That's Dope
In the USA, approximately how many people die everyday from overdoses involving prescription opioids?
A) 10
B) 15
C) 25
D) 40
D) 40
According to the Texas Medical Board, what is the following definition describing:
The normal, predicted, physiological response to a stimulus such as trauma, disease, and operative procedures which is time limited.
Acute Pain
The normal, predicted, physiological response to a stimulus such as trauma, disease, and operative procedures which is time limited.
You are the physician on-call when the nurse calls to tell you that your pt who is in a sickle cell crisis has found any relief with the current opioid regimen they are on, so you increase the patient's dilaudid dose from 1mg to 2mg IV. You go check on the patient just 5 minutes after they receive their dilaudid dose and you realize the pt has started to become lethargic, drifting in and out of sleep and their oxygen saturation begin to decline. What should you do next?
Quickly administer 0.2mg of NARCAN
When dosing opioid medications, what does the unit "MME" stand for and how is it used?
MME: Morphine Milligram Equivalents
Used as a universal unit for the morphine equivalent of several different drugs in order to keep track of a patients opioid load.
* THIS IS NOT USED TO CONVERT FROM ONE OPIOID TO ANOTHER *
In what 3 situations is opioid therapy preferred for the treatment of chronic pain?
Active Cancer
Palliative Care
End-of-Life Care
In the USA, how many people engaged in non-medical use of prescription opioids in the last month?
A) 500,000
B) 1.5 million
C) 3.7 million
D) 4.3 million
D) 4.3 million
According to the Texas Medical Board, what are the two limitations that practitioners have when prescribing opioid medications for acute pain?
1) Practioners may not prescribe opioids for > 10 days
2) Practioners may not provide prescription refills
According to the Texas Medical Board, under what circumstance does the 10-day opioid prescription limit not apply?
The 10-day limitation does not apply to a prescription for an opioid approved by the FDA for the treatment of substance addiction that is issued by a practitioner for the treatment of substance addiction.
What class of medication should never be prescribes with opioids?
Benzodiazepine
What are 4 alternatives to opioids therapy that have been shown to improve the management of chronic pain?
Physical therapy / Exercise
Interventions such as steroid injections
Nonopioid medications such as acetaminophen or ibuprofen
Cognitive Behavioral Therapy
- Nonopioid therapies are always first-line for the treatment of chronic pain. If the patient has failed intervention with nonopioid therapies or if the expected benefit of both pain and function are anticipated to outweigh the risk of using opioids, then opioid therapy is indicated. Nevertheless, opioid therapy for chronic pain should be combined with non-pharmacologic and/or non-opioid pharmacologic therapy.
What percentage of patients who receive long-term opioid therapy in the primary care setting struggle with opioid use disorder?
25% - 1 in 4 patients
Can a physician treat patients with opioids for acute pain for more than 10 days?
Yes, but they may only prescribe 10 days at a time and they may not provide prescription refills. In order to receive more than ten days of therapy, pts must have follow up appointments after ten days to receive a new prescription. The law does not limit how many times this may occur
A pt presents with what appears to be an opioid OD and you quickly administer a dose or NARCAN. The pt then starts to regain consciousness and beside being very upset that you reversed the high that he paid good money for he is also complaining of headache, rapid heart rate, sweating, nausea, vomiting, and tremors. What are the next steps in management and how concerned should you be by this?
The pt is having opioid withdrawal symptoms, which are a common side effect after using NARCAN.
Management for an opioid withdrawal is simply supportive measures. Opioid withdrawals are not deadly but can be very uncomfortable which is why proper weaning of opioids is important.
At what MME value must clinicians be cautions of prescribing more opioids?
What MME value should clinicians never surpass except in very rare circumstances?
If prescribing >50 MME/day of opioids, clinicians should increase follow-up frequency and consider offering pts Naloxone for overdose risk.
- The risk for opioid-related overdose is dose dependent, with significantly increased risk for overdose in patients receiving dosages >90 MME/day
Before starting opioid therapy and periodically during opioid therapy, what is the most important thing a physician must establish with the patient?
Treatment Goals which include:
- Realistic goals for pain and function
- Considerations for how opioid therapy will be discontinued if the benefits do not outweigh the risks
In the USA, how many prescriptions for opioid pain medications were written by healthcare providers in 2018?
A) 168 million
B) 214 million
C) 240 million
D) 255 million
A) 168 million - 51.4 prescriptions for every 100 people
B) 214 million - 66.5 prescriptions for every 100 people (2016)
C) 240 million - 75.6 prescriptions for every 100 people (2014)
D) 255 million - 81.3 prescriptions for every 100 people (2012)
According to the Texas Medical Board, when establishing a pain contract with a physician, what rules must the pt agree to abide by?
(Describe at least 2)
- Only the primary pain management physician or another physician covering for the primary pain management physician may prescribe dangerous and scheduled drugs for the treatment of chronic pain.
- For any prescriptions issued for medications to treat acute or chronic pain by a person other than the primary pain management physician or covering physician, the pt must inform the primary pain management physician of this either on the day of their next appointment or before.
- Only one pharmacy designated by the patient will be used for prescriptions for the treatment of chronic pain
- Pt must agree to provide a toxicology screen as often as the primary pain management physician deems fit
It is your turn to work the whole weekend and are therefore stuck taking care of your co-residents pts. You are an awesome resident who reviews every pts medication list and after paying attention to this lecture you realize that one of your pt's is currently prescribed 92 MME/day of opioids, what should be your next step in management?
Evaluate for tapering to reduced dose or to discontinue
What is the proper rate of reduction of opioid prescriptions when weaning pts off of opioids and how often should you assess them.
Decrease MME by 10% per week or month, depending on how long they have been using them.
Reassess pts every 1 - 2 weeks
What type of opioids should clinicians prescribe when starting opioid therapy for chronic pain?
Immediate-Release opioids: faster acting medications with a shorter duration of pain-relieving action.
Ex:
What is the cause for most prescription opioid related deaths?
Most opioid-related overdoses occurred in patients taking opioids as prescribed
Before prescribing any type of controlled substance you must first look up the patients information on the Texas PMP database.
List at least 4 data points you can find on the Texas PMP that can help direct the course of management for your patient.
- Narcotic Score
- Sedative Score
- Stimulant score
- Pts Risk based on prescription exposure rate
- View pts controlled substance history based on providers or acute/episodic/chronic therapy
- Helps identify needs for frequent monitoring, dose taper and/or naloxone, to reduce risk of opioid-related harm based on MMEs
On average, for how long are patients on opioid therapy before they begin to develop substance dependence?
Evidence suggests that the probability of long-term opioid use increases within the first few days after starting a new opioid prescription, with the sharpest increase between 5 and 31 days of treatment.
When starting pts on opioid therapy, what is the range of MMEs that you should stay within.
20 - 50 MME/day of Immediate release/Short acting opioids
What is the PEG pain scale?
The PEG scale consists of 3 separate numerical scales. Each scale has ratings ranging from 0-10. The PEG scale is scored by averaging the three numbers. The final score helps to track and monitor changes in pain levels over time. A 30% decrease in the score is considered significant in terms of the effectiveness of the therapy.
Question:
1) Rate your pain, on average, over the past week.
2) Rate how pain has interfered with your enjoyment of life in the past week.
3) Rate how pain has interfered with your general activities.
For pts on opioid therapy, at what point are they most at risk for an OD?
Risks for opioid overdose are greatest during the first 3-7 days after opioid initiation or an increase in dosage, particularly when ER/LA opioids are initiated.
This also includes methadone and transdermal fentanyl.
Name 4 of the 7 life-threatening medical conditions that must be identified before starting someone on opioid therapy.
- Sleep-disordered breathing such as sleep apnea
- Pregnancy
- Renal or hepatic insufficiency
- Age >= 65
- Certain mental health conditions
- Substance use disorder
- Previous nonfatal overdose
Name just 2 of the many addiction hot-lines available in Texas.
•Delphi Health Group
•Texas Substance Abuse Treatment Helpline (TSAH)
•StarCare Specialty Health System
•North Texas Behavioral Health Authority (NTBHA)
•Alcohol & Drug Abuse Council of Deep East Texas
•Bluebonnet Trails Community Services
•Tropical Texas Behavioral Health (TTBH)
•Emergence Health Network (EHN)
•PermiaCare
•The Center for Health Care Services
What has research proven to be the efficacy and long-term effects of opioid use for the management of chronic pain.
No evidence supports the use of long-term opioid therapy in patients with chronic non-cancer pain. In fact, evidence demonstrates that long-term opioid use is associated with
- Poorer overall functional status
- Worse quality of life
- Worse pain (possibly mediated through opioid tolerance and hyperalgesic mechanisms).
On average, what is usually a sufficient duration of opioid therapy for most cases of acute pain?
3 days or less will often be sufficient.
More than 7 days will rarely be needed.