Pain Management and Substance Abuse

Question 1

Acute v. Chronic Pain

Answer 1

Acute - new onset less than 3 months

Chronic - persists for more than 3 months or past time of expected healing / resolution and may be result of chronic inflammation or other underlying cause

Question 2

MME

Answer 2

morphine miligram equivalents. A way to calculate the amount of opioids accounting for differences in effect, type, strength.

Question 3

When to prescribe naloxone with pain medications

Answer 3

If the MME is 50 or more, consider naloxone for the patient to have in case of overdose

Question 4

How often should patients with pain on controlled medications be seen?

Answer 4

At least every three months, more often for higher MME

Question 5

How does substance abuse impact care plans?

Answer 5

Higher rates of depression, associated health problems. Patients already having (or had) use disorder are at greater risk for overdose and misuse. Adding naloxone is recommended in case of overdose.

Question 6

Back Pain Management

Answer 6

ACP recommends heat, massage, acupuncture, spinal manipulation, NSAIDs, TENS, muscles relaxers before opioids in most musculoskeletal pain

Question 7

How do you know what a NP is allowed to prescribe?

Answer 7

Vary from state to state as state laws govern prescribing authority for NPs. In states that require a collaborating physician, your prescribing ability is also tied to the physician’s prescribing rules. Finally, some employers can impose additional limits on prescribing.

Question 8

Relationship between prescribing practices and opioid overdoses

Answer 8

long term opioid therapy is associated with higher risk of abuse / dependence

Question 9

recommendations for chronic pain management

Answer 9

Consider full range of therapeutic options. Opioids are effective for acute pain, but less evidence that they work for chronic pain.

CBT and non-opioids are effective as are exercise / physical therapy and preferred

Question 10

Long term opioid therapy

Answer 10

use of opioids on most days for more than 3 months

Question 11

CDC recommendations on opioid prescriptions?

Answer 11

No one year difference in extended release use or escalating dose schemes.

If pain doesn’t meaningfully improve in one month of opioids, it is unlikely to work long-term

Establish treatment goals first, except in cancer / palliative care

Counsel on side effects, risks of misuse

Question 12

CDC recommendations for calculating opioid prescriptions?

Answer 12

Use intermediate release, not extended release/long acting

Prescribe lowest effective dose and reassess in 1-4 weeks

do not prescribe opioids and benzos

Re-evaluate risks if going above 50 MME, avoid going above 90 MME

Acute pain should start at lowest dose, rare to need more than 7 days (3 is best)

Include mitigation and risk plans and review other medications / risk (sleep apnea is often overlooked as risk)

Test for other illicit drugs

Taper down, do not abruptly discontinue

Question 13

Leading cause of accidental death in the US?

Answer 13

Drug overdose

Question 14

Key points to prevent substance abuse in young adults

Answer 14

solid bonds and family support, healthy beliefs, strong values, effective coping strategies, education / awareness, participation in prevention program,

Question 15

Medications used to treat opioid use disorder

Answer 15

Methadone
Buprenorphine
Naltrexone

Question 16

Buprenorpine

Answer 16

Partial opioid agonist. Activates receptors less strongly, as effective as methadone but does not require prescription from approved treatment center like methadone. Must be given at higher dose (16mg a day or more). Preferred in pregnancy.

Question 17

Naltrexone

Answer 17

Opioid antagonist. Blocks activation of receptors, poorly adhered to but available as injectable long acting form. Patient should be fully detoxified first.

Question 18

Methadone

Answer 18

synthetic opioid agonist that eliminates withdrawal symptoms by activating receptors slowly and produces no euphoria.

Question 19

Naloxone

Answer 19

Opioid antagonist used to treat opioid overdose. Not used for routine treatment of opioid abuse.

Question 20

MME Conversions

Answer 20

Oxycodone = 1.5 MME
Hydromorphone = 4 MME
Fentanyl (Transdermal) = 2.4 MME
Hydrocodone = 1 MME
Oxymorphone = 3 MME
Codeine = 0.15 MME
Methadone = 4 MME per 20 mg (so 80 mg/day of methadone is 12x MME)