Pain management

Question 1

The risk for serious GI events (e.g. bleeding) when NSAIDs are used for chronic pain managment is greatest in the first 3 days of administration.
a. True
b. False

Answer 1

b. False

Generally, the timeframe is six months.

Question 2

Acetaminophen does not improve either pain or function for patients with osteoarthritis.
a. True
b. False

Answer 2

True

However, NSAIDS improve both outcomes. APAP (acetaminophen) is not an NSAID and is in a category by itself.

Question 3

When considering a trial of an opioid to manage chronic pain, clinicians should determine if the benefits are likely to outweigh the risks.
a. True
b. False

Answer 3

a. True

In making the risk-benefit calculation, the APRN assesses patients who have failed to respond to non-opioid and nondrug interventions adequately. A change in the CDC/AHRA 2020 guidelines for considering a trial is the deletion of “moderate” in the pain scale - pain should be chronic and severe. The APRN should always evaluate the risk and benefit of prescribing a drug.

Question 4

Reevaluation for risk related to opioid harms should minimally occur with every prescription or every 90 days.
a. True
b. False

Answer 4

b. True

This is best practice as recommended by the CDC, the DEA, and most professional organizations (pain society, cancer society, etc.).

Question 5

For each APRN candidate, the Ohio Board of Nursing requires 6 hours of content about Schedule 2 drugs and a total of 45 hours of pharmacology content before application for his or her initial (first) APRN license.
a. True
b. False

Answer 5

a. False

ORC 4723.482

(B) With respect to the course of study in advanced pharmacology and related topics, all of the following requirements apply:

(1) The course of study shall be completed not longer than five years before the application is filed.

(2) The course of study shall be not less than forty-five contact hours.

(3) The course of study shall meet the requirements to be approved by the board in accordance with standards established in rules adopted under section 4723.50 of the Revised Code.

(4) The content of the course of study shall be specific to the applicant’s nursing specialty.

(5) The instruction provided in the course of study shall include all of the following:

(a) A minimum of thirty-six contact hours of instruction in advanced pharmacology that includes pharmacokinetic principles and clinical application and the use of drugs and therapeutic devices in the prevention of illness and maintenance of health;

(b) Instruction in the fiscal and ethical implications of prescribing drugs and therapeutic devices

(c) Instruction in the state and federal laws that apply to the authority to prescribe;

(d) Instruction that is specific to Schedule 2 controlled substances in drug therapies, including instruction in the following:

(i) Indications for the use of schedule II controlled substances in drug therapies;

(ii) The most recent guidelines for pain management therapies, as established by state and national organizations such as the Ohio pain initiative and the American pain society;

(iii) Fiscal and ethical implications of prescribing schedule II controlled substances;

(iv) State and federal laws that apply to the authority to prescribe schedule II controlled substances;(v) Prevention of abuse and diversion of schedule II controlled substances, including identification of the risk of abuse and diversion, recognition of abuse and diversion, types of assistance available for prevention of abuse and diversion, and methods of establishing safeguards against abuse and diversion.

Question 6

An opioid is likely to be more effective than gabapentin for acute neuropathic pain.
a. True
b. False

Answer 6

a. True

Yes, according to the 2020 AHRQ systematic review, treatments for acute pain. This is for acute neuropathic pain, not chronic. The benefits may outweigh the risks short-term, but not long-term (for chronic neuropathic pain).

Question 7

Generally, long-acting opioids like fentanyl transderemal system or hydromorphone extended release should not be prescribed to opioid naive patients.
a. True
b. False

Answer 7

a. True

CDC 2020 guidelines: when starting an opioid therapy for chronic pain, clinicians should prescribe IR (immediate release) opioids instead of extended-release/long-acting opioids.

Question 8

Antidepressants like SSRIs are used to manage chronic pain and are not assoicated with withrdrawal symptoms when stopped abruptly unless the patient has an addictive disorer.
a. True
b. False

Answer 8

b. False

While SNRIs are useful in managing selected chronic pain syndromes, SSRIs are not. Amitriptyline, a tricyclic antidepressant is also used effectively, off-label, for some chronic pain syndromes.

Antidepressants can lead to dependence.

Dependence can lead to adverse, concerning withdrawal symptoms and need to be weaned, regardless of the condition for which the SNRI, SSRI, or other antidepressant was prescribed.

Question 9

Anticonvulsants like gabapentin demonstrate both short-term improvement of chronic diabetic peripheral neuropathy and no harm from withdrawal symptoms.
a. True
b. False

Answer 9

a. False

According to the AHRQ 2020 Nonopioid pharmacologic treatments for chronic pain systematic review, it is true that anticonvulsants have efficacy in short-term improvements in pain (low-moderate quality of evidence) when pain is chronic. It is false that these drugs have no association with withdrawal symptoms.

Question 10

Patients are considered opioid dependent if they take at least 60 mg oral MED, 60 mg of morphone, or an equianalgesic dose of another opioid) for 7 days or longer.
a. True
b. False

Answer 10

a. True

Opioid tolerance occurs when a person using opioids begins to experience a reduced response to medication, requiring more opioids to experience the same effect. Opioid dependence occurs when the body adjusts its normal functioning around regular opioid use. Unpleasant physical symptoms occur when medication is stopped.

This is the definition of opioid-tolerant. The FDA defines a patient as opioid-tolerant if, for at least 1 week, he or she has been receiving oral morphine 60 mg/day.

Opioid dependency means that the patient will experience withdrawal symptoms (psychological or physical) if the opioid is abruptly stopped. Opioid dependence is when a person is physiologically and psychologically addicted to opioids. Symptoms include tremors, chills, sweating, itching, restlessness, paranoia, nausea, and depression. An individual can become dependent with as few as 2-3 doses of an opioid.

Typically, an opioid must be consumed daily for three weeks or more for physiologic dependence to develop and for the patient to require medically supervised withdrawal. Higher doses and prolonged use are risks for dependence. Some opioids can trigger dependence in as few as 20-50 MED over 1-3 days in some people.

Of course, tolerance can happen earlier or later than the 1 week of 60 MED. Understanding tolerance helps with prescribing clinician understand when it is safe to transition to long-acting or extended-release formulations. Some expert sources say 50 MED/day is the minimum needed to develop tolerance.

Question 11

Patients who have not taken an opioid in the past month are at greater risk for respiratory depression and sedation than patients who have received 60 mg morphine equivalent dose (MED) during the past week.
a. True
b. False

Answer 11

b. False

Opioid naive is variably defined in the literature. Generally, opioid naive patients have no received opioids in the 30 days before the acute event or surgery.

The FDA defines a patient as opioid-tolerant if for at last 1 week he or she has been receiving oral morphine 60 mg/day; transdermal fentanyl 25 mcg/hr; oral oxycodone 30 mg/day; oral hydromorphone 8 mg/day; oral oxymorphone 25 mg/day; or an equi-analgesic dose of any other opioid. Opioid tolerance implies a lesser susceptibility to the effects of opioids - both therapeutic and adverse - and may develop in individuals with long-term use of opioids.

Opioid-naive patients are at the greatest risk for harm from respiratory depression and/or sedation.

Question 12

Opioid rotations for patients receiving chronic opioids may work because of incomplete cross-tolerance among opioids or iherited opioid receptor variability.
a. True
b. False

Answer 12

a. True

Opioid rotation refers to a switch from one opioid to another to improve the response to analgesic therapy or reduce adverse effects, It is a common method to address the problem of poor opioid responsiveness despite optimal dose titration.

Question 13

Generally, extended release/long-acting opioid (ER/LA) opioid analgesics, when no longer required for the patient’s condition, need to be weaned to prevent withdrawal symptoms.
a. True
b. False

Answer 13

a. True

Assuming the patient has been on opioids > 1 week and greater than 60 mg (hence the transition to ER), yes, treat the patient as tolerant and at risk for withdrawal symptoms.

It is reasonable to assume patient has been receiving opioids for > 1 week and > 50 MEDs daily as these are the criteria to switch from short-acting to ER/LA opioids for chronic cancer or noncancer pain.

Question 14

Tolerance to opioids is a function of both time and dose.
a. True
b. False

Answer 14

a. True

Recall that a patient can be tolerant, dependent, and addicted. These categories are not mutually exclusive. Consider clinical implications of the presence of each condition when prescribing or (if CRNA) administering an opioid.

Question 15

Which opioids are not associated with CYP 450 metabolism and instead undergo phase 2 metabolism? Check as many as apply.
a. Morphine
b. Codeine
c. Hydromorphone
d. Oxymorphone
e. Oxycodone

Answer 15

a. Morphine
c. Hydromorphone
d. Oxymorphone

Tapentadol is also associated with phase 2 metabolism.

Codeine, fentanyl, hydrocodone, methadone, oxycodone, and tramadol use CYP 450 enzymes (mostly 3A4 and 2D6).

Question 16

Written documentation in the form of a patient-prescriber agreement (PPA), which both the patient and provider sign when a long-term opioid is prescribed, can help achieve which of the following components of high-quality care? Check as many as apply.
a. Clarify the management plan with the patient, the patient’s family, and other clinicians who may become involved in the patient’s care
b. Provide clear written consequences if there is suspicion or evidence of misuse or diversion, including information that the prescriber will no longer provide opioid prescriptions following a random urine check that indicates illicit drug use or NO prescriptive opioid use.
c. Ensure that patients and caregiver understand the goals and risks of treatment and how to use these medications safely
d. Reinforce expectations about safe use, particularly for patients at higher risk for opioid misuse.

Answer 16

a. Clarify the management plan with the patient, the patient’s family, and other clinicians who may become involved in the patient’s care
b. Provide clear written consequences if there is suspicion or evidence of misuse or diversion, including information that the prescriber will no longer provide opioid prescriptions following a random urine check that indicates illicit drug use or NO prescriptive opioid use.
c. Ensure that patients and caregiver understand the goals and risks of treatment and how to use these medications safely
d. Reinforce expectations about safe use, particularly for patients at higher risk for opioid misuse.

Question 17

Which of the following rules are true in Ohio for prescribing APRN who is writing for an opioid in an approved site? Check as many as apply.
a. The APRN can write for a 90 day of a controlled substance in a hospice practice or setting pharmacy
b. The APRN prescribing a new opioid in a clinic/outpatient setting can only prescribe a total of 7 days of therapy unless the standard care arrangement specifically address the physician initiated/physician collaboration rules
c. The APRN can only prescribe for a patient with a terminal illness and that the prescription is limited to a 24-hour supply of a drug that has been initially prescribed by a physician
d. The APRN can prescribe more than 50 MEDs/day for cancer-related pain with clear documentation
e. The APRN who is prescribing a renewal opioid, can write a supply of up to 90 days in a retail clinic
f. The APRN in an inpatient setting can prescribe a new opioid for 30 days if the employing institution has a 30-day initiation policy

Answer 17

a. The APRN can write for a 90 day of a controlled substance in a hospice practice or setting pharmacy
b. The APRN prescribing a new opioid in a clinic/outpatient setting can only prescribe a total of 7 days of therapy unless the standard care arrangement specifically address the physician initiated/physician collaboration rules
d. The APRN can prescribe more than 50 MEDs/day for cancer-related pain with clear documentation
f. The APRN in an inpatient setting can prescribe a new opioid for 30 days if the employing institution has a 30-day initiation policy

States have very different rules and the APRN is responsible for learning them and practicing within their scope of practice.

Most mail-order pharmacies do not supply opioids - the 90-day supply is likely for a drug to manage ADD/ADHD. For example, CVS Caremark, a mail-order drug prescription manager uses an enhanced opioids utilization management approach that limits the supply of opioids for certain acute prescriptions to seven days for patients that are new to therapy.

APRNs who prescribe in a retail clinical cannot prescribe Schedule 2 drugs.

Question 18

Which of the following is correct regarding written screening tools to use before prescribing an opioid? Check as many as apply.
a. Information from a screening tool is required by the Prescription Drug Monitoring Program in most states
b. Incorporating a tool like the ORT into the eMR is one strategy to increase the identification of individuals at high risk for harm from opioids
c. For patients with anticipated or actual long-term opioid use, screening for potential misuse is considered best practices
d. There are few valid and reliable screening tools that predict risk for drug abuse or diversion

Answer 18

b. Incorporating a tool like the ORT into the eMR is one strategy to increase the identification of individuals at high risk for harm from opioids
c. For patients with anticipated or actual long-term opioid use, screening for potential misuse is considered best practices

ORT = opioid risk tool, a valid and reliable tool to predict risk for opioid misuse

Question 19

Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms using which of the following strategies? Check as many as apply.
a. Determining that a patient is at risk for harm when the daily opioid dose is greater than or equal to 50 miligrams of morphine equivalence
b. Use buprenorphine alone for patients with opioid use disorder to manage pain
c. Avoid concurrent benzodiazepine prescribing with opioid use
d. Furnish naloxone to individuals who are at risk for opioid overdose

Answer 19

a. Determining that a patient is at risk for harm when the daily opioid dose is greater than or equal to 50 milligrams of morphine equivalence
c. Avoid concurrent benzodiazepine prescribing with opioid use
d. Furnish naloxone to individuals who are at risk for opioid overdose

While buprenorphine or methadone can be used as an evidence-based treatment in patients with opioid use disorder, these drugs are generally not used to manage pain.

The other options are highly recommended as strategies to address harms. Guidelines and advice can be found on the CDC website and multiple professional organizations.

Question 20

Best practices for prescribing schedule 2 drugs include which of the following steps? Check as many as apply.
a. Using a written patient (parent)-provider agreement for community dwelling patietns anticipated to require more than a one week supply of a schedule 2 drug.
b. Ordering urine drug test identify the presence of a nonprescribed drug or an illicit substance and to confirm the presence of the prescribed opioid
c. Interviewing the patient to understand if there has been an adequate trial of nonopioid treatment for pain and to assess psychosocial factors/family history for adequate risk stratification
d. Checking the patient’s prescription history in the State Prescription Drug Monitoring Program and documenting findings fromt his step in the eMR
e. Using monitoring tools, such as the Current Opioid Misuse Measure to identify aberrant behaviors that are associated with prescriptive drug abuse

Answer 20

a. Using a written patient (parent)-provider agreement for community dwelling patients anticipated to require more than a one week supply of a schedule 2 drug.
b. Ordering urine drug test identify the presence of a nonprescribed drug or an illicit substance and to confirm the presence of the prescribed opioid
c. Interviewing the patient to understand if there has been an adequate trial of nonopioid treatment for pain and to assess psychosocial factors/family history for adequate risk stratification
d. Checking the patient’s prescription history in the State Prescription Drug Monitoring Program and documenting findings from his step in the eMR
e. Using monitoring tools, such as the Current Opioid Misuse Measure to identify aberrant behaviors that are associated with prescriptive drug abuse

According to the National Alliance for Model State Drug Laws (namsdl.org) all 50 states plus Washington DC and US territory Guam have operational PDMPs that have the capacity to receive and distribute controlled substance prescription information to authorized users. The challenge is that state databases are often not available to prescribing clinicians unless they reside in/prescribe in that state.

Question 21

A woman, 61 years old, with metastatic breast cancer, reports bone pain. Her cancer is being treated appropriately with oncology drugs, and she has received zoledronic acid and radiation treatment for her bone metastases. Despite these internventions, her pain has remained high, interferes with her function, and increased in the past month. Pain is being treated with celecoxib 200 mg daily, acetaminophen 500 mg four times daily and short-acting oxycodone 10 mg as needed every 4 hours. She now takes oxycodone every 4 hours throughout the day (60 mg daily). If she waits more than 4 hours (even overnight), the pain becomes unbearable - she sets her alarm to keep on schedule. She worries about taking this much pain medication and “does not want to get addicted to painkillers.” The ORT and review of OAARS do not provide inforamtion congruent with significant risk factors for opioid misuse. In your interactions, he has not shown any aberrant behaviors. What is your next step?
a. Add ibuprofen or naproxen to the regimen
b. Increase the oxycodone to 15 mg every 4 hours and re-evaluate in 7 days
c. Refer this patient to a pain clinic or pain specialist for treatment with methadone
d. Add oxymorphone 5 mg ER q 12

Answer 21

d. Add oxymorphone 5 mg ER q 12

The presence of breakthrough pain in this patient with a short-acting drug suggests that she is a candidate for a long-acting drug. Could consider a different opioid formulation to overcome suspected tolerance.

Start the ER/LA drug at 50% of the equi-analgesic dose. 20-30 mg oxycodone = 10 mg of oxymorphone. She is getting 60 oxycodone and an equivalent dose of hydromorphone is 20 mg daily, but guidelines suggest starting at 50%; can titrate upward.

There is no evidence that adding a third NSAID will reduce her pain. She is being optimally managed. If a bleeding risk is a concern, add a PPI.

The data suggest that addiction among cancer patients is about the same as the general population, around 15%

While patients worry about addiction, opioids may be the best drug to manage moderate-to-severe pain. Patients may confuse tolerance, dependence, and addiction.

Question 22

A 63-year-old man with a history of hypertension and chronic low back pain from lumbar degeneration presents a routine follow-up visit. He reports that his neighbor’s son recently died from an opioid overdose. He is concerned that his opioid medications could put him at risk for addiction or even an overdose. His current meds are ER morphine 60 mg twice daily, IR oxycodone 10 mg every 4 hours as needed (he fills this prescription for 30 tabs once yearly–rarely uses), ibuprofen 200 mg every 4 h as needed (occasionally uses after watching his grandchild), and lisinopril 20 mg daily. These drugs have been prescribed continuously for the past 8 years. He reports being active in a neighborhood walking club and using hand/arm weights 3x weekly for 30 minutes. He attends tai chi once weekly.

He has been adherent to the patient-provider scheduled drug agreement, and has missed one follow-up appointment in the past 3 years. OAARS shows that opioids are filled at one drug store and are only from you or your practice. He has naloxone at home.

What are reasonable next steps given current guidelines for the management of chronic pain with opioids?

a. Since this patient is receiving 120 MEDs daily, and is worried about opioid use/misuse, discuss a tapering schedule with him.
b. Add a long-acting legend NSAID and titrate his opioid down by 25-30%
c. Continue on his current treatment plan as there are no issues or risks identified with opioid use disorder
d. Refer him to a pain clinic or mental health specialist for opioid use disorder and management

Answer 22

a. Since this patient is receiving 120 MEDs daily, and is worried about opioid use/misuse, discuss a tapering schedule with him.

Clinicians and patients should periodically reevaluate the risks and benefits of chronic opioid therapy for pain. His current dose is 120 MEDs daily - a dose that places him at risk for harm. The CDC recommends avoiding opioid doses >/= 90 MEDS.

The patient has expressed concern - this seems like a good time to try a taper, at least down to 90 MEDs. There is no evidence of the superiority of one taper regimen over another. It could be 10% weekly or monthly. It could be 5% monthly or bimonthly. He is dependent - go slow to avoid harm from withdrawal symptoms.

While you can add APAP or an NSAID around the clock, first evaluate his risks from harm. It may be that he is not a good candidate for an NSAID. If an NSAID is indicated, consider naproxen or another long-acting NSAID. Adding an NSAID is fine, but aggressive titration of his opioid downward will likely result in uncomfortable w/d symptoms and treatment failure.

Question 23

Ketamine is indicated in patients with opioid tolerance during the perioperative period.
a. True
b. False

Answer 23

a. True

According to Consensus Guidelines on the Use of Ketamine Infusions for Acute Pain Management (from the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine (AAPM), and the American Society of Anesthesiologists), ketamine may be used perioperatively in patients with opioid tolerance. It may also be used as an analgesic adjunct in patients with opioid tolerance who are experiencing sickle cell crisis and in patients who have OSA. The guidelines suggest that pregnancy is a contraindication for ketamine use. Other contraindications include poorly controlled cardiovascular disease, psychosis, severe hepatic disease, and elevated intracranial or intraocular pressure.

Question 24

Out of every 10 people who use marijuana (illicit, recreational, medical), how many will become addicted?
a. all 10
b. 0
c. 1
d. 3

Answer 24

c. 1

Research says that about 1 in 10 people who use marijuana may become addicted. This is the same rate as alcohol.

Addiction rates increase in adolescents who use marijuana to 1 in 6 when use begins before age 18. These rates are similar to cocaine.

Current strains of marijuana have much higher levels of THC than 10-25 years ago. Some estimate it about 10x higher than the drug cultivated in the 1970s. The higher levels of THC today may lead to higher rates of addiction.

In the mid 1970s, average THC levels of seized marijuana were less than 1%

By 1985: 3.5%

By 2006: 8.8%

By 2009: 10.1%

This 10-fold increase in potency has coincided with:

• Increased emergency room admissions with marijuana
• Increased admissions to drug treatment programs for marijuana addiction, especially among teens.

Question 25

What problems can marijuana cause during pregnancy and post-birth. Check as many as apply.
a. It can place your APRN license at risk if you prescribe it for mothers, fathers, or other adults
b. It can contaminate breast millk
c. Lower birth weight
d. preterm or stillbirth
e. Increase behavioral and attention problem in the child.

Answer 25

a. It can place your APRN license at risk if you prescribe it for mothers, fathers, or other adults
b. It can contaminate breast milk
c. Lower birth weight
d. preterm or stillbirth
e. Increase behavioral and attention problem in the child.

c, d, and e are seen in newborns, and the brain changes persist. Even small amounts of THC can wind up in breast milk and affect a baby’s development. Studies suggest secondhand smoke from marijuana can affect vulnerable people - like babies!

For mom: research shows that marijuana use can lead to worse education outcomes and lower career achievement, leading to reduced life satisfaction.

In the past decade, a significant body of research has demonstrated the risks of marijuana and driving, with marijuana uses at minimum doubling their risk of crash while under the influence of THC. We do not know what an unsafe level of THC is.

THC can affect work performance and is among substances that employers ban or test for. Marijuana remains illegal at the federal level. In Ohio, only physicians can prescribe medical marijuana and only for certain conditions.

Question 26

Tai chi is effective for treating back pain, fibromyalgia and OA.
a. True
b. False

Answer 26

a. True

According to Tong (2018) in a systematic review in Clinician Reviews, tai chi is effective for treating these conditions and recommends tai chi as an exercise modality.

Question 27

Clinicians should recommend acupuncture to treat pts with chronic low back pain.
a. True
b. False

Answer 27

a. True

A trial should be considered. No harm has been associated with it.

Question 28

Adding chiropractic therapy to a treatment plan that already includes physical therapy, osteopathic manipulation and massage is more likely to bring benefit than adding a mind-body therapy.
a. True
b. False

Answer 28

b. False

Just as with choices in drugs, clinicians who treat chronic pain should use treatments from different categories and avoid more than one treatment from the same category.

Adding chiropractic therapy is one more structural therapy to osteopathic, PT, and massage and less likely to add signficant benefit.

Use mind-body therapy.

Question 29

Massage therapy, when used as a treatment for chronic pain may cause a flare of myfascial pain in pts with central sensitization.
a. True
b. False

Answer 29

a. True

Althouigh massage therapy is safe, more aggressive massage therapy treatmetns can cause pain in select pts who demonstrate central sensitization to pain.

Question 30

Progressive muslce relaxation is effective to reduce pain in pts with arthritis.
a. True
b. False

Answer 30

a. True

Also effective for those with low back pain.

Progressive muscle relaxation is a technique of serially tightening and releasing different muscle groups to induce relaxation and patietns with arthritis and low back pain have the strongest response/most pain reduction.

Question 31

Massage therapy provides long0term chronic pain relief.
a. True
b. False

Answer 31

b. Flase

Massage therapy, in the majority of literature, provides short or immediate pain relief.

Question 32

Spinal manipulation does not relieve low back pain.
a. True
b. False

Answer 32

b. False

It does provide relief in some pts and is considered a therapy worth a trial in all pts with this condition.