COT in CNCP Flashcards
1
Q
COT
A
Chronic Opioid Therapy
2
Q
CNCP
A
Chronic Non Cancer Pain
3
Q
Patients for Opioid Prescribing
A
- 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
4
Q
Starting Opioid Recommendations
A
- 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
5
Q
Prior to Initiating Opioids
A
- 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
6
Q
Initiating Opioids
A
- 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
7
Q
MED vs MME
A
MED = Morphine Equivalent Dose MME = Morphine Milligram Equivalent
8
Q
Opioid Dosing Range
A
- Low: 5-30 mg per day MED (MME)
- Moderate: 35-50 per day MED (MME)
- High: >90 per day MED (MME)
9
Q
Methadone Cautions
A
- 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
10
Q
Fentanyl Cautions
A
- ~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
11
Q
4 A’s of Opiate Monitoring
A
- Analgesia
- Activities of daily living
- Adverse events
- Aberrant drug-related behaviors
12
Q
Undesired Opioid Use Outcomes
A
- Physical Dependence
- Tolerance-larger doses for same effect
- Addiction vs pseudo-addiction
- Withdrawal
- Hyperalgesia
- Aberrant medication related behavior
13
Q
Signs/Symptoms of Aberrant Medication-Related Behavior
A
- 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
14
Q
Urine Drug Monitoring
A
- 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)
15
Q
Immunoassay Presumptive Screen
A
- 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
