until the patient no longer reports withdrawal symptoms or until they reach the induction day 1 maximum dose of 8 mg. An opioid antagonist, such as naloxone, should be provided to patients as a combined medication (buprenorphine-naloxone) or in addition to buprenorphine to prevent the risk of overdose.
A 37-year-old woman presents to her primary care clinic for buprenorphine initiation. She states that she has regularly used intravenous heroin for the last year and is ready to quit. Her last use of heroin was approximately 16 hours ago. She does not take any medications and reports no significant medical conditions or history of chronic pain. She does not use prescription opioids, benzodiazepines, or fentanyl and reports no use of alcohol or other drugs. After completing the intake assessment, her physician determines that the patient's Clinical Opiate Withdrawal Scale score is 20. The physician educates the patient on the proper technique for taking the medication and observes as the patient self-administers a 4 mg dose of sublingual buprenorphine in the office. The patient's Clinical Opiate Withdrawal Scale score at 1 hour after administration is 13. What is the best next step in management? AAdminister an additional 4 mg of sublingual buprenorphine and observe for response BAdminister an additional 6 mg of sublingual buprenorphine and observe for response CInstruct the patient to return tomorrow for the second dose of buprenorphine since she has displayed an appropriate response to the medication DProvide symptomatic treatment and hold the next dose of buprenorphine for 24 hours since the patient is likely experiencing precipitated withdrawalYour Answer EProvide symptomatic treatment and instruct the patient to return tomorrow for her next dose since she has reached the recommended maximum dose for day 1 of buprenorphine initiation
Administer oxygen via nasal cannula to maintain oxygen saturation > 95% Xylazine is an alpha-2 agonist exclusively approved for veterinary medicine for analgesia and sedation. Frequently referred to as tranq Xyalzine use is predominant in the northeastern United States Adverse effects of xylazine include respiratory depression,bradycardia, dysrhythmias, and hypotension. Chronic xylazine use may also result in severe skin necrosis andulceration at the site of injection. There are no xylazine antidotes approved for human use, and urine drug screening performed at most hospitals will not detect xylazine. Xylazine use is often suspected based on the history and clinical picture, particularly in patients with known opioid use that have symptoms refractory to naloxone. must be placed on acardiac monitor to watch for dysrhythmias, hypoxia, and hypercapnia, which would indicate inadequate ventilation.
A 41-year-old man with a history of opioid use disorder presents to the ED via ambulance due to suspected overdose. Paramedics state they found the patient experiencing respiratory depression while lying on the street next to a used needle. The patient received two doses of naloxone approximately 10 minutes prior to arrival and an additional dose in the ED, with only partial improvement in respiratory status. His vital signs include a blood pressure of 101/66 mm Hg, HR of 68 bpm, RR of 11 breaths/minute, SpO2 of 93% on room air, and ETCO2 of 37 mm Hg. On examination, the patient is somnolent but arousable. He is unable to provide a complete history. His airway is patent, and lung sounds are clear to auscultation, but respirations are shallow. There are necrotic skin ulcers on the upper extremities but no signs of acute trauma. The patient is noted to be in sinus rhythm on the cardiac monitor. A urine drug screen is positive for fentanyl and negative for benzodiazepines and other agents. Which of the following is the most appropriate next course of action for this patient? AAdminister a dose of flumazenil BAdminister an additional dose of naloxone CAdminister oxygen via nasal cannula to maintain oxygen saturation > 95% DOrder a noncontrast head CT EPrepare for rapid sequence intubation
Methadone PO Intravenous fentanyl has a half-life of 2-4 hours, while methadone can have an extended half-life of 8-59 hours. Hydromorphone and morphine both have half-lives of about 2-3 hours. displays extreme interpatient variability, making dosing challenging. The variability is due to different expression and activity levels of enzymes involved in methadone excretion, such as P-glycoprotein, cytochrome P3A4, and cytochrome P2B6.
A 42-year-old man who is opioid naive presents to the emergency department in emergency distress. He is not responsive, and his vital signs include a heart rate of 60 bpm, blood pressure of 100/76 mm Hg, respiratory rate of 6 breaths/minute, oxygen saturation of 84% on room air, and temperature of 98.6°F. A dose of 4 mg naloxone intranasally dramatically improves his condition. When he is able, he reports he took a dose of an unknown opioid 24 hours ago. Which opioid did he most likely take? AFentanyl IV BHydromorphone IV CMethadone PO DMorphine PO
Partial mu-agonist and pure opioid antagonist Buprenorphine is a partial mu-agonist commonly used as a first-line treatment for OUD. Buprenorphine has a high affinity for mu-opioid receptors, displacing other opioid agonists from its receptor and potentially precipitating withdrawal. Transmucosal buprenorphine, a commonly administered formulation, is prepared with naloxone, an opioid receptor antagonist. This combination aims to deter misuse, as naloxone can precipitate withdrawal symptoms if the dissolving tablets are injected. vs Full mu-agonist (A) is the mechanism of action of methadone, another opioid agonist used in treating OUD. Methadone is a long-acting opioid agonist that may be preferred in individuals with high tolerance. However, methadone may be associated with QTc prolongation, and having a QTc interval ≥ 500 msec merits discontinuing or not starting the medication.
A 43-year-old man presents to the clinic following a recent admission to the hospital for substance intoxication. Approximately 2 weeks ago, the patient presented to the emergency department with a reduced level of arousal, slurred speech, and 0.5-1 mm pupils. Head CT without contrast and CBC and CMP were unrevealing. He was admitted to the hospital for further care, and ECGs during that time demonstrated QTc intervals between 502 and 504 msec. He had a similar presentation to the emergency department 3 months ago. His medical history includes chronic lower back pain, which has been difficult to manage. He has not taken any substances for the past 2 days. Which of the following is the mechanism of action of the most appropriate combination treatment for this patient? AFull mu-agonist BPartial mu-agonist and pure opioid antagonist CPartial mu-antagonist and kappa-agonist DSigma-agonist and N-methyl-D-aspartate receptor antagonist
Consider other diagnoses Deprescribing opioid medications for patients who have been taking the medication for more than 30 days can be challenging. Expert consensus and emerging evidence show the BRAVO method is a compassionate and empathetic framework to begin opioid tapering discussions. The protocol includes broaching the subject, risk-benefit calculation, acceptance that addiction and dependence happen, velocity and validation with tapering off, and recognizing other strategies for dealing with pain. opioid taper with a 5% to 10% dose reduction every 1 to 2 weeks. Patients on chronic opioid therapy may not be able to tolerate that velocity and may need a 5% dose reduction every mont
A 43-year-old man presents to the clinic for monitoring of long-term pain. He was in a car collision 1 year prior and has slowly recovered his day-to-day functioning and routines. He was seen by pain management specialists and physical therapists previously but has no upcoming appointments with them. Instead, he was told to continue care with his primary care provider. The patient is doing well, has returned to work, and has no issues with activities of daily living. He has occasional back pain, for which he takes a hydrocodone-acetaminophen tablet. He was prescribed the medication shortly after the collision and has not had a discussion about discontinuation. Which of the following is recommended when discussing opioid medication tapering? AConsider other diagnoses BDisregard the patient's emotions CLimit alternative treatment options DRemember that the risks to opioid tapering are negligible EStart with a 15% dose reduction
Acetaminophen 1 g every 8 hours for 4-7 days The first-line treatment for postoperative pain control for patients without complications is acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs
A 43-year-old woman with a history of gallstones presents to the clinic for a preoperative visit. She is scheduled for an elective laparoscopic cholecystectomy next week. The patient is concerned about pain following the procedure and would like to know what medication she will be given. You tell her you plan to prescribe a short course of pain medication. Which of the following is the most appropriate medication to prescribe for postoperative pain control? AAcetaminophen 1 g every 8 hours for 4-7 days BHydrocodone-acetaminophen 7.5 mg/325 mg 1 tablet every 4 hours for 4-7 days CIbuprofen 200 mg every 8 hours for 4-7 days DOxycodone 10 mg 1 tablet every 4 hours for 4-7 days
22.5 morphine milligram equivalents (15 × 1.5 = 22.5). Oxycodone has a conversion factor of 1.5 Morphine milligram equivalents (MME)
A 63-year-old man presents to the clinic for a routine follow-up visit. He reports no symptoms. His medical history includes anxiety treated with escitalopram 10 mg once daily, generalized osteoarthritis treated with celecoxib 200 mg once daily and oxycodone 5 mg three times daily, and hypertension treated with valsartan 320 mg once daily. Vital signs are notable for a temperature of 98.8°F, blood pressure of 122/74 mm Hg, heart rate of 82 bpm, respiratory rate of 12 breaths/minute, and oxygen saturation of 99% on room air. Physical exam reveals lungs clear to auscultation bilaterally and normal heart rate and rhythm. How many morphine milligram equivalents per day is this patient taking? A15 morphine milligram equivalents B22.5 morphine milligram equivalents C36 morphine milligram equivalents D45 morphine milligram equivalents
Perform a standardized opioid screening tool to assess substance use disorder risk Screening tools provide a standardized approach to all patients reporting significant chronic pain. They can decrease personalized or subjective red flags that a clinician may be using to assess patients for drug-seeking behaviors.
A 67-year-old woman with a history of hypertension, depression, and generalized anxiety disorder presents to the emergency department for the second time in 1 week reporting 1 month of gradual-onset, persistent low back pain. She describes the pain as dull and throbbing and rates the severity of pain as 8 out of 10. She reports no trauma or recent injuries preceding the discomfort. During her first visit to the emergency department, X-rays of her lumbar spine were completed and were negative for any acute findings. She was discharged home at that time with a prescription for 800 mg ibuprofen, which she states did not help her pain, so she stopped taking it after two doses. She reports that she also went to urgent care in the interim and did not receive helpful medications at that visit. She is tearful during her exam and requests stronger pain medication. On physical exam, the patient has 5 out of 5 strength in all four extremities with good muscle bulk and tone. She has normal deep tendon reflexes. Her sensation is intact and equal throughout. She has a negative straight leg raise test bilaterally, and her spine is nontender to palpation. Laboratory work shows no evidence of infection or metabolic abnormalities. What is the most appropriate next step in addressing her pain? AAdminister 2 mg of IV morphine to acutely manage the patient's discomfort BObtain CT imaging of the lumbar spine due to persistent, severe pain CPerform a standardized opioid screening tool to assess substance use disorder risk DPrescribe only nonopioid analgesics due to the patient exhibiting possible drug-seeking behavior
Hydromorphone is the preferred opioid medication for managing chronic pain in cancer patients with liver cirrhosisand kidney impairment. Offering opiate treatment with hydromorphone is reasonable, given her chronic kidney disease and liver cirrhosis. can be used at a reduced dose for moderate hepatic impairment (Child-Pugh class B). It should be avoided in patients with severe hepatic impairment (Child-Pugh class C).
A 68-year-old woman with a history of chronic kidney disease and liver cirrhosis (Child-Pugh class B) has enrolled in palliative care for advanced hepatocellular carcinoma. She is not a candidate for cancer-directed systemic treatment due to poor performance status. She has developed progressively worsening severe abdominal pain, back pain, and jaundice for the past 2 weeks. On vital signs, her temperature is 98°F, blood pressure is 100/80 mm Hg, heart rate is 110 beats/min, respiratory rate is 18/min, and oxygen saturation is 98%. Physical examination reveals scleral icterus and diffuse abdominal tenderness. Her most recent lab tests show a hemoglobin of 11.1 g/dL, leukocyte count of 10,500/µL, platelet count of 305,000/µL, bilirubin of 5.6 mg/dL, alkaline phosphatase of 315 U/L, alanine aminotransferase of 245 U/L, aspartate aminotransferase of 135 U/L, and creatinine of 2.3 mg/dL. Which of the following is the most appropriate pain medicine to offer? ACodeine BHydromorphone CMeperidine DMorphine
Tramadol immediate-release know the beers criteria Tramadol is a type of opioid believed to bind to mu receptors and weakly block serotonin and norepinephrine reuptake, thereby conferring an analgesic effect. For patients with a creatinine clearance under 30 mL/min, the AGS Beers Criteria recommend avoiding the extended-release form due to increased risk of adverse central nervous system effects (e.g., delirium). Rather, the immediate-release formulation at a reduced maximum dosage is advised. Per the AGS, tramadol is not universally contraindicated in the older population. The other (nonopioid) alternatives listed may be associated with greater harm for this patient, given his advanced age and comorbidities. Judicious initiation of opioid therapy may be appropriate to safely and effectively manage the patient's pain, improve his functional status, improve his quality of life, and prevent disability.
A 70-year-old man with a history of gastric ulcer and chronic kidney disease (creatinine clearance < 30 mL/min) presents with chronic low back pain. He had made a concerted effort to try the many nonpharmacologic approaches recommended by his physician, including low-intensity walking, tai chi, physical therapy, and acupuncture, with minimal improvement in his symptoms. The patient expresses that his pain makes it difficult to take care of his daily basic needs, perform his job, and engage in his usual social activities. Which of the following medications would be most appropriate to manage this patient's pain at this time? ACyclobenzaprine extended-release BDuloxetine CMeloxicam DTramadol immediate-release
An initial recommendation of walking, exercise therapy, yoga, and spinal manipulation for a graduate student with 4 months of low back pain is a reasonable and advisable pain management strategy. Low back pain is considered chronic when present for > 12 weeks duration. The American College of Physicians (ACP) recommends that physicians should consider nonpharmacologic interventions prior to pharmacologic therapies when treating chronic low back pain. The professional society promotes noninvasive nonpharmacologic therapy as the cornerstone of managing chronic low back pain, given the decreased risks associated with these options compared to pharmacologic interventions
A community is overwhelmed and saddened by a rise in opioid-related overdoses and fatalities. In response, a special committee is created at the town's suburban hospital to help combat the local opioid crisis. The group aims to examine opioid prescribing patterns, trends in recommending nonopioid therapies, and patient outcomes. The team conducts comprehensive chart reviews. Which of the following instances in the committee's review best exemplifies an advisable strategy for pain control? AExtended-release opioid prescribed for a middle-aged man with hyperlipidemia after a simple tooth extraction for decay BIbuprofen prescribed for acute ankle sprain pain for a woman in her eighth month of pregnancy CInitial recommendation of walking, exercise therapy, yoga, and spinal manipulation for a graduate student with 4 months of low back pain DOxycodone prescribed as first-line treatment for headaches in a relatively healthy young man with episodic migraines
MME = daily hydromorphone dose × conversion factor, so MME = 4 mg × 5 = 20. 2022 CDC-Recommended Conversion Factors for MME for Common Opioids Codeine: 0.15 Fentanyl transdermal (in mcg/hr): 2.4 Hydrocodone: 1.0 Hydromorphone: 5.0 Methadone: 4.7 Morphine: 1.0 Oxycodone: 1.5 Oxymorphone: 3.0 Tapentadol: 0.4 Tramadol: 0.2 All doses in mg/day except fentanyl transdermal True or false: when switching from one opioid to another, the dose of the initial opioid in morphine milligram equivalents should be used to derive the appropriate dose of the new opioid. Answer: False.
A patient is admitted to the hospital with mild acute pancreatitis. The patient has never used opioids. Hydromorphone 1 mg PO is ordered every 6 hours for severe pain in addition to nonsteroidal analgesics. According to CDC practice guidelines, the conversion factor for hydromorphone is 5. Based on this information, what is the morphine milligram equivalent for this medication order? A20 B30 C4 D5
Nonsteroidal analgesic therapy Expert guidance recommends the cautious use of opioids for acute pain management when warranted for severe acute pain, usually traumatic. Judicious prescribing of opioids for pain control must be practiced, even for those currently on chronic opioid therapy. When opioids are being considered, the ED or inpatient care setting is most amenable to a trial, as this setting allows for opioid titration and monitoring. For nonsevere acute pain, opioids are not considered a first-line therapy for pain control. This patient has a traumatic injury, but that injury is muscular strain
A patient presents to the ED following a minor motor vehicle collision not involving the deployment of the airbag. The patient's history is significant for chronic pain currently managed with transdermal fentanyl. The workup reveals no acute fractures, and the patient is diagnosed with neck strain. Which of the following should be prescribed as the best next step in clinical management? AAs-needed opioid therapy BNonsteroidal analgesic therapy CScheduled opioid therapy DTransmucosal fentanyl therapy
Answer: True.
True or false: patients who are prescribed extended-release opioids as their initial prescription are at a higher risk of overdose compared to patients initially prescribed immediate-release opioids.
Safe opioid use True or false: violation of a patient prescriber agreement is always suggestive of opioid use disorder. Answer: False. Patient prescriber agreements (PPAs) serve a myriad of important purposes in the practice of opioid prescribing. These agreements are meant to direct a patient-doctor conversation about pain management and the role of opioids. The agreements are also written documents verifying that a verbal conversation occurred and that the patient and prescriber have reached a shared decision regarding the patient's care. Research shows that in practice, PPAs have variable use and effectiveness and their purpose is variably understood by both patients and prescribers. PPAs are purposed to reduce opioid misuse and diversion, but many patients see them as a punitive construct. Rather than focusing on negatives around prescription opioids and stigmatizng prescription opioid use
A patient presents to the clinic to establish a new primary medical doctor. The patient had previously been prescribed opioid therapy by their former physician. The patient would like to continue on their opioid and is requesting a refill. Before refilling the medication, the physician reviews the patient's medical history and clinical indication for opioid therapy. The physician determines that opioid therapy should be continued. The physician's health practice has implemented a patient prescriber agreement for all opioid prescriptions. Which of the following elements is most important to include in this patient prescriber agreement? AAdministrative actions BLegal enforcement COpioid pharmacology DSafe opioid use
Initiating clonidine when switching to acetaminophen with codeine it is best to slow down an opioid taper when a patient exhibits signs of withdrawal. dx: Iatrogenic opioid withdrawal syndrome (IOWS) presents a considerable concern for patients and physicians, especially among patients receiving high doses of opioid therapy in an inpatient setting. IOWS constitutes opioid withdrawal that occurs due to the abrupt decrease or total discontinuation of opioid therapy. Hallmarks of IOWS include classic signs of opioid withdrawal, such as agitation, restlessness, tremors, vomiting, diarrhea, lacrimation, piloerection, yawning, and pupillary dilation. Labile vital signs may also be seen, which heightens the need for proper attention and care of patients experiencing this condition.
A patient was admitted to the hospital following a serious motor vehicle collision in which they sustained multiple fractures and contusions. The patient experienced severe pain, and scheduled opioid therapy with hydromorphone was started preoperatively. Following a series of orthopedic surgeries, the patient continued opioid therapy. Over the course of their recovery, the patient had a substantial dose requirement and switched to an as-needed oral opioid protocol 2 days before discharge. On several occasions, they requested medication before the scheduled time. On the day before discharge, the analgesic protocol was switched to acetaminophen with codeine. That evening, the patient developed agitation, shaking, and vomiting. Assessment revealed labile vital signs. On exam, the patient appeared diaphoretic, with increased lacrimation, frequent yawning, and dilated pupils. Which of the following steps would most likely have prevented this patient's condition? AAvoiding intravenously administered opioid therapy BCombining a benzodiazepine with opioid therapy CInitiating clonidine when switching to acetaminophen with codeine DSwitching to acetaminophen only
Buprenorphine Buprenorphine is the preferred option for opioid use disorder during pregnancy. It lacks known teratogenic effects, lowers the risk of preterm birth, and leads to less severe neonatal abstinence syndrome than methadone. Buprenorphine also has limited interactions with other medications vs Methadone (B) can be used as a first-line MOUD for opioid use disorder in pregnancy since it is not associated with teratogenic effects. However, it can cause a more severe neonatal abstinence syndrome than buprenorphine. Methadone also interacts with medications that a patient with bipolar I disorder may take, such as anticonvulsants and antipsychotics.
A patient with bipolar I disorder presents to the clinic 2 weeks after a positive pregnancy test. She is interested in starting treatment for opioid use disorder but is concerned about interactions with other medications she takes. Which of the following is the best treatment option? ABuprenorphine BMethadone CNaloxone DNaltrexone EPharmacologic therapy for opioid withdrawal
Methadone dx: opined withdrawal Classic signs and symptoms of opioid withdrawal include mydriasis, insomnia, yawning, lacrimation, rhinorrhea, piloerection, tachycardia, hypertension, vomiting, and diarrhea. Volume depletionfrom uncontrolled nausea, vomiting, and diarrhea is an important concern with opioid withdrawal syndrome
A patient with chronic noncancer pain presents to an emergency department with dehydration following uncontrolled episodes of nausea, vomiting, and diarrhea for the past 24 hours. They report that they ran out of their prescribed opioid. Physical examination shows an ill-appearing individual in physical distress. The patient has enlarged pupils, increased lacrimation, and rhinorrhea. They also yawn frequently during the assessment. Which of the following therapies is backed by scientific evidence and holds regulatory approval from the FDA for management of this patient's condition? AMethadone BMitragyna speciosa (kratom) CTizanidine DTramadol
Heroin may have been recently used Heroin is a semisynthetic opiate that is metabolized to morphine and will be detected as morphine on a drug screening test. Therefore, the only conclusion that can be drawn in this scenario is that heroin may have been recently used (i.e., in the 2 days prior to sample submission). True or false: the effects of heroin can be reversed with naloxone. Answer: True.
A patient with chronic pain has an opioid therapy contract with their primary medical doctor's office. The patient is prescribed hydrocodone bitartrate-acetaminophen 10 mg/325 mg tablets every 4 to 6 hours as needed for pain. As part of the contract, the patient and physician have agreed to perform monthly urine drug screening tests. The patient has requested to come in ahead of their scheduled appointment. They report running out of their medicine early, stating that they dropped some pills on the floor and threw them away. The last time they report taking a tablet was 5 days prior to this appointment. The patient hands the physician an empty pill bottle. The state prescription drug monitoring program shows no other prescriptions for controlled substances, and the patient takes no other regular medications. The physician agrees to provide two tablets on a provisional basis, pending the results of the urine drug screening test. Following sample submission, the medical office is faxed a preliminary report, shown above. Which of the following conclusions can most confidently be drawn based on the information provided? AAn adulterated urine sample may have been provided BFentanyl may have been recently used CHeroin may have been recently used DHydrocodone was not recently used
Opioid overdose was potentiated by benzodiazepines
An older adult is found down by a helpful bystander, who immediately recognizes the need to administer intranasal naloxone. An ambulance transports the patient to the hospital for further management. A review of the prescription drug monitoring database reveals that the patient was receiving hydromorphone 4 mg every 6 hours following a recent surgical procedure. Verification with the pharmacy showed that 120 tablets were dispensed 10 days prior. The patient has also been taking clonazepam for anxiety disorder for the past 2 years. Urine drug tests with immunoassay and gas chromatography yield positive results for opiates, benzodiazepines, cocaine, and marijuana. A separate fentanyl screen is negative. The patient reports no intention for self-harm or suicide. Which of the following conclusions can most likely be drawn based on this information? ACocaine increased the risk of near-fatal overdose BIllicit opioids were likely used CMarijuana use had no effect on opioid overdose DOpioid overdose was potentiated by benzodiazepines
Start topical diclofenac gel
An older adult patient with fibromyalgia controlled with duloxetine presents to the clinic with acute pain following a slip and fall injury. The patient states that they were in the grocery store when they accidentally slipped on a wet floor. They broke their fall by outstretching their right arm and falling on their right hand. The patient rates their pain as 5 out of 10 in severity. On exam, there is erythema and edema but no laceration or ecchymosis of the right hand. Radiographs are negative for fracture or displacement. Which of the following is the best next step in clinical management after immobilization and compression? AAdminister acetaminophen plus codeine BAdminister tramadol CRefer for general acupressure treatment DStart topical diclofenac gel
To calculate a patient's total morphine milligram equivalent How often, at minimum, should a prescription monitoring program be queried when continuing a patient on opioid therapy? Answer: Every 3 months.
The opioid epidemic has sparked innovation in patient safety resources and technologies. One such tool is the prescription drug monitoring program, an electronic database that stores information and tracks opioid prescriptions. In clinical practice, prescribers are able to consult these databases to help guide opioid prescribing decisions. Which of the following uses of a prescription drug monitoring program is most appropriate? ATo calculate a patient's total morphine milligram equivalent BTo dismiss a patient from a medical office CTo inform a family member of a patient's whereabouts DTo validate suspicions of pill-seeking behavior
Patients with an acute worsening of withdrawal symptoms and increase in COWS score after buprenorphine administration are likely experiencing precipitated withdrawal and should receive symptomatic treatment before trying induction again in 24 hours.
Buprenorphine is a long-acting partial mu-opioid receptor agonist with a strong receptor binding affinity capable of displacing other opioids and causing precipitated withdrawal symptoms. It is important to provide a structured, supportive, and closely monitored environment for the induction and initial titration of buprenorphine to avoid precipitating withdrawal in patients with active opioid use disorder. After an initial assessment, patients should abstain from opioids for 8-96 hours (depending on whether they use long- or short-acting opioids) so they experience mild to moderate withdrawal symptoms prior to initiating buprenorphine to prevent precipitated withdrawal. A Clinical Opiate Withdrawal Scale (COWS) score of 6-12 corresponds with mild withdrawal and 13-24 with moderate withdrawal. The first dose of 2-4 mg should be administered under clinician supervision to ensure proper technique. After 30-60 minutes, the COWS score should be repeated to assess for changes in clinical withdrawal symptoms. If the patient's COWS score has decreased but they still have withdrawal symptoms, a second dose of 2-4 mg should be administered. This process can be repeated every hour until the patient no longer reports withdrawal symptoms or until they reach the induction day 1 maximum dose of 8 mg. An opioid antagonist, such as naloxone, should be provided to patients as a combined medication (buprenorphine-naloxone) or in addition to buprenorphine to prevent the risk of overdose.
Opioid use disorder (OUD)
Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a diagnosis of OUD is established by the presence of at least two of the following features related to the patient's opioid use in the past 12 months: Using greater amounts or over a longer period than intended Continual desire or unsuccessful attempts to curb opioid use Spending considerable time obtaining or using opioids or recovering from the effects Experiencing strong cravings for opioids Continued opioid use leading to difficulties in fulfilling work, school, or home obligations Continued opioid use despite repeated social or interpersonal problems stemming from or made worse by opioid use Stopping or reducing significant social, occupational, or recreational activities due to opioid use Repeated use of opioids in situations in which it is physically hazardous Continued opioid use despite knowledge of an ongoing physical condition or psychological problem caused or exacerbated by opioid use Exhibiting tolerance (i.e., the need to take higher dosages to achieve intoxication or experiencing diminished effects with continued use of the same amount of the substance) Exhibiting opioid withdrawal syndrome or taking opioids (or a closely related substance) to alleviate or avoid withdrawal symptoms
Lipophilicity fentanyl is NOT detectable on most urine drug immunoassay screening tests. narrow spectrum of FDA-approved uses, primarily for surgical pain control and anesthesia. It is lipophilic, which is a property that impacts its potential for lethal overdose. The drug's ability to dissolve in lipids allows it to easily cross the blood-brain barrier and concentrate in the brain. Scientists believe this property also explains why overdose reversal is more difficult with fentanyl than other opioids.
Fentanyl is a synthetic opioid and an important drug of concern in the opioid epidemic. Many misconceptions exist around the safety of fentanyl, both in the lay public and the medical community. Which of the following properties most likely contributes to fentanyl's risk for overdoses and deaths? ALipophilicity BShort half-life CSlow onset of action DWeak potency
Answer: QT interval prolongation, which can cause torsades de pointes and sudden death.
What ECG abnormality is associated with methadone use?
Answer: Opioid tapering.
What additional prescribing protocol should be followed by the prescribing physician if scheduled opioids were used for more than a few days?
Answer: Buccal film, sublingual tablet, intravenous injection, intramuscular injection, transdermal patch, subcutaneous extended-release injection, and subdermal extended-release implant.
What are the possible routes of administration for medication-assisted treatment with buprenorphine?
Answer: Mu, delta, and kappa.
What are the three opioid receptor types?
Answer: Mu-opioid agonist and serotonin norepinephrine reuptake inhibitor.
What are the two mechanisms of action for the analgesic effects of tramadol?
Answer: Hypogonadism.
What is a common endocrine side effect associated with chronic opioid use?
Answer: Benzodiazepines.
What is one class of medications commonly used for panic disorder that increases the risk of overdose when combined with opioids? What medication class is used to manage the symptoms of alcohol withdrawal?
Answer: Nonselective opioid receptor antagonist.
What is the mechanism of action of naltrexone?
Answer: Hydroxyurea.
What long-term medication reduces the frequency of pain episodes in patients with sickle cell anemia?
Answer: Socioeconomic status.
What major factor other than ethnicity plays a role in health equity in the treatment of pain?
Answer: Clonidine. Both clonidine and xylazine are alpha-2 receptor agonists.
What medication used for management of opioid withdrawal is in the same class as xylazine?
Answer: Methadone and buprenorphine.
What medications are most often used to treat patients with opioid use disorder?
Answer: Mu-opioid receptor.
What receptor does methadone act on? What type of opioid receptor is targeted by naloxone to reverse opioid-induced respiratory depression?
Answer: In the liver, by the cytochrome P450 pathway.
Where is oxycodone metabolized?
Answer: Verapamil.
Which antihypertensive agent may yield a positive screening result on a urine immunoassay for opiates?
Answer: Norepinephrine.
Which neurotransmitter is decreased by the targeted use of central alpha-2 adrenergic agonists in the management of opioid withdrawal syndrome?
Answer: Buprenorphine-naloxone or methadone maintenance therapy.
Which opioid agonist therapies have robust evidence to support their use as a treatment for patients with opioid use disorder?
Answer: Fentanyl.
Which opioid is more potent at mu-opioid receptors: morphine or fentanyl?
Neighboring hospital requesting a large and out-of-the-ordinary transfer of methadone due to what they deem to be unexpected usage True or false: Drug Enforcement Administration registrants are required to report suspicious activity to the Suspicious Orders Report System but must also distribute the substance as requested. Answer: False. The transferring institution is required to report this but is not required to fill the order. vs A private practice down the street requesting a transfer of a controlled substance to their clinic but of reasonable and nonsuspicious quantities (D) is an example of a transaction between two DEA registrants. In this case, the physician leader's hospital is the distributor and has been requested to distribute to a private practice. If the request does not meet any of the criteria for a suspicious order, then it does not need to be reported to SORS.
physician leader of a hospital has been tasked with ensuring compliance with the Suspicious Orders Report System. In which situation would they be required to report suspicious activity to the Suspicious Orders Report System? AFamily member asking for a prescription of hydromorphone BNeighboring hospital requesting a large and out-of-the-ordinary transfer of methadone due to what they deem to be unexpected usage CPatient asking for a large quantity of oxycodone DPrivate practice down the street requesting a transfer of a controlled substance to their clinic from the hospital, but quantities are reasonable and nonsuspicious
