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Arizona Continuing Medical Education
ARIZONA MEDICAL LICENSURE PROGRAM MANDATORY CME REQUIRED FOR ARIZONA LICENSE RENEWALS ENCLOSED PROGRAM INCLUDES: • Responsible Prescribing of Controlled Substances - 3 Credit Hours (Mandatory) • Chronic Pain Syndromes: Current Concepts and Treatment Strategies - 15 Credit Hours (Elective)
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In support of improving patient care, TRC Healthcare/ NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™
MOC STATE LICENSURE
CME DEADLINE: MD & PA: Midnight On Licensee’s Date Of Birth DO: Midnight On December 31
AVAILABLE ONLINE AT: AZ.CME.EDU
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RESPONSIBLE PRESCRIBING OF CONTROLLED SUBSTANCES
MANDATORY COURSE CODE: MDAZ03CS SATISFIES THE ARIZONA BOARDS OF MEDICINE, OSTEOPATHIC EXAMINERS AND PHYSICIAN ASSISTANTS MANDATORY REQUIREMENT FOR THREE (3) AMA PRA CATEGORY 1 CREDIT™ OR EQUIVALENT ON OPIOIDS/ SUBSTANCE ABUSE/ADDICTION. 3 CE HOURS $30.00 Opioid analgesic medications can bring substantial relief to patients suffering from pain. However, the inappropriate use, abuse, and diversion of prescription drugs in America, particularly prescription opioids, has increased dramatically in recent years and has been identified as a national public health epidemic. A set of clinical tools, guidelines, and recommendations are now available for prescribers who treat pain patients with opioids. By implementing these tools, clinicians can effectively address issues related to the clinical management of opioid prescribing, opioid risk management, regulations surrounding the prescribing of opioids, and problematic opioid use by patients. In doing so, healthcare professionals are more likely to achieve a balance between the benefits and risks of opioid prescribing, optimize patient attainment of therapeutic goals, and avoid the risk to patient outcome, public health, and viability of their own practice imposed by deficits in knowledge.
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CHRONIC PAIN SYNDROMES: CURRENT CONCEPTS AND TREATMENT STRATEGIES
ELECTIVE COURSE CODE: MDAZ15CP Advances in pain science have the potential to greatly assist healthcare providers in delivering more effective pain management approaches, in part through greater elucidation of disease-treatment relationships. Equally important is that some of the most established practices of pain management are now being challenged by recent research evidence. This course intends to provide primary care providers with an understanding of neurobiological mechanisms that underlie common chronic pain conditions and the latest recommendations on pain management. Consistent among treatment guidelines for a wide range of chronic pain conditions are recommendations for using a mechanistic-based treatment approach. This strategy matches the analgesic mechanism of action with the likely underlying pain pathophysiology, combining pharmacologic, psychologic, physical rehabilitation, and interventional treatment approaches into a single, multi-modal approach that addresses the sensory, emotional, cognitive, interpersonal, and social contributions to causation and maintenance of pain. 15 CE HOURS $108.00
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COURSE PARTICIPANT SHEET
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PHYSICIAN CONTINUING EDUCATION
Book code: MDAZ1827
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FREQUENTLY ASKED QUESTIONS What are the requirements for license renewal? LICENSES EXPIRE
CME HOURS REQUIRED
MD & PA: 40 AMA PRA Category 1 Credits ™ DO: 40 Credit Hours, 24 AOA Category 1 Credit ™, 16 AMA PRA Category 1 Credit ™
MD & PA: Biennially Birthdate DO: Biennially December 31
MANDATORY SUBJECTS
3 credit hours of Opioids, Substance Abuse or Addiction
How do I complete this course and receive my certificate of completion? See the above information for step-by-step instructions to complete and receive your certificate. Are you an Arizona board-approved provider?
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No problem, we have several options for you to choose from! Online at EliteLearning.com/Physician you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll free at 800-237-6999, Monday - Friday 9:00 am - 6:00 pm Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home study. Also, make sure that you notify the board of any changes of address. It is important and Saturday 10:00 am - 4:00 pm, EST. Important information for licensees:
In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and
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that your most current address is on file. Licensing board contact information: Arizona Medical Board 1740 W Adams St, Suite 4000 Phoenix, AZ 85007 (480) 551-2700
©2026: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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Book code: MDAZ1827
PHYSICIAN CONTINUING EDUCATION
__________________________________________________ Responsible Prescribing of Controlled Substances MDAZ03CS — 3 CREDIT S R elease D ate : 09/01/25 E xpiration D ate : 08/31/28
Responsible Prescribing of Controlled Substances
In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 3 ABIM MOC Points, 3 ABS MOC Points, 3 ABA MOCA Points, 3 ABP MOC Points, 3 ABPath CC Points.
Faculty Mark Rose, BS, MA, LP , is a licensed psychologist in the State of Minnesota with a private consulting practice and a medical research analyst with a biomedical communications firm. Earlier healthcare technology assessment work led to medical device and pharmaceutical sector experience in new product development involving cancer ablative devices and pain therapeutics. Along with substantial experience in addiction research, Mr. Rose has contributed to the authorship of numerous papers on CNS, oncology, and other medical disorders. He is the lead author of papers published in peer-reviewed addiction, psychiatry, and pain medicine journals and has written books on prescription opioids and alcoholism published by the Hazelden Foundation. He also serves as an Expert Advisor and Expert Witness to law firms that represent disability claimants or criminal defendants on cases related to chronic pain, psychiatric/substance use disorders, and acute pharmacologic/toxicologic effects. Mr. Rose is on the Board of Directors of the Minneapolis-based International Institute of Anti-Aging Medicine and is a member of several professional organizations. Faculty Disclosure Contributing faculty, Mark Rose, BS, MA, LP, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planners John V. Jurica, MD, MPH Margo A. Halm, RN, PhD, ACNS-BC, FAAN Senior Director of Development and Academic Affairs Sarah Campbell Division Planners/Director Disclosure The division planners and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
HOW TO RECEIVE CREDIT
• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.
Audience This course is designed for all physicians, osteopaths, physician assistants, and nurses who may alter prescribing practices or intervene to prevent drug diversion and inappropriate controlled substance use. Course Objective The purpose of this course is to provide clinicians who prescribe or distribute opioids with an appreciation for the complexities of opioid prescribing and the dual risks of litigation due to inadequate pain control and drug diversion or misuse in order to provide the best possible patient care and to prevent a growing social problem. Learning Objectives Upon completion of this course, you should be able to: 1. Apply epidemiologic trends in opioid use and misuse to current practice so at-risk patient populations can be more easily identified, assessed, and treated. 2. Create comprehensive treatment plans for patients with pain that address patient needs as well as drug diversion prevention. 3. Evaluate behaviors that may indicate drug seeking or diverting as well as approaches for patients suspected of misusing opioids. 4. Identify state and federal laws governing the proper pre- scription and monitoring of controlled substances. 5. Describe the available treatment modalities for opioid use disorder.
EliteLearning.com/Physician 1 Mention of commercial products does not indicate endorsement.
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Accreditations & Approvals
Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physi- cians and Surgeons of Canada, medical practitioners participat- ing in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrat- ing new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Fur- thermore, commercial interests are prohibited from distributing or providing access to this activity to learners. INTRODUCTION Pain is the leading reason for seeking medical care, and pain management is a large part of many healthcare professionals’ practice. Opioid analgesics are approved by the U.S. Food and Drug Administration (FDA) for moderate and severe pain and are broadly accepted in acute pain, cancer pain, and end-of- life care, but are controversial in chronic noncancer pain. In response to the long-standing neglect of severe pain, indica- tions for opioid analgesic prescribing were expanded in the 1990s, followed by inappropriate prescribing and increasing abuse, addiction, diversion, and overdose through the 2000s. In tandem with the continued under-treatment of pain, these practice patterns led to needless suffering from uncontrolled pain, opioid analgesic addiction, and overdose. Opioid analge- sic prescribing and associated overdose peaked in 2011, with both now in multi-year decline [1; 2]. Patients show substantial opioid response variations in anal- gesia and tolerability and may exhibit a range of psychologic, emotional, and behavioral responses that reflect inadequate pain control, an emerging opioid use problem, or both. Clini- cian delivery of best possible care to patients with pain requires appreciation of the complexities of opioid prescribing and the dual risks of inadequate pain control and inappropriate use, drug diversion, or overdose. A foundation for appropriate opioid prescribing is the understanding of factual data that clarify the prevalence, causality, and prevention of serious safety concerns with opioid prescribing.
In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accred- itation Council for Pharmacy Education (ACPE), and the American Nurses Creden- tialing Center (ANCC), to provide continuing education for the healthcare team. Designations of Credit NetCE designates this enduring material for a maximum of 3 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes par- ticipation in the evaluation component, enables the participant to earn up to 3 MOC points in the American Board of Inter- nal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant comple- tion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes par- ticipation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to sub- mit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anes- thesiology’s ® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiol- ogy Program ® (MOCA ® ), known as MOCA 2.0 ® . Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program ® and MOCA ® are registered certification marks of the American Board of Anesthesiology ® . MOCA 2.0 ® is a trade- mark of the American Board of Anesthesiology ® . Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the partici- pant to earn 3 MOC points in the American Board of Pediat- rics’ (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 3 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Cer- tification Program.
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This disproportionate rate of opioid consumption reflects sociocultural and economic factors and standards of clinical medicine. To assist in monitoring the public health problem associated with prescribed opioids, numerous governmental, non-profit, and private sector agencies and organizations are involved in collecting, reporting, and analyzing data on use and misuse, addiction, fatal overdose, and treatment admissions related to opioid analgesics. The Drug Abuse Warning Network (DAWN) provides annual estimates of drug-related emergency department visits in the U.S, for prescription opioids, heroin, fentanyl, and other opi- oids. In 2022, DAWN found that, among all opioid-related emergency department visits, heroin accounted for 44%, followed by prescription/other opioids (39.4%), and fentanyl (20.8%). Within the prescription/other category, oxycodone was reported in for 32.9% of emergency department visits, followed by hydrocodone (10.7%), tramadol (5.3%), morphine (3.8%), hydromorphone (3.0%), and codeine (1.4%) [7]. As prescription opioid abuse and unintentional overdose has become a growing concern, more emphasis has been placed on prescribing patterns. In 2023, Louisiana had the fourth highest rate of opioid dispensing at 62.7 prescriptions per 100 persons, following Arkansas (71.5 per 100 persons), Alabama (71.4 per 100 persons), and Mississippi (63.1 per 100 person), higher than the national average of 40.1 opioid prescriptions per 100 persons [9]. PAIN MANAGEMENT APPROACHES Healthcare professionals should know the best clinical prac- tices in opioid prescribing, including the associated risks of opioids, approaches to the assessment of pain and function, and pain management modalities. Pharmacologic and non- pharmacologic approaches should be used on the basis of cur- rent knowledge in the evidence base or best clinical practices. Patients with moderate-to-severe chronic pain who have been assessed and treated, over a period of time, with non-opioid therapy or nonpharmacologic pain therapy without adequate pain relief, are considered to be candidates for a trial of opioid therapy. Initial treatment should always be considered indi- vidually determined and as a trial of therapy, not a definitive course of treatment [1; 2]. In response to a growing need for guidance regarding opioid prescribing practices for chronic pain that also limits diversion and misuse, the Centers for Disease Control and Prevention (CDC) released guidelines for opioid prescribing in 2016 [10]. However, these guidelines were met with criticism, and in response, the American Academy of Pain Medicine (AAPM) published a consensus panel report evaluating challenges with implementing the CDC guideline [11]. While the AAPM panel generally agreed with the CDC’s recommendations, it identi- fied six challenges caused by guideline misapplication [11]:
SCOPE OF THE PROBLEM Inappropriate opioid analgesic prescribing for pain is defined as the non-prescribing, inadequate prescribing, excessive prescribing, or continued prescribing despite evidence of ineffectiveness of opioids. Appropriate opioid prescribing is essential to achieve pain control; to minimize patient risk of abuse, addiction, and fatal toxicity; and to minimize societal harms from diversion. The foundation of appropriate opioid prescribing is thorough patient assessment, treatment plan- ning, and follow-up and monitoring. Essential for proper patient assessment and treatment planning is comprehension of the clinical concepts of opioid abuse and addiction, their behavioral manifestations in pain patients, and how these potentially problematic behavioral responses to opioids both resemble and differ from physical dependence and pseudo- dependence [1; 2]. Prescriber knowledge deficit has been iden- tified as a key obstacle to appropriate opioid prescribing and, along with gaps in policy, treatment, attitudes, and research, contributes to widespread inadequate treatment of pain [1; 3]. The extent of opioid analgesic use in the United States was unprecedented in the country’s history and unparalleled anywhere in the world. Before 1990, physicians in the United States were skeptical of prescribing opioids for chronic non- cancer pain. However, by 2011, opioid prescribing reached its peak, with more than 257.9 million opioid prescriptions dispensed. By 2020, the number of opioid prescriptions dispensed was 143.4 million, a decrease of more than 44% since 2011 [4]. Despite the decrease in opioid prescribing, opioid-related overdose deaths are still a primary concern, due largely in part to the increased use and strength of illicit and synthetic opioids [4; 5]. Worldwide consumption of opioid analgesics has increased dramatically in the past few decades, with the United States driving a substantial proportion of this increase. For example, the 1990 global consumption of hydrocodone was 4 tons (3,628 kg), compared with the 2023 consumption of 25.6 tons (23,224 kg); 98.7% of this was consumed in the United States. Similarly, 3 tons (2,722 kg) of oxycodone were consumed globally in 1990, versus 60.2 tons (54,613 kg) in 2023, of which 40.8 tons (37,013 kg or 67.7%) were consumed in the United States [6]. With only 4.5% of the world’s population, the United States annually consumes more than 80% of all
opioid supplies, including [6]: • 99% of all hydrocodone • 68% of all oxycodone • 56% of all methadone • 38% of all hydromorphone • 13% of all fentanyl
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• Inflexible application of recommended ceiling doses or prescription durations as hard limits • Abrupt opioid taper or cessation in physically dependent, opioid-treated patients without regard for CDC emphasis on empathically reviewing benefits and risks of continued high-dosage therapy and working collaboratively with patients on a tapering plan • Lack of availability and coverage for recommended comprehensive, multimodal pain care • Difficulty of opioid use disorder diagnosis and barriers to accessing evidence-based treatment • Underutilization of naloxone • Incomplete data in reporting of overdose death statistics Taking into consideration input from the AAPM, other organizations, and the emerging evidence, these guidelines were updated in 2022 to update and clarify prescribing rec- ommendations for pain management in acute, subacute, and chronic pain in adults (not related to sickle cell disease, cancer, palliative/end-of-life-care). The 2022 CDC opioid prescribing guideline emphasizes that the recommendations are voluntary and are intended to be flexible to assist in individualized, patient-centered care. The CDC specifically discourages use of the recommendations to set a minimum or maximum dosage requirement and instead recommends “avoiding increasing dosage above levels likely to yield diminishing returns in ben- efits relative to risks to patients” [2]. The guideline contains 12 recommendations grouped into four areas of consideration: determining whether or not to initiate opioids for pain; opioid selection and determining dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use ( Table 1 ) [2]. The CDC highlights five guiding principles for implementa- tion of these recommendations, to ensure safety and patient- centered care, including [2]: • Acute, subacute, and chronic pain should be appropriately assessed and treated independent of whether opioids are part of a treatment regimen. • Recommendations are voluntary and are intended to support, not supplant, individualized, person- centered care. Flexibility to meet the care needs and the clinical circumstances of a specific patient is paramount. • A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes and well-being of each person is critical.
• Special attention should be given to avoid misapplying this clinical practice guideline beyond its intended use or implementing policies purportedly derived from it that might lead to unintended and potentially harmful consequences for patients. • Clinicians, practices, health systems, and payers should vigilantly attend to health inequities; provide culturally and linguistically appropriate communication, including communication that is accessible to persons with disabilities; and ensure access to an appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain management regimen for all persons. ACUTE AND SUBACUTE PAIN Because the line between acute pain and initial chronic pain is not always clear, it might be difficult for clinicians to determine when they are initiating opioids for chronic pain rather than treating acute or subacute pain. Acute pain is generally defined as pain with a sudden onset lasting less than one month and is most commonly caused by injury, trauma or medical treat- ments (e.g., surgery). Subacute pain, or unresolved acute pain, is pain that does not resolve within one month and continues for up to three months after initial symptoms (within the time of normal tissue healing). Subacute pain may evolve into chronic pain (pain lasting longer than three months) [1; 2]. The CDC notes that nonopioid therapies are at least as effec- tive as opioids for many common types of acute pain and clinicians should maximize the use of nonopioid pharma- cologic (e.g., topical or oral NSAIDS, acetaminophen) and nonpharmacologic (e.g., ice, heat, elevation, rest, immobiliza- tion, stretching) options. However, when the diagnosis and severity of acute pain are required, clinicians should prescribe the lowest effective dose of immediate-release opioids in a quantity no greater than that needed for the expected dura- tion of severe pain. Clinicians should prescribe and advise opioid use only as needed, rather than on a scheduled basis, and recommend an opioid taper if opioids are taken several times a day for more than a few days [2]. For acute pain, an initial opioid prescription of four to seven days is generally acceptable. If longer opioid therapy is required for acute pain, patients should be evaluated at least every two weeks. If acute pain evolves to subacute pain, and opioids are continued for more than one month, clinicians should ensure that potentially reversible causes of chronic pain are addressed and that opioid prescribing for acute pain does not unintentionally become long-term opioid therapy [2]. With postoperative, acute, or intermittent pain, analgesia often requires frequent titration, and the two- to four-hour analgesic duration with short-acting hydrocodone, morphine, and oxy- codone is more effective than extended-release formulations. Short-acting opioids are also recommended in patients who are medically unstable or with highly variable pain intensity [2].
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CDC RECOMMENDATIONS FOR PRESCRIBING OPIOIDS FOR PAIN, EXCLUDING SICKLE CELL DISEASE OR CANCER, PALLIATIVE, OR END-OF-LIFE CARE Determining Whether or Not to Initiate Opioids for Pain Recommendation 1 : Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies. Opioid therapy should only be considered for acute pain if expected benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy. Recommendation 2 : Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies. Opioid therapy for subacute and chronic pain should only be used if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Recommendation 3 : When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. Selecting Opioids and Determining Opioid Dosages Recommendation 4 : When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients. Recommendation 5 : For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages. Deciding Duration of Initial Opioid Prescription and Conducting Follow-Up Recommendation 6 : When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Recommendation 7 : Clinicians should evaluate benefits and risks with patients within one to four weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly re-evaluate benefits and risks of continued opioid therapy with patients. Assessing Risk and Addressing Harms of Opioid Use Recommendation 8 : Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone. Recommendation 9 : When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose. Recommendation 10 : When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances. Recommendation 11 : Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants. Recommendation 12 : Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death. Source: [2] Table 1
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CHRONIC NON-CANCER PAIN Chronic non-cancer pain is defined as ongoing pain not related to malignancy with a duration of greater than three months that may or may not be the result of an underlying medical disease or condition, injury, medical treatment, inflammation; the etiology may also be unknown. As with acute and subacute pain, nonpharmacologic therapy and non-opioid pharmaco- logic therapy are the preferred first-line therapies for chronic pain. If opioids are used, they should be combined with non- pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. Clinicians should consider opioid therapy only if expected benefits for pain and function are anticipated to outweigh risks to the patient, and as part of a comprehensive pain management approach [2]. Opioid therapy for chronic pain should not be initiated with- out consideration by the clinician and patient on follow-up, taper, and exit strategy if opioid therapy is unsuccessful. The goals of treatment should be established with all patients prior to the initiation of opioid therapy, including reasonable improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use. The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consultations, referrals, and therapies [1; 2]. In opioid-naïve patients, start at the lowest possible dose and titrate to effect. Dosages for opioid-tolerant patients should always be individualized and titrated by efficacy and tolerabil- ity. When starting opioid therapy for chronic pain, clinicians should prescribe short-acting instead of extended-release/ long-acting opioid formulations [1; 2]. The need for frequent progress and benefit/risk assessments during the trial should be included in patient education. Patients should also have full knowledge of the warning signs and symptoms of respiratory depression [2]. Prescribers should be knowledgeable of federal and state opioid prescribing regulations. Issues of equianalgesic dosing, close patient monitoring during all dose changes, and cross-tolerance with opioid conversion should be considered. If necessary, treatment may be augmented, with preference for nonopioid and immediate-release opioids over long-acting/extended- release opioids. Taper opioid dose when no longer needed [12]. PALLIATIVE CARE AND PAIN AT THE END OF LIFE Unrelieved pain is the greatest fear among people with a life- limiting disease, and the need for an increased understanding of effective pain management is well-documented. Although experts have noted that 90% of end-of-life pain can be managed effectively, rates of pain are high, even among people receiving palliative care [13; 14; 15].
The inadequate management of pain is the result of several factors related to both patients and clinicians. In a survey of oncologists, patient reluctance to take opioids or to report pain were two of the most important barriers to effective pain relief. This reluctance is related to a variety of attitudes and beliefs [13; 16; 17]: • Fear of addiction to opioids • Worry that if pain is treated early, there will be no options for treatment of future pain • Anxiety about unpleasant side effects from pain medications • Fear that increasing pain means that the disease is getting worse • Desire to be a “good” patient • Concern about the high cost of medications Education and open communication are the keys to overcom- ing these barriers. Every member of the healthcare team should reinforce accurate information about pain management with patients and families. The clinician should initiate conversa- tions about pain management, especially regarding the use of opioids, as few patients will raise the issue themselves or even express their concerns unless they are specifically asked [18]. It is important to acknowledge patients’ fears individually and provide information to help them differentiate fact from fiction. For example, when discussing opioids with a patient who fears addiction, the clinician should explain that the risk of addiction is low. It is also helpful to note the difference between addiction and physical dependence [1; 13]. There are several other ways clinicians can allay patients’ fears about pain medication [1; 17]: • Assure patients that the availability of pain relievers cannot be exhausted; there will always be medications if pain becomes more severe. • Acknowledge that side effects may occur but emphasize that they can be managed promptly and safely and that some side effects will abate over time. • Explain that pain and severity of disease are not necessarily related. Encouraging patients to be honest about pain and other symptoms is also vital. Clinicians should ensure that patients understand that pain is multidimensional and emphasize the importance of talking to a member of the healthcare team about possible causes of pain, such as emotional or spiritual distress. The healthcare team and patient should explore psychosocial and cultural factors that may affect self-reporting of pain, such as concern about the cost of medication [1; 17].
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__________________________________________________ Responsible Prescribing of Controlled Substances
Clinicians’ attitudes, beliefs, and experiences also influence pain management, with addiction, tolerance, side effects, and regulations being the most important concerns. A lack of appropriate education and training in the assessment and man- agement of pain has been noted to be a substantial contributor to ineffective pain management. As a result, many clinicians, especially primary care physicians, do not feel confident about their ability to manage pain in their patients [13; 16; 17]. Clinicians require a clear understanding of available medica- tions to relieve pain, including appropriate dosing, safety profiles, and side effects. If necessary, clinicians should consult with pain specialists to develop an effective approach. ASSESSMENT OF PAIN Pain should be assessed routinely, and frequent assessment has become the standard of care [19]. Pain is a subjective experience, and as such, the patient’s self-report of pain is the most reliable indicator. Research has shown that pain is underestimated by healthcare professionals and overestimated by family members [19; 20]. Therefore, it is essential to obtain a pain history directly from the patient, when possible, as a first step toward determining the cause of the pain and selecting appropriate treatment strategies. When the patient is unable to communicate verbally, other strategies must be used to determine the characteristics of the pain. Questions should be asked to elicit descriptions of the pain characteristics, including its location, distribution, quality, temporal aspect, and intensity. In addition, the patient should be asked about aggravating or alleviating factors. Pain is often felt in more than one area, and physicians should attempt to discern if the pain is focal, multifocal, or generalized. Focal or multifocal pain usually indicates an underlying tissue injury or lesion, whereas generalized pain could be associated with damage to the central nervous system. Pain can also be referred, usually an indicator of visceral pain. The quality of the pain refers to the sensation experienced by the patient, and it often suggests the pathophysiology of the pain [19]. Pain that is well localized and described as aching, throbbing, sharp, or pressure-like is most likely somatic noci- ceptive pain. This type of pain is usually related to damage to bones and soft tissues. Diffuse pain that is described as squeezing, cramping, or gnawing is usually visceral nociceptive pain. Pain that is described as burning, tingling, shooting, or shock-like is neuropathic pain, which is generally a result of a lesion affecting the nervous system. Documentation of pain intensity is key, as several treatment decisions depend on the intensity of the pain. The numeric rating scale is the tool used most often to assess pain; with this tool, patients rate pain on a scale of 0 to 10 [19]. Functional assessment is also important. The healthcare team should observe the patient to see how pain limits movements and should ask the patient or family how the pain interferes with normal activities. Determining functional limitations can help
enhance patient compliance in reporting pain and adhering to pain-relieving measures, as clinicians can discuss compliance in terms of achieving established functional goals [18]. The Memorial Pain Assessment Card can be used to evaluate both the severity of pain and the effect of pain on function [19; 21]. Physical examination can be valuable in determining an under- lying cause of pain. Examination of painful areas can detect evidence of trauma, skin breakdown, or changes in osseous structures. Auscultation can detect abnormal breath or bowel sounds; percussion can detect fluid accumulation; and palpa- tion can reveal tenderness. A neurologic examination should also be carried out to evaluate sensory and/or motor loss and changes in reflexes. During the examination, the clinician should watch closely for nonverbal cues that suggest pain, such as moaning, grimacing, and protective movements. These cues are especially important when examining patients who are unable to verbally communicate about pain. CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for pain and function are anticipated to outweigh risks to the patient. Pharmacologic and nonpharmacologic approaches should be used on the basis of current knowledge in the evidence base or best clinical practices. Patients with moderate-to-severe chronic pain who have been assessed and treated, over a period of time, with non-opioid pharmacologic or nonpharmacologic pain therapy without adequate pain relief are considered to be candidates for a trial of opioid therapy. The treatment plan should always be individualized for the patient and begun as a trial for a defined period of time (usually no more than 30 days) before embarking on a definitive course of treatment [1; 2]. If opioids are used, they should be combined with nonphar- macologic therapy and non-opioid pharmacologic therapy, as appropriate. Before starting opioid therapy for chronic pain, clinicians should, for all patients [2]: • Discuss the realistic benefits and known risks of opioid therapy. • Establish treatment goals for pain and function. • Consider how therapy will be discontinued if benefits do not outweigh risks. • Continue opioid therapy only if clinically meaningful improvement in pain and function outweighs safety risks.
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Several nonpharmacologic approaches are therapeutic comple- ments to pain-relieving medication, lessening the need for higher doses and perhaps minimizing side effects. These interventions can help decrease pain or distress that may be contributing to the pain sensation. Approaches include palliative radiotherapy, complementary/alternative methods, manipulative and body-based methods, and cognitive/behav- ioral techniques. The choice of a specific nonpharmacologic intervention is based on the patient’s preference, which, in turn, is usually based on a successful experience in the past [2]. Multidisciplinary functional restoration programs, which are intensive (>100 hours) biopsychosocial interventions whereby physical rehabilitation is combined with cognitive-behavioral therapy and delivered by an interdisciplinary team, embody this recommendation. Moderate-to-strong evidence supports their efficacy in chronic pain. They have been found effec- tive in reducing pain and improving physical function, work readiness, and return to work. Weaker outcomes are found in programs that are less intensive or lacking a behavioral component. Patients who do not improve with less intensive therapy options and have high levels of pain, distress, and dis- ability should be considered for multidisciplinary functional restoration programs [2]. Nonopioid analgesics, such as aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs), are primar- ily used for mild pain and may also be helpful as coanalgesics for patients with moderate or severe pain. Acetaminophen is among the safest of analgesic agents, but it has essentially no anti-inflammatory effect. Toxicity is a concern at high doses, and the maximum recommended dose is 3–4 g per day. Acetaminophen should be avoided or given at lower doses in people with a history of alcohol abuse or renal or hepatic insufficiency [19; 22]. NSAIDs are most effective for pain associated with inflam- mation. Among the commonly used NSAIDs are ibuprofen, naproxen, and indomethacin. There are several classes of NSAIDs, and the response differs among patients; trials of drugs for an individual patient may be necessary to determine which drug is most effective. NSAIDs inhibit platelet aggrega- tion, increasing the risk of bleeding, and also can damage the mucosal lining of the stomach, leading to gastrointestinal bleed- ing. There is a ceiling effect to the nonopioid analgesics; that is, there is a dose beyond which there is no further analgesic effect. In addition, many side effects of nonopioids can be severe and may limit their use or dosing [2; 22]. Moderate pain has often been treated with analgesic agents that are combinations of acetaminophen and an opioid, such as codeine, oxycodone, or hydrocodone. However, these combination drugs, when taken as needed or in conjunction with other medications, may exceed the total the maximum acetaminophen daily dose of 4 grams/day. Clinicians should be aware of all medications and frequency of use. In some cases, prescribing separate components of the combined drug
is preferred, allowing for increases in the dose of the opioid without increasing the dose of acetaminophen or other coan- algesic [2; 23]. Strong opioids are used for severe pain [2; 19]. Unlike nonopioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. Information obtained by patient history, physical examination, and interview, from family members, spouse, or state prescrip- tion drug monitoring program (PDMP), and from the use of screening and assessment tools can help the clinician to stratify the patient according to level of risk for developing problematic opioid behavioral responses ( Table 2 ) [24]. Low-risk patients receive the standard level of monitoring, vigilance, and care. Moderate-risk patients should be considered for an additional level of monitoring and provider contact, and high-risk patients are likely to require intensive and structured monitoring and follow-up contact, additional consultation with psychiatric and addiction medicine specialists, and limited supplies of short-acting opioid formulations [24]. Before deciding to prescribe an opioid analgesic, clinicians should perform and document a detailed patient assessment that includes [1]: • Medical history, review of systems, and physical examination targeted to the pain condition • Review current medications, including over-the- counter and natural remedies • Medical indications for opioid therapy • Nature and intensity of pain • Past and current pain treatments and patient response • Underlying or comorbid conditions that may cause pain or complicate treatment • Pain impact on physical and psychologic function • Social support, housing, and employment • Pain impact on sleep, mood, work, relationships, leisure, and substance use • Patient history of physical, emotional, or sexual abuse • Personal and family history of substance use disorder • History of behavioral health disorders • A review of PDMP results • Consultation with other clinicians, including specialists, when applicable • Urine, blood or other types of biological samples, and diagnostic markers
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__________________________________________________ Responsible Prescribing of Controlled Substances
RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS
Low Risk Definable physical pathology Objective signs and reliable symptoms Clinical correlation with diagnostic testing, including MRI, physical examination, and interventional diagnostic techniques With or without mild psychologic comorbidity With or without minor medical comorbidity No or well-defined and controlled personal or family history of alcohol or substance use disorder Age 45 years or older High levels of pain acceptance and active coping strategies High motivation and willingness to participate in multimodal therapy and attempting to function at normal levels Medium Risk Significant pain problems with objective signs and symptoms confirmed by radiologic evaluation, physical examination, or diagnostic interventions Moderate psychologic problems, well controlled by therapy Moderate coexisting medical disorders that are well controlled by medical therapy and are not affected by chronic opioid therapy (e.g., central sleep apnea) Develops mild tolerance but not hyperalgesia without physical dependence or addiction Past history of personal or family history of alcohol or substance use disorder Pain involving more than three regions of the body
Defined pathology with moderate levels of pain acceptance and coping strategies Willing to participate in multimodal therapy, attempting to function in normal daily life High Risk Widespread pain without objective signs and symptoms Pain involving more than three regions of the body Aberrant drug-related behavior History of alcohol or substance use disorder, , diversion, dependency, tolerance, or hyperalgesia
Major psychologic disorders Age younger than 45 years HIV-related pain High levels of pain exacerbation and low levels of coping strategies
Unwilling to participate in multimodal therapy Not functioning close to a near normal lifestyle HIV = human immunodeficiency syndrome, MRI = magnetic resonance imaging. Source: [24]
Table 2
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