AMDG - DOH Pain Management Rules and 2015 Interagency Guideline CME Package

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DOH Pain Management Rules and 2015 Interagency Guideline CME Package

Select the item that best answers each question. Select only one item per question.

If you have not already done so, you may find it helpful to open the guideline in a new browser window, or print the guideline for reference, as you will be referring to it throughout.

PDF AMDG 2015 Interagency Guideline on Prescribing Opioids for Pain (1.75 MB PDF)


If you have not already done so, please be sure to watch the DOH Pain Management Rules Video (20 minutes). Clicking on the video icon below will take you to an external site in a new browser window. This video is housed on the GoToWebinar server and is viewable on demand, 24 hours a day, at no charge.

DOH Pain Rule Video

In this activity you might be asked to click on external link(s) to be able to answer the corresponding question. These links will open in a new browser window, and will not close you out of the activity by doing so.

Question 1:

A recent Agency for Healthcare Research and Quality (AHRQ) report found insufficient, evidence of effectiveness for chronic opioids, but strong evidence of dose-related severe potential harms. Chronic opioid analgesic therapy (COAT) may be associated with which of the following? (Answer on pages 7-8)

a.  Development of tolerance to its analgesic effects.
b.  Hyperalgesia.
c.  Physical dependence.
d.  Opioid use disorder, or addiction.
e.  All of the above.

Question 2:

Adverse events commonly associated with COAT include which of the following? (Answer on page 7)

a.  Sleep disordered breathing.
b.  Gingival hypertrophy.
c.  Falls and fractures in the elderly.
d.  Stevens-Johnson Syndrome.
e.  Answer a and c.

Question 3:

The 2015 AMDG opioid guideline introduces and defines Clinically Meaningful Improvement in Function (CMIF), which should accompany improvement in pain if the opioid therapy is effective. Which of the following meet the definition of CMIF? (Answer on page 9)

a.  Pain and function both improve by at least 10%.
b.  Function improves by at least 30%.
c.  Pain is reduced by 30%, but function has not improved.

Question 4:

Once initiated, COAT can be difficult to discontinue. The likelihood that a patient who uses opioids for 3 months will still be on opioids 5 years later is: (Answer on page 9)

a.  20%.
b.  40%.
c.  60%.
d.  80%.

Question 5:

Assessing the effectiveness of opioid treatment should entail tracking and documenting both functional improvement and pain relief. Which of the following tools are recommended as options to easily track function and pain? (Answer on pages 9-11)

a.  The Neck Disability Index and “Pain Faces Scales”.
b.  The Short Musculoskeletal Function Assessment and “Pain Faces Scales”.
c.  The two-item Graded Chronic Pain Scale and three-item PEG Assessment Scale.
d.  The QuickDash and Oswestry Disability Index.

Question 6:

When starting someone on COAT for chronic non-cancer pain, patient education regarding realistic expectations of the analgesic therapy should include which one of the following? (Answer on pages 6-14)

a.  Anticipate a small reduction in pain intensity, although some patients may achieve as much as a 30-50% reduction in pain.
b.  Anticipate complete or near-complete pain relief within the first few weeks of COAT.
c.  Instruction that the dose of COAT will be escalated every few weeks until the pain intensity rating is reduced to 3 out of 10, or less.
d.  A discussion of the strong research evidence for the long-term effectiveness and minimal side effects of COAT.

Question 7:

Although this guideline recommends obtaining a pain management consult before exceeding 120mg/day MED, four population-based studies show a strong association between overdose risk and total daily opioid dose. Which one of the following statements is true regarding the level of risk? (Answer on page 12)

a.  Opioid doses below 120mg/day MED are safe.
b.  There is up to a 9-fold increased risk at doses between 50-99mg/day MED compared to less than 20mg/day MED.
c.  There is no safe opioid dose, particularly in the presence of other risk factors, such as use of concurrent benzodiazepines.

Question 8:

In addition to medication, which of the following treatment(s) is/are recommended for managing chronic pain? (Answer on pages 14-15).

a.  Transcutaneous electrical nerve stimulation (TENS)
b.  Cognitive behavioral therapy.
c.  Rest.
d.  Mindfulness-based Stress Reduction (MBSR).
e.  Answer b and d.

Question 9:

For most pain conditions, non-opioid analgesics and adjuvant analgesics are equally or more effective with less risk for harm than opioids. Which one of the following statements about non-opioid analgesics is true? (Answer on pages 18-21)

a.  It is recommended to start with acetaminophen for mild to moderate pain.
b.  Tricyclic antidepressants (TCAs) are recommended for muscle spasm.
c.  Carisoprodol (SOMA) is recommended for use with opioids because of a synergistic effect.
d.  Benzodiazepines are recommended for chronic pain patients with insomnia.

Question 10:

Which statement below is TRUE regarding the non-specific “muscle relaxants” such as methocarbamol (Robaxin), cyclobenzaprine (Flexeril), and carisoprodol (Soma)? (Answer on pages 18-19)

a.  Carisoprodol is metabolized to meprobamate and it should be avoided due to the high risk for misuse and abuse.
b.  There is good evidence for the effectiveness of long term utilization of muscle relaxants to relieve chronic back pain.
c.  Cyclobenzaprine acts directly on the muscles, to prevent spasms.
d.  Methocarbamol is structurally similar to tricyclic antidepressants.

Question 11:

Which one of the following statements is TRUE regarding opioid use for acute pain? (Answer on page 22)

a.  Opioids are a suitable first choice for mild to moderate pain.
b.  Long acting opioids are appropriate for either acute or chronic pain.
c.  For minor surgical procedures, such as dental procedures (e.g., removal of impacted wisdom teeth), prescriptions of opioids should be limited to 2-3 days.
d.  Opioids are indicated for non-specific low back pain, headache or fibromyalgia.
e.  There are no good alternatives to opioids.

Question 12:

Which one of the following actions is NOT recommended to be performed and documented in the file when considering COAT? (Answer on pages 22-25)

a.  Assess whether opioid use in the acute phase resulted in clinically meaningful improvement in function.
b.  Check the PMP to ensure that the patient’s controlled substance history is consistent with the prescribing record.
c.  Screen for depression using the PHQ-9.
d.  Screen for PTSD using CAGE-AID.
e.  Administer a baseline urine drug test.

Question 13:

Which one of the following statements best describes what should be done with patients on COAT who present for elective surgery? (Answer on pages 26-28)

a.  Lower chronic opioid doses.
b.  Discontinue chronic opioids.
c.  Develop a post-operative taper plan for return to pre-operative doses.
d.  Consider escalation of doses pre-operatively.

Question 14:

Regarding proper disposal of controlled substances, which one of the following is the best way to dispose of unused opioids? (Answer on page 29)

a.  Return via an DEA-approved return site.
b.  Mixed in kitty litter and placed in the garbage.
c.  Returned to the pharmacy that dispensed them.
d.  Locked up safely for future use.

Question 15:

For patients who are on COAT prior to surgery, which one of the following is recommended at time of hospital discharge? (Answer on page 29)

a.  Prescribe new benzodiazepines, sedative-hypnotics, and anxiolytics to aid recovery from surgery.
b.  Inform patients and family on timeline for taper of added postoperative opioids.
c.  Prescribe 6 weeks of opioids for minor surgery.
d.  Explain that there is no significant risks with using alcohol and other CNS depressants with opioids.

Question 16:

Mr. Jones has chronic pain from arthritis and has been taking several opioids for nine months with a total daily MED of 100mg. Mr. Jones continues to have considerable pain, and his prescribing provider is considering increasing the total daily MED to 140mg. Before increasing the dose, the prescriber should do which one of the following? (Answer on page 33)

a.  Presume that there are no significant psychological issues or evidence of drug-seeking behaviors.
b.  Consider seeking an opioid management consultation only if the dose goes above 140mg MED.
c.  Consider prescribing naloxone as a preventive rescue medication and counsel family members or significant others who would be able to assist the patient if an overdose event were to occur.
d.  Get a pain consultation before exceeding 120mg/day MED.

Question 17:

The use of methadone for pain is complicated. According to the guideline, which one of the following statements is TRUE about methadone? (Answer on pages 33-34)

a.  Mentoring services for prescribing methadone are available for a small fee using the Providers’ Clinical Support System.
b.  Overdose deaths have been reported during initiation and conversion of pain patients to methadone treatment.
c.  QT prolongation and serious arrhythmia are observed when other opioids are added to methadone treatment.
d.  Methadone has linear pharmacokinetic and predictable clearance.

Question 18:

Not all patients benefit from opioids, and prescribers frequently face the challenge of reducing the opioid dose or discontinuing opioids altogether. Which one of the following statements about weaning opioids is CORRECT? (Answer on pages 36-38)

a.  A decrease by 25% of the original dose per week is usually well tolerated with minimal physiological adverse effects.
b.  Symptoms of an abstinence syndrome can be managed with clonidine 0.1-0.2 mg orally every 6 hours while monitoring often for significant hypotension and anticholinergic side effects.
c.  Providers should treat withdrawal symptoms with opioids or benzodiazepines after discontinuing opioids.
d.  Referral for counseling or other support during this period is not recommended if there are significant behavioral issues.

Question 19:

Which one of the following statements is TRUE about recognizing an Opioid Use Disorder?

a.  A patient with strong craving who takes opioids in larger amounts than intended meets DSM-5 criteria.
b.  Telling a patient that he is a "drug addict" is an effective way to get him to recognize a problem and accept help.
c.  A primary care provider should not attempt to assess a patient for opioid use disorder using DSM-5 criteria, but should always refer for consultation with an addiction specialist.

Question 20:

Opioid therapy can lead to the development of opioid use disorder. According to a recent study, the lifetime prevalence of DSM 5, prescription opioid use disorder among patients on chronic opioids is: (Answer on page 40).

a.  1%.
b.  10%.
c.  16%.
d.  21%.

Question 21:

Which of the following is TRUE about treatment for Opioid Use Disorder?

a.  Medication-assisted treatment and abstinence-based treatment are equally effective options for patients with chronic pain.
b.  Medication-assisted treatment leads to lower rates of illicit opioid use and likely reduces health care utilization and criminal justice involvement.
c.  The U.S. Drug Enforcement Administration (DEA) is recommended as a place to seek an expert physician mentor to assist with questions and concerns about treatment of substance use disorders.
d.  Methadone may be prescribed for Opioid Use Disorder in an office-based setting after obtaining a waiver.

Question 22:

Counseling is recommended before (preconception) and during pregnancy for women on COAT for which of the following reasons? (Answer on pages 42-44).

a.  To assess and educate about potential maternal, fetal, and neonatal risks.
b.  To plan for opioid detoxification during pregnancy.
c.  To plan a transition from opioids to NSAIDs.
d.  To develop a plan to consolidate all chronic opioids to short-acting opioids.

Question 23:

Regarding non-cancer pain in children and adolescents, which one of the following statements is true? (Answer on pages 45-47)

a.  There is good evidence for the safety and efficacy of opioids for chronic non-cancer pain in children and adolescents.
b.  Opioids are indicated for a small number of conditions in children and adolescents, such as osteogenesis imperfect and epidermolysis bullosa.
c.  Adolescents who are prescribed opioids do not need to be screened for risk of substance use disorder as long as their parents have been educated about the risks and appropriate safeguards are in place.
d.  Opioids should never be prescribed for infants and children with acute pain.

Question 24:

The initial recommended starting dose of an opioid in an older adult is which one of the following? (Answer on pages 47-49)

a.  25-50% higher than for pediatrics.
b.  25-50% lower than for younger adults.
c.  25-50% higher than for younger adults.
d.  The same as for younger adults.

Question 25:

The term “chronic cancer-related pain” (CCRP) is defined as pain in a cancer survivor due to earlier treatment for active cancer or residual effects from the previous tumor. Which of the following is NOT included in this classification?  (Answer on page 49)

a.  Radiation treatment effects.
b.  Chemotherapy-induced peripheral neuropathy.
c.  Residual effects from the previous tumor.
d.  Compression fractures.

Question 26:

Using the Opioid Dose Calculator (*), the morphine equivalent dose for oxycodone extended release, 20mg twice daily plus hydrocodone/APAP 5/325 1 every 8 hours equates to which of the following? (Answer in Appendix A)

a. 55 mg oral morphine equivalents.
b. 75 mg oral morphine equivalents.
c.  90 mg oral morphine equivalents.

d.  20 mg oral morphine equivalents.

* To answer this question, Microsoft Excel Version 97 or newer is required to view the Opioid Dosing Calculator. If you do not have Microsoft Excel, a free viewer is available for download from You may also answer this question by referring to Table 15, on page 57 of the Guideline.

Question 27:

The Washington State Prescription Drug Monitoring Program (PMP) offers key clinical benefits. Providers or their qualified delegated staff should access the PMP in which of the following situations? (Answer in Appendix C)

a.  Prior to prescribing opioids for a new episode of pain or for transferred patients who are already using opioids.
b.  During the transition from subacute to COAT.
c.  Regularly for patients who are being treated for addiction disorder.
d. When conducting a preoperative history and medical exam.
e.  When there is evidence of aberrant behaviors.
f.  All of the above.

Question 28:

Besides the prescriber, who in the hospital or clinic can access the PMP in Washington? (Answer in Appendix C)

a.  Front office staff during insurance authorization.
b.  Staff working in medical record department.
c.  Licensed medical assistants and nurses if delegated by the prescriber.
d.  Any hospital or clinic staff member as long as they are a part of the care team.

Question 29:

Regarding urine drug testing (UDT), which one of the following statements is TRUE? (Answer in Appendix D):

a.  While prescribing COAT, the prescriber should randomly repeat testing at the approximate frequency determined by the patient’s risk category based on the ORT or similar screening tool.
b.  For patients at moderate risk of opioid addiction by ORT, the recommended frequency of UDT is once a year.
c.  Chromatography/mass spectrometry is typically used for initial screening.
d.  Unexpected immunoassay results should be acted on promptly by a rapid taper or referral to an addiction specialist.

Question 30:

Which of the following drugs cannot be detected by an opioid immunoassay? (Answer in Appendix D)

a.  Morphine.
b.  Methadone.
c.  Hydrocodone.
d.  Codeine.

Questions 31-40 are based on the video on the Rules for the Treatment of Chronic Non-Cancer Pain promulgated by the Washington State Department of Health. (See test instructions for details.)

Question 31:

ESHB 2876 was passed to:

a.  Reduce the number of opioid prescriptions in the state of Washington.
b.  Legislate the practice of medicine.
c.  Address the rising death rate from unintended opioid deaths.
d.  Reduce the prescribing of long-acting opioids.

Question 32:

Exceptional circumstances to the rule include:

a.  Hospice care.
b.  Palliative care or other end of life care.
c.  Management of a new medical problem that involves acute pain.
d.  All of the above.

Question 33:

Informed consent shall be a part of every treatment plan:

True   False

Question 34:

Written agreements for treatment must be obtained for:

a.  All patients receiving opioids.
b.  Patient determined to be a high risk.
c.  Anyone under the age of 18 years.
d.  For long-acting opioids only.

Question 35:

Periodic review of the treatment plan shall occur:

a.  On a regular basis.
b.  Generally every six months.
c.  Whenever it seems necessary.
d.  Yearly.

Question 36:

Prescribers of long-acting opioids should have a one-time (lifetime) completion of at least four hours of CME:

True   False

Question 37:

Episodic care practitioners may NEVER prescribe long-acting opioids:

True   False

Question 38:

The mandatory consultation threshold for adults is:

a.  Twice the patient's weight in kilograms.
b.  120 mg of morphine equivalent dose (MED).
c.  When the treatment is not working.
d.  After six months of treatment.

Question 39:

To be an exempt provider the practitioner must:

a.  Have practiced for three years or more.
b.  Have over 50 chronic pain patients.
c.  Have completed in the previous two years, 12 hours of chronic pain CME with at least two hours dedicated to long-acting opioids.
d.  Work in a pain clinic.

Question 40:

If a provider cannot find a pain specialist to refer to for whatever reason he/she must:

a.  Stop prescribing opioids.
b.  Use only short acting opioids.
c.  Document in the health record the reason why.
d.  Use any opioid but Methadone.

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Activity Version 2, July 2011