Week 2 Exam: NR565 / NR 565 (Latest 2026 / 2027) Advanced Pharmacology Fundamentals | Questions & Answers | 100% Correct | Grade A - Chamberlain

Week 2 Exam: NR565 / NR 565 (Latest 2026 / 2027) Advanced Pharmacology Fundamentals | Questions & Answers | 100% Correct | Grade A - Chamberlain Question: Nurse practitioner prescriptive authority is regulated by: Answer The State Board of Nursing Question: The benefits to the patient of having an Advanced Practice Registered Nurse (APRN) prescriber include: Answer Nurses care for the patient from a holistic approach and include the patient in decision making regarding their care. Question: Clinical judgment in prescribing includes: Answer Factoring in the cost to the patient of the medication prescribed Question: Criteria for choosing an effective drug for a disorder include: Answer Consulting nationally recognized guidelines for disease management Question: Nurse practitioner practice may thrive under health-care reform because of: Answer The demonstrated ability of nurse practitioners to control costs and improve patient outcomes Question: The U.S. Food and Drug Administration regulates: Answer The official labeling for all prescription and over-the-counter drugs Question: The U.S. Food and Drug Administration approval is required for: Answer Medical devices, including artificial joints Question: An Investigational New Drug is filed with the U.S. Food and Drug Administration: Answer Prior to human testing of any new drug entity Question: Phase IV clinical trials in the United States are also known as: Answer Postmarketing research Question: Off-label prescribing is: Answer Legal if there is scientific evidence for the use Question: The U.S. Drug Enforcement Administration: Answer Registers manufacturers and prescribers of controlled substances Question: Drugs that are designated Schedule II by the U.S. Drug Enforcement Administration: Answer May not be refilled; a new prescription must be written Question: Precautions that should be taken when prescribing controlled substances include: Answer Using tamper-proof paper for all prescriptions written for controlled drugs Question: Strategies prescribers can use to prevent misuse of controlled prescription drugs include: Answer Use of chemical dependency screening tools Firm limit-setting regarding prescribing controlled substances Practicing "just say no" to deal with patients who are pushing the provider to prescribe controlled substances Question: Behaviors predictive of addiction to controlled substances include: Answer Stealing or borrowing another patient's drugs Question: Medication agreements or "Pain Medication Contracts" are recommended to be used: Answer Universally for all prescribing for chronic pain Question: A prescription needs to be written for: Answer Legend drugs Most controlled drugs Medical devices Question: Michael asks you about why some drugs are over-the-counter and some are prescription. You explain that in order for a drug to be approved for over-the-counter use the drug must: Answer Be safe and labeled for appropriate use Have a low potential for abuse or misuse Be taken for a condition the patient can reliably self-diagnose Question: In the United States, over-the-counter drugs are regulated by: Answer The U.S. Food and Drug Administration Center for Drug Evaluation and Research Question: As drugs near the end of their patent, pharmaceutical companies may apply for the drug to change to over-the-counter status in order to: Answer Continue to make large profits from their blockbuster brand-name drug New over-the-counter drug ingredients must undergo the U.S. Food and Drug Administration New Drug Application process, just as prescription drugs do. 1. True 2.False Answer True The ailment that generates the greatest over-the-counter annual drug sales is: Answer Cough and colds When obtaining a drug history from Harold, he gives you a complete list of his prescription medications. He denies taking any other drugs, but you find that he occasionally takes aspirin for his arthritis flare ups. This is an example of: Answer A common misconception that intermittently taken over-the counter medications are not an important part of his drug history Common over-the-counter pain relievers such as acetaminophen or ibuprofen: Answer Are harmful if taken in higher than recommended amounts The Combat Methamphetamine Epidemic Act, which is part of the 2006 U.S. Patriot Act: Answer Restricts the sales of drugs that contain methamphetamine precursors, including a daily and 30 day limit on sales When prescribing a tetracycline or quinolone antibiotic it is critical to instruct the patient: Answer Not to take antacids while on these medications, as the antacid decreases absorption Henry presents to clinic with a significantly swollen, painful great toe and is diagnosed with gout. Of the following, which would be the best treatment for Henry? Answer Low-dose colchicine Patient education when prescribing colchicine includes: Answer Colchicine always causes some degree of diarrhea. Larry is taking allopurinol to prevent gout. Monitoring of a patient who is taking allopurinol includes: Answer BUN, creatinine, and creatinine clearance Phil is starting treatment with febuxostat (Uloric). Education of patients starting febuxostat includes: Answer Gout may worsen with therapy. Sallie has been taking 10 mg per day of prednisone for the past 6 months. She should be assessed for: Answer Osteoporosis Patients whose total dose of prednisone will exceed 1 gram will most likely need a second prescription for: Answer Omeprazole, a proton pump inhibitor to prevent peptic ulcer disease Daniel has been on 60 mg of prednisone for 10 days to treat a severe asthma exacerbation. It is time to discontinue the prednisone. How is prednisone discontinued? Develop a tapering schedule to slowly wean Daniel off the prednisone. Patients with rheumatoid arthritis who are on chronic low-dose prednisone will need co treatment with which medications to prevent further adverse effects? A bisphosphonate Calcium supplementation Vitamin D Patients who are on or who will be starting chronic corticosteroid therapy need monitoring of: Serum glucose Patients who are on chronic long-term corticosteroid therapy need education regarding: Reporting black tarry stools or abdominal pain All nonsteroidal anti-inflammatory drugs (NSAIDS) have an FDA Black Box Warning regarding: Potential for causing life-threatening GI bleeds Jamie has fractured his ankle and has received a prescription for acetaminophen and hydrocodone (Vicodin). Education when prescribing Vicodin includes: He should not take any other acetaminophen-containing medications. When prescribing NSAIDS, a complete drug history should be conducted as NSAIDs interact with these drugs: Warfarin, an anticoagulant Josefina is a 2-year-old child with acute otitis media and an upper respiratory infection. Along with an antibiotic she receives a recommendation to treat the ear pain with ibuprofen. What education would her parent need regarding ibuprofen? Josefina needs to be well-hydrated while taking ibuprofen. Henry is 82 years old and takes two aspirin every morning to treat the arthritis pain in his back. He states the aspirin helps him to "get going" each day. Lately he has had some heartburn from the aspirin. After ruling out an acute GI bleed, what would be an appropriate course of treatment for Henry? Add an H2 blocker such as ranitidine to his therapy. The trial period to determine effective anti-inflammatory activity when starting a patient on aspirin for rheumatoid arthritis is: 4 to 6 days Patients prescribed aspirin therapy require education regarding the signs of aspirin toxicity. An early sign of aspirin toxicity is: Tinnitus Monitoring a patient on a high-dose aspirin level includes: Salicylate level Complete blood count Urine pH Patients who are on long-term aspirin therapy should have ______ annually. Complete blood count Different areas of the brain are involved in specific aspects of pain. The reticular and limbic systems in the brain influence the: Motivational aspects of pain Patients need to be questioned about all pain sites because: Patients tend to report the most severe or important in their perception. The chemicals that promote the spread of pain locally include: Neurokinin A Narcotics are exogenous opiates. They act by: Attaching receptors in the afferent neuron to inhibit the release of substance P Age is a factor in different responses to pain. Which of the following age-related statements about pain is NOT true? 1. Preterm and newborn infants do not yet have functional pain pathways. 2. Painful experiences and prolonged exposure to analgesic drugs during pregnancy may permanently alter neuronal organization in the child. 3. Increases in the pain threshold in older adults may be related to peripheral neuropathies and changes in skin thickness. 4. Decreases in pain tolerance are evident in older adults. 1. Preterm and newborn infants do not yet have functional pain pathways. Which of the following statements is true about acute pain? Referred pain is present in a distant site for the pain source and is based on activation of the same spinal segment as the actual pain site. One of the main drug classes used to treat acute pain is NSAIDs. They are used because: Inflammation is a common cause of acute pain. Opiates are used mainly to treat moderate to severe pain. Which of the following is NOT true about these drugs? Opiates stimulate only mu receptors for the control of pain. If interventions to resolve the cause of pain (e.g., rest, ice, compression, and elevation) are insufficient, pain medications are given based on the severity of pain. Drugs are given in which order of use? Non-opiate, increased dose of non-opiate, opiate The goal of treatment of acute pain is: Reduction or elimination of pain with minimum adverse reactions Which of the following statements is true about age and pain? Acetaminophen is especially useful in both children and adults because it has no effect on platelets and has fewer adverse effects than NSAIDs. Pain assessment to determine adequacy of pain management is important for all patients. This assessment is done to: Determine if the diagnosis of source of pain is correct Determine if the current regimen is adequate or different combinations of drugs and non-drug therapy are required Determine if the patient is willing and able to be an active participant in his or her pain management Pathological similarities and differences between acute pain and chronic pain include: Chronic pain has a predominance of C-neuron stimulation. A treatment plan for management of chronic pain should include: Negotiation with the patient to set personal goals for pain management Discussion of ways to improve sleep and stress An exercise program to improve function and fitness Chronic pain is a complex problem. Some specific strategies to deal with it include: Scheduling return visits on a regular basis rather than waiting for poor pain control to drive the need for an appointment Chemical dependency assessment is integral to the initial assessment of chronic pain. Which of the following raises a "red flag" about potential chemical dependency? Multiple times when prescriptions are lost with requests to refill The Pain Management Contract is appropriate for: Patients with chronic pain who will require long-term use of opiates Types of Acute Pain -Referred Pain • Pain that is present in an area removed or distant from its point of origin -Acute Somatic Pain • Arises from connective tissue, muscle, bone & skin • Sharp & localized or dull & non-localized • Responds best to: acetaminophen, corticosteroids, NSAIDs, opiates, local anesthetics, ice, massage -Acute visceral pain • Pain in the internal organs & abdomen • Poorly localized (C-fibers) • Radiates • Most responsive to opiates • May also use corticosteroids, NSAIDs *rated by severity inflammatory response -inflammation • redness • swelling • heat • pain chemokines small proteins cells release as a signaling mechanism -best known for their ability to stimulate the migration of cells, most notably white blood cells (leukocytes). mast cells -release histamine • goes to endothelial cells that line capillaries, makes capillaries larger (vasodilation), causing swelling, capillary walls become more porous (things get through more easily) first responders phagocytes neutrophils diapedesis the passage of blood cells through the intact walls of the capillaries, typically accompanying inflammation. extravasation escape of fluid from a blood vessel into surrounding tissue pain is influenced by: gender, genetics, social, cultural, and personal factors Acute pain has an occurrence of fewer than __________ three months -often precipitated by trauma & acute medical conditions or tx Treatment goals about pain relief: Considerations -reducing the intensity of pain while enhancing physical & psychological functioning -common goal is to resume the activities of daily life -Complete elimination of pain is often not realistic if the source of pain continues to exist • finding the lowest effective dose to achieve tolerable pain levels is paramount -Non-pharmacological treatments may also be considered to promote comfort Appropriate selection of medications includes: -Patient factors • age, ethnicity, gender, the presence of hepatic and/or renal impairment, genetic polymorphisms, and/or coexisting cardiorespiratory or cerebrovascular disease -Drug factors • drug metabolism, receptor binding strength, potential for drug-drug interactions, and/or co administration with other CNS depressants commonly used agents for acute pain management -Opioids -Acetaminophen -NSAIDs -Salicylates -COX-2 Inhibitors Opioids -Drug Indication: • Moderate to severe pain -Dosing Considerations: • Opioid naïve vs chronic pain pt -Adverse Drug Reactions: • Sedation, drowsiness, mental clouding; constipation; nausea & decreased appetite; sexual dysfunction; tolerance/ dependency • ADRs worse when combined with alcohol or benzodiazepines -Patient Education: • Clear instructions regarding safety & ADRs • discuss length of tx; discuss non-opiate therapy -Monitoring: • Is pain medication effective? Is the dose being tapered or discontinued? If not reassess cause of pain. -Drug Interaction: • Any other drug that causes a sedative effect. Acetaminophen -Drug Indication: • Mild to moderate pain -Dosing Considerations: Dose appropriately • Mild pain: 325 to 650 mg q4-6 hrs • Children: 10/kg/mg every 4 to 8 hours • Moderate pain: 500 to 1,000 mg q4-6 hrs drugging indication used for fever • Max: 4 gms/ 24 hrs use for fever &/or pain • Children: 15 mg/kg/dose -Adverse Drug Reactions: • Usually well-tolerated • Hepatic injury with overdose • Renal disease with chronic use -Drug interactions: • alcohol -Patient Education: • Do not exceed maximum dose (4gm/24 hours) -Monitoring: • Monitor for effectiveness. May need to add an opioid agonist -Drug Interaction: • None NSAIDS -Drug Indication: • Use for fever &/or pain • inflammation as an antiplatelet -Avoid in pregnancy & renal dysfunction -Dosing Considerations: -Ibuprofen dosing: • 200-800 mg/ dose every 6-8 hrs • Maximum: 3,200 mg/day • Children: 5 to 10 mg/kg/dose (Pediatric dosage maximum is 40mg/kg/day) -Naproxen dosing: • 500mg Then 500mg every 12 hours or 250mg every 6-8 hrs • Maximum: 1,250 mg/day •-Adverse Drug Reactions: • Gastrointestinal (GI) upset, dyspepsia, abdominal pain, GI bleed, fluid retention, edema, hypertension, renal damage Salicylates -Drug Indication: • Use for fever, pain, inflammation, antiplatelet use. -Avoid in pregnancy, children, & renal dysfunction. -Dosing Considerations: • Dosing for pain: 325 mg to 1,000 mg q4-6 hrs (max: 4 gm/day) • Arthritis: 3.6 to 5.4 gm/day in divided doses -Adverse Drug Reactions: • GI upset, dyspepsia, abdominal pain, GI bleed, renal impairment, tinnitus -Monitoring: • Monitor for effectiveness. May need to add an opioid agonist COX-2 Inhibitors -Drug Indication: • Use for pain &/or inflammation. -Avoid in pregnancy, children, renal dysfunction, pain after coronary artery bypass graft surgery, use caution in heart failure, hypertension, & fluid retention -Dosing Considerations: • pts with renal impairment & cardiovascular disease -Adverse Drug Reactions: • GI upset, abdominal pain, GI bleed, edema, HTN, thrombi events (myocardial infarction & stroke), fluid retention, renal impairment, poor metabolizers of CYP2C9 -Patient Education: • Avoid alcohol use. • Avoid aspirin & OTC medications. • May increase risk of myocardial infarction or stroke -Monitoring: • Monitor for effectiveness. May need to add an opioid agonist. -Drug Interaction: • Drugs that inhibit CYP2C9, drugs that are metabolized by CYP2D6, increased risk of renal failure with angiotensin-converting enzyme inhibitors Chronic Pain Management Pain that persists beyond three months or the expected time of healing is chronic -Agents used to manage are often the same ones used to manage acute pain Special Considerations in Opioid Medication Management -An opioid is an agent that works at an opioid receptor, is a derivative from opium -includes full agonists, partial agonists, mixed agonist-antagonists, and antagonists -Opioids have a variable affinity for certain receptors -absorption and therapeutic effects are impacted by the route and individual characteristics. -Short-acting opioids should be used exclusively for the treatment of acute pain in opioid naïve patients -Titration to optimal therapeutic effects is faster, safer, and easier with immediate-release opioids -Unintentional overdose may be more likely when opioid therapy begins with long-acting opioids in opioid naïve patients. Guidelines in Opioid Prescribing -three main principles to improve opioid prescribing • determining when to initiate or continue opioids for chronic pain • opioid selection, dosage, duration, follow-up, & discontinuation • assessing risk & addressing harms of opioid use Conversion of opioid analgesia formulations -requires extreme caution & consideration of the unique characteristics of the patient -Use of conversion calculators • requires consideration of the specific patient characteristics & variability -Referral to a pain specialist is required for pts who take 120mg/day of morphine milligram equivalents 12 essential considerations for safe pain management 1. Opioids are not first-line therapy 2. Establish goals for pain & function 3. Discuss risk & benefits 4. Use IR opioids when starting 5. Use the lowest effective dose 6. Prescribe short durations for acute pain 7. Evaluate benefits & harms frequently 8. Use strategies to mitigate risk 9. Review PDMP data 10. Use urine drug testing 11. Avoid concurrent opioid & benzodiazepine prescribing 12. Offer tx for opioid disorder Opioid Use Disorder -2017, federal gov declared the opioid crisis a national emergency -DSM-IV describes opioid use disorder as a pattern of use that leads to significant impairment or distress • Typically marked by unsuccessful efforts to reduce or control use resulting in the inability to fulfill work, school, or home responsibilities Opioid use -Opioid use creates high levels of positive reinforcement, increasing the likelihood of continued use -often a chronic lifelong disorder -serious consequences such as disability and death -can lead to physical dependence in only 4-8 weeks Opioid use disorder can lead to: severe withdrawal symptoms, uncontrolled pain, as well as psychological distress, and suicidal ideation Risk Evaluation and Mitigation Strategy (REMS) & Naloxone -REMS • drug safety program to reinforce safe medication use • issued by the U.S. Food and Drug Administration (FDA) • Goals: ensure that medication is used according to FDA-approved prescribing & that the benefits outweigh the risk of misuse & abuse -FDA requires drug manufacturers to add recommendations about naloxone to prescribing information • used to quickly reverse an opioid overdose Preventing Opioid Overdose Deaths -Substance Abuse and Mental Health Service Administration (SAMHSA) identifies five strategies to prevent overdose deaths: • encourage providers, persons at high risk, their family members, & others to learn how to prevent & manage opioid overdose • ensure access to tx for individuals who are misusing opioids or have a SUD • ensure ready access to naloxone • call 911 for any suspected signs of opioid OD; administer life-saving services until emergency medical help arrives • encourage prescribers to use state PDMPs PDMPs -Prescription Drug Monitoring Programs • electronic databases enable providers to access info regarding a Pt's prescription hx of controlled substances • shown promising results in changing prescribing behaviors, decreasing the use of multiple providers by patients, and decreasing substance abuse treatment admissions Applying CDC's Guidelines for Prescribing Opioids -use a validated assessment tool to establish a baseline for evaluating the effectiveness of tx -establish criteria for initiating opioids & clarify how therapy will be discontinued if an opioid is prescribed & the risks start to outweigh the benefits -calculate the morphine milligram equivalent (MME) to help dose medications appropriately and refer to pain specialists as indicated. assess potential harms of opioid therapy four actions to take: 1. Assess -Evaluate for factors that could increase your pt's risk for harm from opioid therapy such as: • Personal or family hx of SUD • Anxiety or depression • Pregnancy • Age 65+ • COPD or other underlying respiratory conditions • Renal or hepatic insufficiency 2. Check -Consider urine drug testing for other prescription or illicit drugs & check your state's PDMP for: • Possible drug interactions (such as benzodiazepines) • High opioid dosage (≥50 MME/day) • Obtaining opioids from multiple providers 3. Discuss -Ask your patient about concerns & determine any harms they may be experiencing such as: • Nausea or constipation • Feeling sedated or confused • Breathing interruptions during sleep • Taking or craving more opioids than prescribed or difficulty controlling use 4. Observe -Look for early warning signs for overdose risk such as: • Confusion • Sedation • Slurred speech • Abnormal gait opioid use disorder (OUD) -diagnosed by the DSM-5 assessment criteria & not speculation alone -tx option • medication assisted therapy (MAT) Morphine Milligram Equivalents -an opioid dosage's equivalency to morphine. -often used as a gauge of the overdose potential of the amount of opioid that is being given at a particular time. -Calculating the total daily dosage of opioids helps ID pts who may benefit from closer monitoring, reduction or tapering of opioids, prescribing of naloxone, or other measures to reduce risk of overdose. Calculating MME 1. Determine the total daily amount of each opioid the patient takes. 2. Convert each opioid to MMEs by multiplying the daily dosage for each opioid by its conversion factor. 3. Add all opioid MMEs together. -Codeine: 0.15 -Fentanyl transdermal (in mcg/hr): 2.4 -Hydrocodone: 1 -Hydromorphone: 4 -Methadone: • 1-20 mg/day: 4 • 21-40 mg/day: 8 • 41-60 mg/day: 10 • =61-80 mg/day: 12 -Morphine: 1 -Oxycodone: 1.5 -Oxymorphone: 3 A new patient is suffering from chronic lower back pain. For his pain, he takes ER oxycodone 30 mg BID. What is the daily MME that your patient has been prescribed? 90 MME per day total Rationale: The first step is to determine the total daily amount of each prescription. 30 mg X 2 = 60 mg oxycodone/day Oxycodone has a conversion factor of 1.5. 60 mg X 1.5 = 90 MME per day total Dosages =50 MME per day increase risk for opioid-related harms. USE EXTRA CAUTION with: methadone, transdermal fentanyl, and buprenorphine: -Dosing methadone is complicated because of its long and unpredictable half-life, as well as its association with QTc prolongation and potential cardiac arrhythmia. -Transdermal fentanyl is dosed in mcg/hr instead of mg/day, and absorption is affected by heat and other factors. -relation between dosage and overdose risk is different for buprenorphine. The MME thresholds of 50 and 90 MME do not apply, and there isn't a calculation to identify equivalency. -Conversion factors for drugs used as part of medication-assisted treatment for opioid use disorder should not be evaluated using opioid dosage indexes intended for chronic pain. Therefore, buprenorphine is not included in CDC's MME table. Why not start with ER/LA opioids? -Patients may experience better pain control if they take opioids when needed rather than on a scheduled basis. -Taking opioids on a scheduled basis may contribute to tolerance & dose escalations. medical conditions that may pose serious and life-threatening risks with opioid use -Sleep-disordered breathing such as sleep apnea -Pregnancy -Renal or hepatic insufficiency -Age = 65 -Certain mental health conditions -SUD -Previous nonfatal overdose Titrating Opioids to =50 MME/day When considering increasing dosage to =50 MME/day: -Carefully reassess individual benefits and risks for such a dosage increase, including whether opioids are meeting the patient's treatment goals -Increase follow-up intervals to every 1 to 4 weeks -Consider offering naloxone and overdose prevention education to both patient and the patient's household members Avoid Titrating Opioids to ________ =90 MME/Day Providers should reevaluate benefits and harms with patients within _______ weeks of starting opioid therapy or a dose escalation. 1 to 4 weeks -provides an opportunity to minimize risks of long-term opioid use by discontinuing opioids among patients not receiving a clear benefit from these medications. Providers should reevaluate benefits and harms of continued therapy with patients every ________ or more frequently. 3 months Initiating ER/LA Opioids -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 • also includes methadone & transdermal fentanyl -Follow-up within 3 days is appropriate when initiating or increasing the dosage of methadone -Follow-up within 1 week is appropriate when initiating or increasing the dosage of other ER/LA opioids If the patient's dosage is increased to 5/325 mg oxycodone/acetaminophen QID PRN, what would the daily maximum MME be, assuming the patient takes the full four doses each day? Select the best answer. 15 MME/day 50 MME/day 30 MME/day 20 MME/day 30 MME/day Rationale: 5 mg oxycodone QID is 20 mg/day. When you multiply 20 by the conversion factor of 1.5, the result is 30 MME/day. A follow-up visit within two weeks is appropriate for which of the following reasons? Select all that apply. a. Providers should reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or a dose escalation b. This patient's new dosage is above the 50 MME/day threshold and therefore should be closely monitored c. It is less likely that continued opioid therapy will be effective for this patient if she is not receiving relief 1 month after starting an opioid d. Reassessment of pain and function within 1 month of initiating opioids provides an opportunity to minimize risks of long-term opioid use a c d High-Dosing Risks add risk without clear benefit. Furthermore, benefits of high-dose opioids for chronic pain have not been established. A randomized controlled trial found no difference in pain or function between liberal dose escalation and maintenance of current opioid dosage -increase risk of serious harm, including fatal and nonfatal overdose Dosage and Overdose Risk -Dosages =50 MME/day increase the risk of overdose by at least two-fold compared with dosages 20 MME/day. -Dosages greater than 100 MME/day increase overdose risk up to nine times. Considerations for the Use of ER/LA Opioids reserved for severe, continuous pain -considered only for patients who have received IR opioids daily for at least 1 week without improvement -used when treating end-of-life pain ER/LA opioids in combination with IR opioids should _________ be avoided Methadone is associated with: -cardiac arrhythmias and QTc prolongation -complicated pharmacokinetics and pharmacodynamics, including a long and variable half-life -peak respiratory depressant effect occurring later and lasting longer than its peak analgesic effect. -hard to taper and can interact with other drugs unpredictably. Transdermal Fentanyl -Even the lowest dose of transdermal fentanyl is too high for starting opioid therapy -Intermittent or as-needed doses are not possible -Absorption can be unreliable or variable • heat (e.g., hot showers/baths, fevers) can release medication suddenly, leading to overdose Indications for Tapering and Discontinuation of IR Opioids -The patient has no sustained clinically meaningful improvement in pain and function. -The patient is taking opioid dosages =50 MME/day without evidence of benefit. -The patient is on concurrent benzodiazepines that cannot be tapered. -The patient requests dosage reduction or discontinuation. -The patient experiences overdose, other serious adverse events, and/or warning signs of such events. Tapering Considerations and Precautions -reasonable starting regimen would be a reduction of 10% of the original dose/week or month -Do not try to taper too quickly, Slower tapers can help minimize withdrawal symptoms, Opioids may be stopped when taken less frequently than once a day. -Providers should discuss with patients undergoing tapering the increased risk for overdose on abrupt return to a previously prescribed higher dose. -Symptoms of withdrawal can be treated supportively if necessary (e.g., antidiarrheal medications). -taking both immediate-release and long-acting opioids, allow them to choose whether long acting or short-acting opioids are tapered first. Many patients choose to taper long-acting opioids first. Patients taking both benzodiazepines and opioids concurrently can also be offered the choice of tapering their benzodiazepine first, if prescribed, although many patients may find it more practical to taper the opioid first. -monitor depression, anxiety, and insomnia before and during the tapering process. important to avoid starting or increasing dosage of a benzodiazepine. Patient: Williams, Jim DOB: 10/09/1965 Chief complaint/reason for visit: Ongoing hip pain, with poor daily function. Past Medical History: Hip painOngoing for the past 5 years, following a strain injuryPrevious provider recommended physical therapy, although patient admits to not following through with recommended exercisesCurrently takes extended-release oxycodone 30 mg 2 times daily Social History: Self-employed truck driver Non-smoker, drinks occasionally, no illicit drug use Which of the following statements are correct considering this patient's current situation and medical history? Select all that apply. a. The patient's concern about "out-of-control" pain is realistic and warrants a dosage increase. b. The patient's current daily MME is potentially dangerous because it meets the established threshold of 90 MME/day. Dosages at or over this threshold increase the risk of overdose significantly. c. Better opti b c Rationale: This patient is currently taking 90 MME/day of oxycodone. Given the increased risk of overdose and lack of significant improvement in pain and function, increasing the dosage above 90 MME/day is not justifiable. The provider should optimize other therapies and work with the patient to taper opioids to lower dosages or to taper and discontinue opioids. Which of the following considerations are relevant for an opioid taper and/or discontinuation? Select all that apply. a. Providers should discuss the increased risk for overdose on abrupt return to a previously prescribed higher dose. b. Tapers should not be flexible and should involve a fixed weekly dosage reduction, to avoid having a patient change his or her mind about continuing with the taper. c. Tapering plans should be designed to address each patient's specific needs. d. A reasonable starting regimen would be a reduction of 30% of the original dose per week or month. e. Providers should optimize pain management to support the taper and/or discontinuation. a c e MME recommendations carefully reassess evidence of individual benefits and risks when increasing dosage to =50 morphine milligram equivalents (MME)/day; and should avoid increasing dosage to =90 MME/day or carefully justify a decision to titrate dosage to =90 MME/day. APPLYING CDC'S GUIDELINES FOR PRESCRIBING OPIOIDS: TREATING CHRONIC PAIN WITHOUT OPIOIDS -Nonopioid medications (i.e. NSAIDS) and nonpharmacologic treatments (i.e. yoga, heat) are the preferred methods for treating chronic pain such as osteoarthritis (OA). -Use communication techniques to facilitate a patient-centered approach • Compassion • Relationship-building APPLYING CDC'S GUIDELINES FOR PRESCRIBING OPIOIDS: ASSESSING AND ADDRESSING OPIOID USE DISORDER (OUD) -OUD is diagnosed by DSM-5 criteria -Medication assisted therapy (MAT) is available for OUD • Buprenorphine, naltrexone, or methadone • Consider offering naloxone if indicated (i.e. concurrent benzodiazepine use) -Patient and provider resources are available for the treatment of OUD from the CDC APPLYING CDC'S GUIDELINES FOR PRESCRIBING OPIOIDS: REDUCING THE RISKS OF OPIOIDS Objective strategies to monitor for drug diversion -Routine urine drug tests • medicine being prescribed, should be in the urine. If it is not in the urine, there should be a clear reason why it is not • allow for providers to see if there are illicit drugs present as well that could complicate treatment and would need to be discussed. APPLYING CDC'S GUIDELINES FOR PRESCRIBING OPIOIDS: DETERMINING WHETHER TO INITIATE OPIOIDS FOR CHRONIC PAIN -Criteria for prescribing opioids • Establish treatment goals • Determine how effectiveness will be evaluated • Outline a plan for discontinuation -Risks and benefits should be considered and discussed -Strategies to improve patient safety • MME calculation to inform dosage changes and reduce overdose risk • Use extra precautions when increasing to ≥50 MME per day • Avoid or carefully justify increasing dosage to ≥90 MME/day APPLYING CDC'S GUIDELINES FOR PRESCRIBING OPIOIDS: USING THE PDMP TO POMOTE PATIENT SAFETY IN OPIOID PRESCRIBING AND DISPENSING -Utilized by providers, state health departments, and pharmacists -Can help identify high risk patients and send proactive reports to providers • Helps identify if a patient is currently receiving a controlled substance from another provider APPLYING CDC'S GUIDELINES FOR PRESCRIBING OPIOIDS: RENAL AND HEPATIC CONSIDERATION -Patients with renal or hepatic insufficiency can experience greater peak effect and longer duration of action for medications, thereby reducing the dose at which respiratory depression and overdose may occur -patients ages 65 years and older, reduced renal function and medication clearance due to age can result in a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose. Drug Enforcement Agency: Regulation of Controlled Substances -The U.S. Department of Justice Drug Enforcement Agency (DEA) • coordinates with local, state, and federal agents to reduce illicit drug use • enacted the Controlled Substances Act (CSA) in 1970 to regulate drugs and other substances based on their potential for abuse and dependency Five schedules of controlled substances created, updated annually Classes of scheduled substances: narcotics, depressants, stimulants, hallucinogens, anabolic steroids • issues eligible providers with a registration number to write prescriptions for controlled substances Characteristics of a valid DEA number include: -DEA numbers consist of two letters followed by seven numbers: • first letter identifies the type of provider: A=before 1985; B=after 1985; F=after 2007; M=nurse practitioner or physician assistant • 2nd letter the 1st letter of the provider's last name at the time of initial registration Schedule I Drugs Substances or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse -Heroin, Lysergic Acid Diethylamide (LSD), marijuana (cannabis), 3, 4- Methylenedioxymethamphetamine (ecstasy), Methaqualone, and Peyote Schedule II Drugs Substances or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence -Combination products with less than 15 milligrams of hydrocodone per dosage unit (Vicodin), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), Meperidine (Demerol), Oxycodone (oxycontin) fentanyl, Dexedrine, Adderall and Ritalin. Schedule III Drugs Substances or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence. Schedule III drugs abuse potential is less than schedule I and Schedule II drugs but more than schedule IV. -Products containing less than 90 milligrams of codeine per dosage unit (Tylenol and codeine), ketamine, anabolic steroids, testosterone Schedule IV Drugs Substances or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. -Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol Schedule V Drugs Substances or chemicals are defined as drugs with lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive and analgesic purposes. -Cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, parepectolin Ethical Prescribing involves: -evaluating the risks and benefits associated with pharmacological therapy -obtaining informed consent -monitoring drug effects -Adherence to state laws ethical principles beneficence, nonmaleficence, respect for autonomy, and justice -should inform all prescription-writing