COT in CNCP

Question 1

COT

Answer 1

Chronic Opioid Therapy

Question 2

CNCP

Answer 2

Chronic Non Cancer Pain

Question 3

Patients for Opioid Prescribing

Answer 3

• Outpatient settings
• Doesn’t include active cancer treatment, palliative care, and end-of-life care
• Treat patient >= 18 years old with pain longer than 3 months or past time of normal tissue healing

Question 4

Starting Opioid Recommendations

Answer 4

• Start at the lowest effective dosage
• Should consider risks vs benefits when increasing the dosage >= 50 MME/day
• Avoid increasing dosage >= 90 MME/day or should carefully justify titrating a dosage to that range

Question 5

Prior to Initiating Opioids

Answer 5

• Maximize non opioid medications
• Use screening tests like SOAPP or ORT
• Controlled Substance Agreement
• Review PMP Report
• Baseline UDM
• Discuss risks and benefits of using controlled substances with patient

Question 6

Initiating Opioids

Answer 6

• Complete Critical 1st Assessment
• Start low and go slow
• Start on short acting opioid
• Reassess in ~2 weeks
• Prescribe immediate release formulas over extended-release or long-acting

Question 7

MED vs MME

Answer 7

MED = Morphine Equivalent Dose
MME = Morphine Milligram Equivalent

Question 8

Opioid Dosing Range

Answer 8

• Low: 5-30 mg per day MED (MME)
• Moderate: 35-50 per day MED (MME)
• High: >90 per day MED (MME)

Question 9

Methadone Cautions

Answer 9

• Variable half life and duration (Dose: q6-12 hours)
• DDI: alcohol, azoles, thioridazine (avoid)
• Can increase QTc interval (decrease dose if this occurs)
• Can accumulate in the elderly
• No changes in dose until 5-7 days after starting methadone

Question 10

Fentanyl Cautions

Answer 10

• ~100x more potent than morphine (don’t use in the opioid naive)
• Takes 24 hours before full effect is known
• NOT for breakthrough/acute pain
• Highly lipophilic (caution in high BMI)
• Different generic products are not truly interchangeable
• Can only titrate in 3 day increments

Question 11

4 A’s of Opiate Monitoring

Answer 11

• Analgesia
• Activities of daily living
• Adverse events
• Aberrant drug-related behaviors

Question 12

Undesired Opioid Use Outcomes

Answer 12

• Physical Dependence
• Tolerance-larger doses for same effect
• Addiction vs pseudo-addiction
• Withdrawal
• Hyperalgesia
• Aberrant medication related behavior

Question 13

Signs/Symptoms of Aberrant Medication-Related Behavior

Answer 13

• Selling prescription drugs
• Forging prescriptions
• Stealing drugs
• Injecting oral formulations
• Obtaining prescription drugs from non-medical sources
• Concurrently abusing alcohol/illicit substances
• Escalating doses on multiple occasions despite warnings
• “Losing” prescriptions on multiple occasions
• Repeatedly seeking prescriptions from other providers/ED without informing provider or after warnings to desist
• Evidence of deteriorating function due to drug use

Question 14

Urine Drug Monitoring

Answer 14

• For suspected medication related aberrant behavior
• Make sure test ordered will test for the medication in question
• May damage provider-patient relationship
• Document when patient took last dose of medication tested
• High risk medication, not high risk patients (good data => good therapy)

Question 15

Immunoassay Presumptive Screen

Answer 15

• In-office/PoC or lab-based IA test
• Less specific/sensitive
• Results in minutes
• Detects drug classes and few meds, illicit substances
• Guidance for preliminary treatment decisions
• Cross-reactivity common, more false positives
• High cutoff levels: more false negatives

Question 16

GC-MS or LC-MS/MS Definitive Quantitative

Answer 16

• Laboratory test
• Highly specific and sensitive
• Results in hours to days
• Measures [all medications, illicit substances, and metabolites]
• Definitive identification and analysis
• False-positives/negatives and rare

Question 17

LA Opioids

Answer 17

• Theoretically have less abuse potential
• Help with patient adherence
• Provide consistent levels of analgesic
• Allow patients to focus less on pain/pain medications

Question 18

Abuse Deterrent Formulations

Answer 18

• Physical Barriers
• Aversive components
• Sequestered antagonists

All brand names, most not covered, and all ER/LA

Question 19

Physical Barriers Advantages/Disadvantages

Answer 19

Advantages

• Prevents crushing/chewing
• No AEs in compliant patients

Disadvantages

• Doesn’t deter abuse of intact tablets
• Only one approved formulation available

Question 20

Aversive Components Advantages/Disadvantages

Answer 20

Advantages

• May prevent chewing/crushing
• May limit abuse of intact tablets (amplifying niacin AEs)

Disadvantages

• Potential AEs for compliant patients
• AEs may prevent appropriate dose increase
• AEs may not be sufficient to deter abuse
• No FDA-approved formulation

Question 21

Sequestered Antagonists Advantages/Disadvantages

Answer 21

Advantages

• Prevent crushing/chewing
• FDA-approve formulations available

Disadvantages

• Doesn’t deter abuse of intact tablets
• Chewing/crushing tablets may cause severe withdrawal symptoms

Question 22

Buprenorphine Pros for Pain

Answer 22

• Partial agonist with ceiling effect for analgesia/AE
• Simpler dosing
• Less DDI, better safety
• CIII
• More optimal choice for patients with aberrant behavior/addiction
• Doesn’t need DEA for CNCP treatment

Question 23

Buprenorphine Cons for Pain

Answer 23

• If on other opioid meds, may need to decrease to =< 30 MME
• May not be adequate for severe pain
• Insurance obstacles

Question 24

Opioids + Endocrine System

Answer 24

• Inhibit the release of gonadotropin releasing hormone and corticotropin releasing factor from hypothalamus
• Inhibits pituitary release of several hormones
• Secondary hypogonadism

Question 25

Opioids + Sleep Apnea

Answer 25

• Cause central sleep apnea by decreasing medullary responsiveness to CO2 levels
• Worsens obstructive sleep apnea
• Compounded by use with other CNS depressants like benzos

Question 26

Opioids + Hyperalgesia

Answer 26

• Heightened pain perception with opioid use in absence of disease progression
• Treated by decreasing opioid dose

Question 27

Holy Trinity

Answer 27

• Opioid + Benzo + Carisoprodol
• Don’t use Soma!
• Metabolized to meprobamate which is anxiolytic (inhibits anxiety)
• Benzos also greatly increase risk of accidental overdose, avoid using with opioid medications

Question 28

Opioids + Gabapentinoids

Answer 28

• Significant increase in opioid related deaths
• Increased likelihood to blackout or OD
• Shown to increase effects of heroin
• Especially be concerned in the patient is on a high dose of gabapentinoids