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Quantum Units Education

Opioid Treatment Guidelines for Chronic Pain

Recommendations

1. Consideration of opioid therapy beyond _____ days requires reevaluation and discussion with patients of risks and benefits.

A. 30

B. 60

C. 90

D. 180


2. Risks for opioid use disorder start at any dose and increase in a dose dependent manner.

A. True

B. False


3. Prescribing long-acting opioids is recommended against:

A. For acute pain

B. As an as-needed medication

C. On initiation of long-term opioid therapy

D. All of the above


Algorithm

4. All of the following are absolute contraindications to initiating opioid therapy for chronic pain, except for:

A. Co-occurring medical or mental health conditions that increase risk

B. Life-threatening allergy to opioids

C. Active SUD

D. Elevated suicide risk


5. Which of the following may indicate need for more frequent follow-up?

A. Non-adherence to comprehensive pain care plan such as attendance at appointments.

B. Unexpected UDT and PDMP results.

C. Non-adherence to opioid prescription.

D. All of the above.


6. The best treatments for chronic pain are non-drug treatments such as psychological therapies and rehabilitation therapies and non-opioid medications.

A. True

B. False


Background

7. In 2009, drug overdose became the second leading cause of injury-related death in the U.S., surpassed only by traffic accidents.

A. True

B. False


8. In a survey of patients prescribed opioids for chronic non-cancer pain and their family members, 34% of patients reported that they used the medication:

A. Because they thought they were “addicted” or “dependent” on opioid pain medication.

B. For “fun” or to “get high.”

C. Both (A) and (B).

D. None of the above.


9. OT has a limited role, primarily in the treatment of:

A. Severe acute pain

B. Post-operative pain

C. End-of-life pain

D. All of the above


10. Pain is all of the following, except for:

A. An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

B. Always objective.

C. Always unpleasant and therefore an emotional experience.

D. Pain is all of the above.


11. Chronic pain is:

A. Often associated with changes in the central nervous system known as central sensitization.

B. Pain lasting 30 days or more.

C. Thought to involve primarily nociceptive processing areas in the central nervous system.

D. All of the above.


12. In the 2000s, the majority of people entering treatment for heroin use used prescription opioids as their first opioid.

A. True

B. False


13. All of the following are more likely to continue using opioids, except for:

A. Those with schizophrenia and bipolar diagnoses

B. Those 50 - 65 years of age

C. Those who are married

D. Those on higher doses of opioids


14. Which risk factors have the greatest impact for development of opioid-related adverse events?

A. Severe respiratory instability and sleep disordered breathing

B. Duration and dose of OT

C. Acute psychiatric instability and intermediate to high acute suicide risk

D. History of drug overdose and pain conditions worsened by opioids


15. A history of _____ is significantly associated with opioid-related toxicity / overdose and LOT has been associated with worsening symptoms.

A. Depression

B. PTSD

C. Suicidal behavior

D. All of the above


16. A history of overdose is a red flag and providers should proceed with utmost caution when considering LOT for these patients.

A. True

B. False


17. Which of the following combinations is dangerous?

A. Opioids with benzodiazepines

B. Fentanyl with CYP3A4 inhibitors

C. Methadone with drugs that can prolong the QT interval

D. All of the above


18. Which of the following is a sign of medication diversion?

A. A negative UDT for the prescribed opioids

B. Frequent requests for early refills

C. Atypically large quantities required to control pain

D. All of the above


19. For patients with an OUD, sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose.

A. True

B. False


20. LOT is an effective treatment modality for patients with migraine headaches, tension-type headaches, occipital neuralgia, and myofascial pain.

A. True

B. False


21. The itching that is caused by morphine’s release of histamine indicates the beginning stages of an allergic reaction and administration of morphine should be immediately stopped.

A. True

B. False


22. Generally, allergy to one opioid means the patient is allergic to other opioids.

A. True

B. False


About this Clinical Practice Guideline

23. Which of the following is a universal approach that should be used in the management of care for the patient regardless of the location from which that patient is transferred?

A. Each new patient should be provided with a full evaluation.

B. Previous medical records should be reviewed to determine what diagnostic and therapeutic options have already been tried.

C. It should be determined what the patient knows about current concerns related to OT and how comfortable he or she is with an approach that will be addressing opioid safety along with an integrated whole person approach to pain.

D. All of the above.


24. Until full record review and communication with the previous prescriber are completed, there are significant risks of taking over opioid prescribing unless it is with intent to taper.

A. True

B. False


25. The Stratification Tool for Opioid Risk Mitigation does which of the following?

A. It incorporates co-occurring medical and mental health conditions, SUD, opioid dose, co-prescribed sedatives, and information about prior adverse events and generates estimates of patients’ risk or hypothetical risk when considering initiation of opioid therapy.

B. It quantifies risk for poisoning or suicide-related events and for drug-related events, accidents, falls, and drug-induced conditions over a three-year window.

C. It provides suggestions as to what alternative treatments have not been tried and what risk mitigation strategies need to be applied.

D. All of the above.


Discussion of Recommendations

26. If a decision is made to initiate LOT:

A. A careful assessment of benefits and risks should be made to ensure that the benefits are expected to outweigh the well-documented risks.

B. A multimodal treatment plan should be integrated into the patient’s care prior to LOT consideration.

C. Both (A) and (B).

D. None of the above.


27. The underlying concepts of the biopsychosocial model of pain includes the idea that pain perception and its effects on the patient’s function is mediated by biology alone.

A. True

B. False


28. In light of the low harms associated with exercise and psychological therapies when compared with LOT these treatments are preferred over LOT, and should be offered to all patients with chronic pain including those currently receiving LOT.

A. True

B. False


29. A retrospective cohort study found that even greater than opioid dose, _____ was the strongest predictor of developing OUD.

A. Co-occurring depression

B. Duration of OT

C. Having an acute psychiatric instability

D. Having a history of overdose


30. Long-term opioid therapy for pain is recommended against in patients with all of the following untreated substance use disorders, except for:

A. Alcohol

B. Tobacco

C. Both (A) and (B)

D. None of the above


31. Concurrent benzodiazepine and LOT use is a serious risk factor for unintentional overdose death, however, abrupt discontinuation of benzodiazepines should be avoided as it can lead to serious adverse effects including seizures and death.

A. True

B. False


32. Concomitant use of benzodiazepines is considered a contraindication to initiation of OT.

A. True

B. False


33. All patients who take opioids chronically are at risk for OUD and overdose, but especially those who are younger than _____ years of age.

A. 18

B. 26

C. 30

D. 65


34. When their pain is aggressively managed starting soon after injury, hospitalized patients recovering from battlefield injuries are known to have less of all of the following, except for:

A. Anxiety

B. Chronic pain

C. Depression

D. PTSD


35. Studies indicate that developing brains are at increased risk of abnormalities and addiction when exposed to substance use early in life.

A. True

B. False


36. Patients may decline which of the following?

A. Offered treatment such as OT.

B. Risk mitigation strategies such as urine drug testing and pill counts.

C. Both (A) and (B).

D. None of the above.


37. Studies have shown that naloxone administration has been efficacious if given by:

A. Medical personnel

B. Lay people

C. Either (A) or (B)

D. None of the above


38. Fentanyl analogs that may be used to create counterfeit opioid analgesic pills can cause a toxidrome characterized by significant CNS and profound respiratory depression requiring multiple naloxone doses for reversal.

A. True

B. False


39. Returning unused opioid medications has been explored as a strategy to reduce the amount of opioids in the community, as it has been estimated that _____% of opioid prescriptions are left unused.

A. 90

B. 70

C. 50

D. 30


40. For those patients who develop OUD and progress to intravenous drug use, the first recommendation is:

A. Medication-assisted treatment.

B. Educating the patient regarding sterile injection techniques and community-based needle exchange programs.

C. Both (A) and (B).

D. None of the above.


41. Continuing LOT to “prevent suicide” in someone with chronic pain is recommended as an appropriate response only if suicide risk is high or increases.

A. True

B. False


42. Which of the following may change the risk/benefit calculus for LOT?

A. Lab abnormalities

B. Alcohol use

C. Nursing of infants

D. All of the above


43. What is considered to be a safe dose of opioids?

A. Below 20 mg morphine equivalent daily dose

B. Below 50 mg morphine equivalent daily dose

C. Below 100 mg morphine equivalent daily dose

D. None of the above


44. Although it is widely accepted that progressively higher doses of prescribed opioids result in correspondingly higher risks of opioid overdose, patients using any dose of opioids can still experience life-threatening respiratory or CNS depression, especially when opioid-naive.  This risk begins to increase with MEDD as low as:

A. 20 - 50 mg

B. 40 - 50 mg

C. 60 - 80 mg

D. 80 - 100 mg


45. In patients receiving LOT, evidence indicates that women are 50% more likely to escalate to high-dose opioids and twice as likely to experience an opioid-related death compared to men.

A. True

B. False


46. Healthcare workers need to be especially aware of the risk associated with a fentanyl transdermal delivery system, including its:

A. Continuous delivery, even after the patch is removed

B. Increased rate of delivery

C. Unpredictable variation in rate of delivery

D. All of the above


47. Transdermal fentanyl should not be used in opioid-naive patients.

A. True

B. False


48. Which method continues to be the most common method of abuse?

A. Chewing, crushing, cutting, grating, and/or grinding.

B. Consumption of a large number of intact capsules or tablets.

C. Extraction of the opioid with use of a common solvent.

D. Taking an agent intended for oral use nasally or parenterally.


49. Due to the partial mu agonist activity of _____ and its demonstrated safety profile when used in connection with acetaminophen in elderly patients, it may be a preferred agent in that patient group.

A. Tramadol

B. Tapentadol

C. Both (A) and (B)

D. None of the above


50. All of the following are properties that make buprenorphine potentially desirable as an analgesic, except for:

A. It is a synthetic opioid analgesic with partial mu opioid agonist and kappa opioid antagonist properties.

B. It can be added to patients that are on a full mu agonist without precipitating withdrawal.

C. It has high affinity to the opiate receptor and a long duration of action.

D. It is a partial agonist agent and as such may be associated with less euphoria and easier withdrawal.


51. All of the following require consideration of monotherapy (buprenorphine without naloxone), except for:

A. Pregnancy

B. Liver disease

C. Kidney disease

D. All of the above require monotherapy


52. All of the following are unique pharmacologic properties of methadone that make it particularly risky to prescribe, except for:

A. Methadone caries a risk of cardiac arrhythmia, and risk assessment for QT prolongation and electrocardiographic monitoring is essential.

B. Methadone has a variable half-life with peak respiratory depressant effect occurring sooner and lasting a shorter time that peak analgesic effect.

C. The metabolism of methadone varies by dose and individual, making dosing unpredictable.

D. There are medications that interact with methadone and should not be prescribed concurrently.


53. At least _____ should pass on a particular dose of methadone before increasing dosage of methadone to make sure that the full effects of the previous dosage are evident.

A. 1 month

B. 14 days

C. 1 week

D. 3 days


54. OT should be tapered when patients voice their preference to reduce dosage and/or discontinue LOT.

A. True

B. False


55. Patients on LOT with OUD are at increased risk of overdose when opioids are _____ without appropriate treatment for OUD.

A. Continued

B. Discontinued

C. Either (A) or (B)

D. None of the above


56. Patients should be strongly cautioned that it takes as little as _____ to lose tolerance to their prior opioid dose and that they are at risk of an overdose if they resume their prior dose.

A. 1 month

B. 1 week

C. 3 days

D. 1 day


57. Long-acting opioids may be associated with higher overdose, overdose death, and all-cause mortality rates when compared to short-acting opioids, therefore, long-acting opioids should always be tapered first and never simultaneously with short-acting opioids.

A. True

B. False


58. When determining the pace of opioid tapering, which factors would suggest the need for a more gradual taper?

A. Higher opioid dose and longer duration of OT.

B. Non-adherence to the treatment plan.

C. Escalating high-risk medication-related behaviors.

D. All of the above.


59. Which high-risk medication-related behavior suggests the presence of an SUD?

A. Early refills

B. Lost or stolen medications

C. Problematic findings on urine tests

D. Any of the above


60. By far, the most powerful risk factor for developing OUD is:

A. Long-term opioid analgesics use

B. Other substance use

C. Co-occurring mental illness

D. Age


61. Which factor increases overdose risk when opioids are used for acute pain?

A. High prescribed dose

B. History of SUD

C. History of mental health concerns

D. All of the above


Appendix B: Urine Drug Testing

62. While a patient can decline to consent to a urine drug test, the healthcare provider cannot factor that declination into their thinking about whether it is safe to continue with OT for that patient.

A. True

B. False


63. Which type of urine drug testing can give a confirmation for a large number of medications, substances, and drugs at one time and may be helpful in many patients at initiation of OT, periodically during OT, and following cessation of OT if SUD is a possibility?

A. Immunoassay

B. Gas chromatography-mass spectrometry

C. Liquid chromatography-mass spectrometry

D. None of the above


64. Urine collected in the early morning is most concentrated and most reliable.

A. True

B. False


Appendix D: Drug Tables

65. When converting one opioid to another, the calculated dose of one opioid in morphine milligram equivalents can be used to determine the dose of another opioid in morphine milligram equivalents.

A. True

B. False


66. When converting opioids, the new opioid is typically dosed at _____% lower than the calculated MME dose to avoid accident overdose due to incomplete cross-tolerance and individual variability in opioid pharmacokinetics.

A. 10 - 20

B. 20 - 40

C. 33 - 50

D. 50 - 75


67. When converting _____, caution must be taken because it is dosed in mcg/hr instead of mg/d.

A. Fentanyl

B. Codeine

C. Hydrocodone

D. Oxycodone


68. With repeated dosing of methadone, duration of analgesia is:

A. 4 - 6 hours

B. 8 - 12 hours

C. 12 - 16 hours

D. 12 - 24 hours


69. Significant methadone toxicity can occur, particularly when:

A. Doses are increased too frequently

B. Conversion doses are too high

C. Dosing intervals are too close

D. Any of the above


70. Switching from methadone to another opioid is simply the reverse process, that is, the morphine to methadone conversion ratio is the same as the methadone to morphine ratio.

A. True

B. False


Appendix H: 2010 Recommendation Categorization Table

71. Intensity of pain should be measured using a numeric rating scale (0 - 10 scale) for which of the following?

A. Current pain

B. Least pain in last week

C. “Usual” or “average” pain in last week

D. All of the above


72. Opioid therapy trial can be initiated with caution in which of the following situations?

A. Unwillingness to adjust at-risk activities resulting in serious re-injury.

B. Acute psychiatric instability or uncontrolled suicide risk.

C. Prior adequate trials of specific opioids that were discontinued due to intolerance, serious adverse effects that cannot be treated, or lack of efficacy.

D. Opioid therapy trial can be initiated with caution in all of the above.


73. If a high dose of medication (greater than _____ mg/day morphine equivalent) provides no further improvement in function, consultation should be considered rather than further increasing the dose.

A. 100

B. 200

C. 350

D. 500


74. The patient should be required to provide an opioid log at each visit.

A. True

B. False


75. Opioid therapy should be tapered off and discontinued if:

A. The medication fails to show partial analgesia with incremental dose titration.

B. Trials with different agents provide inadequate analgesia.

C. The patient requests it.

D. Any of the above.


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