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Quantum Units Education

Prescribing Opioids for Chronic Pain

Introduction

1. Evidence supports short-term efficacy of opioids for reducing pain and improving function in noncancer nociceptive and neuropathic pain in randomized clinical trials lasting primarily less than:

A. 4 weeks

B. 8 weeks

C. 12 weeks

D. 16 weeks


2. Having a history of a prescription for an opioid pain medication increases the risk for overdose and opioid use disorder.

A. True

B. False


3. Which of the following is true with regard to adolescents?

A. Adolescents who misuse opioid pain medication often misuse medications from their own previous prescriptions, with an estimated 20% of adolescents with currently prescribed opioid medications reporting using them intentionally to get high or increase the effects of alcohol or other drugs.

B. Use of prescribed opioid pain medication before high school graduation is associated with a 33% increase in the risk of later opioid misuse.

C. Misuse of opioid pain medications in adolescence strongly predicts later onset of heroin use.

D. All of the above are true.


Summary of the Clinical Evidence Review

4. Long-term opioid therapy is defined as use of opioids on most days for greater than:

A. 7 days

B. 30 days

C. 3 months

D. 6 months


5. A cohort study of Veterans Affairs patients found initiation of therapy with an immediate-release opioid associated with greater risk for nonfatal overdose than initiation of therapy with an ER/LA opioid, with risk greatest in the first 2 weeks after initiation of treatment.

A. True

B. False


6. Use of opioids within _____ of surgery is associated with increased risk for use at 1 year.

A. 3 days

B. 7 days

C. 14 days

D. 30 days


Summary of the Contextual Evidence Review

7. Which of the following nonpharmacologic treatments have been shown to be effective in managing chronic pain?

A. Cognitive Behavioral Therapy

B. Exercise therapy

C. Multimodal and multidisciplinary therapies

D. All of the above


8. Several guidelines agree that first- and second-line drugs for neuropathic pain include all of the following, except:

A. NSAIDs

B. Anticonvulsants

C. Tricyclic antidepressants

D. SNRIs


9. As noted by the FDA, there are serious risks of ER/LA opioids, and the indication for this class of medications is for management of pain severe enough to require daily, around-the-clock, longterm opioid treatment in patients for whom other treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain.

A. True

B. False


10. Consistent with the clinical evidence review, the contextual review found that opioid-related overdose risk is dose-dependent, with higher opioid dosages associated with increased overdose risk.

A. True

B. False


11. Patients who do not experience clinically meaningful pain relief within _____ in treatment are unlikely to experience pain relief with longer-term use.

A. 7 days

B. 1 month

C. 3 months

D. 6 months


12. It has been found that most fatal overdoses can be identified retrospectively on the basis of which piece of information?

A. Multiple prescribers

B. High total daily opioid dosages

C. Both (A) and (B)

D. None of the above


13. Which of the following has been found to increase retention in treatment and to decrease illicit opioid use among patients with opioid use disorder involving heroin?

A. Methadone

B. Buprenorphine

C. Both (A) and (B)

D. None of the above


Recommendations

14. When starting opioid therapy for chronic pain, extended-release / long-acting opioids should be prescribed instead of immediate-release opioids.

A. True

B. False


15. Prescribing opioid pain medication and _____ concurrently should be avoided whenever possible.

A. Benzodiazepines

B. Methadone

C. Naloxone

D. All of the above


Determining When to Initiate or Continue Opioids for Chronic Pain

16. Patients with co-occurring pain and depression are especially likely to benefit from antidepressant medication.

A. True

B. False


17. Evidence is limited or insufficient for improved pain or function with long-term use of opioids for which chronic pain condition that opioids are commonly prescribed for?

A. Low back pain

B. Headache

C. Fibromyalgia

D. All of the above


18. Experts agree that opioids should not be considered first-line or routine therapy for chronic pain.

A. True

B. False


19. Patients should be required to sequentially fail nonpharmacologic and nonopioid pharmacologic therapy before proceeding to opioid therapy.

A. True

B. False


20. Opioid therapy should not be initiated without consideration of an “exit strategy” to be used if the therapy is unsuccessful.

A. True

B. False


21. Pain lasting longer than _____ is generally no longer considered acute.

A. 1 month

B. 3 months

C. 6 months

D. 9 months


22. Clinically meaningful improvement has been defined as a _____% improvement in scores for both pain and function.

A. 30

B. 50

C. 70

D. 90


23. Patients should be advised about which common effect of opioids?

A. Confusion

B. Physical dependence

C. Withdrawal symptoms when stopping opioids

D. All of the above


24. Given the possibility that benefits of opioid therapy might diminish or that risks might become more prominent over time, it is important to review expected benefits and risks of continued opioid therapy with patients at least every:

A. 1 month

B. 3 months

C. 6 months

D. 9 months


Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

25. Clinical evidence shows that:

A. There is a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediate-release opioids.

B. Continuous, time-schedule use of ER/LA opioids is more effective or safer than intermittent use of immediate-release opioids.

C. Time-scheduled use of ER/LA opioids reduces risks for opioids misuse or addiction.

D. Clinical evidence shows all of the above.


26. Abuse-deterrent technologies prevent unintentional overdose through oral intake.

A. True

B. False


27. The contextual evidence review found that a single dose threshold below _____ eliminates overdose risk.

A. 20 MME

B. 50 MME

C. 100 MME

D. None of the above


28. Most experts agree that opioid dosages should not be increased to greater than _____ without careful justification based on diagnosis and on individualized assessment of benefits and risks.

A. 50 MME/day

B. 90 MME/day

C. 150 MME/day

D. 200 MME/day


29. Experts note that patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodations to lower opioid dosages.

A. True

B. False


30. Signs of _____ that might be unmasked by an opioid taper should be watched for and management arranged.

A. Anxiety

B. Depression

C. An opioid use disorder

D. All of the above


31. Additional opioids for acute pain should be prescribed to patients just in case pain continues longer than expected.

A. True

B. False


32. Experts note that risks for opioid overdose are greatest during the first _____ days after opioid initiation or increase in dosage.

A. 1 - 2

B. 2 - 4

C. 3 - 7

D. 5 - 10


33. Which of the following should be determined at reassessment?

A. Whether opioids continue to meet treatment goals, including sustained improvement in pain and function.

B. Whether the patient has experienced common or serious adverse events or early warning signs of serious adverse events.

C. Whether opioid dosage can be reduced or opioids can be discontinued.

D. All of the above.


34. Which of the following patients should be re-evaluated more frequently than every 3 months?

A. Patients with depression or other mental health conditions.

B. Patients with a history of substance use disorder.

C. Patients taking other central nervous system depressants with opioids.

D. All of the above.


35. A decrease of _____% of the original dose per week is a reasonable starting point for tapering.

A. 10

B. 20

C. 30

D. 40


36. It should be discussed with patients undergoing tapering that there is an increased risk for overdose on abrupt return to a previously prescribed higher dose.

A. True

B. False


37. Most experts agree that naloxone should be offered when prescribing opioids to patients at increased risk for overdose, including:

A. Patients with a history of overdose.

B. Patients taking benzodiazepines with opioids.

C. Patients at risk for returning to a high dose to which they are no longer tolerant.

D. All of the above.


38. Experts agree that prior to starting opioids for chronic pain and periodically during opioid therapy, urine drug testing should be used to assess for prescribed opioids as well as other controlled substances and illicit drugs that increase risk for overdose when combined with opioids, including nonprescribed opioids, benzodiazepines, and heroin.

A. True

B. False


39. A case-cohort study found concurrent _____ prescription with opioid prescription to be associated with a near quadrupling of risk for overdose death compared with opioid prescription alone.

A. Benzodiazepines

B. Methadone

C. Naloxone

D. All of the above


40. When patients receiving both benzodiazepines and opioids require tapering to reduce risk for fatal respiratory depression, it is safer and more practical to taper benzodiazepines first.

A. True

B. False


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