This interactive Tennessee Physician Ebook contains 17 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
Tennessee Continuing Medical Education
TENNESSEE MEDICAL LICENSURE PROGRAM MANDATORY TRAINING REQUIRED FOR TENNESSEE LICENSE RENEWAL ENCLOSED PROGRAM INCLUDES: • 2 HOURS Controlled Substance Prescribing (Mandatory) • 15 HOURS Palliative Care (Elective)
In support of improving patient care, 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 ™ MIPS MOC STATE LICENSURE
CME DEADLINE: Prior to your upcoming license renewal
AVAILABLE ONLINE AT: TN.CME.EDU
TENNESSEE PHYSICIAN
Dear Colleagues,
Physicians licensed by the Tennessee Board of Medical Examiners may now complete their CME requirements in the twenty-four (24) months preceding their license renewal. In accordance with board rule, all licensees must complete two (2) hours of CME in controlled substance prescribing, unless exempt under TENN. CODE ANN. § 63-1-402 (c). For educational requirements specific to your license type, please visit your board’s website or see inside the program for more details.
Need to complete the DEA’s new requirement under the Medication Access and Training Expansion (MATE) Act?
InforMed has the solution. Scan the QR code or go to https://uqr.to/deamate to get started. Effective June 27, 2023, renewing DEA-registered practitioners must complete 8 credit hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Get the training you need in a self-paced, convenient format with a course specifically designed for physicians to meet the Drug Enforcement Administration (DEA)’s new requirement under the Medication Access and Training Expansion (MATE) Act.
The InforMed Tennessee Medical Licensure Program is designed to fulfill this legislative CME requirement for physicians in Tennessee. Completion of this program satisfies the two (2) hour mandatory CME requirement in controlled substance prescribing, plus fifteen (15) hours on palliative care and pain management at the end-of-life.
Thank you for choosing lnforMed as your CME provider. We strive to create a high-quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards,
The lnforMed CME Team
We are a nationally accredited CME provider. For all board-related inquiries please contact:
Tennessee Board of Medical Examiners | 665 Mainstream Drive, 2nd Floor Nashville, TN 37243 | 615-532-3202 local or 1-800-778-4123 nationwide
BOOK.CME.EDU
BOOK CODE: MDTN1726
1-800-237-6999
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What’s Inside
01
PRESCRIPTION OPIOIDS AND PAIN MANAGEMENT: THE TENNESSEE GUIDELINES COURSE ONE | 2 CREDIT HOURS SATISFIES THE MANDATORY CME REQUIREMENT IN CONTROLLED SUBSTANCE PRESCRIBING WHICH MUST INCLUDE INSTRUCTION IN THE DEPARTMENT’S CHRONIC PAIN GUIDELINES. The purpose of this course is to provide updated clinical guidance on management of chronic pain, including opioid prescription drug use that conforms with the Tennessee Department of Health recommendations and core competencies developed by the Commission on Pain and Addiction Medicine Education. Included is a discussion of clinical tools used to assess the risk of drug- seeking and drug-diverting behaviors. The goal is best practice chronic pain management while preventing the growing public health problem of drug misuse, diversion, and overdose.
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PALLIATIVE CARE AND PAIN MANAGEMENT AT THE END OF LIFE COURSE TWO | 15 CREDIT HOURS
This course is designed to bridge the gap in knowledge of palliative care by providing an overview of the concept of palliative care and a discussion of the benefits and barriers to optimum palliative care at the end of life. Central to this discussion is an emphasis on the importance of talking to patients about the value of palliative care, of clearly presenting the prognosis and appropriate treatment options and goals, and of ensuring that advance planning is completed. The majority of the course focuses on the assessment and management of the most common end-of-life symptoms, with particular attention to pain, the most prevalent, as well as the most distressing, physical symptom. Psychosocial and spiritual needs of the patient and family are also discussed. Palliative care presents unique challenges for some patient populations, most notably older patients, children/adolescents, and patients receiving critical care. An overview of the most important issues specific to these settings is provided.
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FINAL EXAMINATION ANSWER SHEET REQUIRED TO RECEIVE CREDIT
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MOC CREDIT INFORMATION
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABA
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABS
American Board of Surgery’s Continuous Certification program
ABPath
American Board of Pathology’s Continuing Certification program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M
Activity Title
ABA ABIM ABS
ABPath
ABP
Prescription Opioids and Pain Management: The Tennessee Guidelines
2 AMA PRA Category 1 Credits TM
2 Credits LL
2 Credits MK
2 Credits SA + AC
2 Credits LL
2 Credits LL
15 Credits LL
Palliative Care and Pain Management at the End of Life
15 AMA PRA Category 1 Credits TM
15 Credits MK
15 Credits SA + AC
15 Credits LL
15 Credits LL+SA
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, AC = Accredited CME
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow-up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
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How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE
FASTEST AND EASIEST!
• Go to BOOK.CME.EDU and enter code MDTN1726 in the book code box, then click GO. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your final examination. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
Enter book code
MDTN1726
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
BY MAIL
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options
Price
Option
Code
Credits
ENTIRE PROGRAM • Prescription Opioids and Pain Management: The Tennessee Guidelines • Palliative Care and Pain Management at the End of Life
$110
MDTN1726 17 Credit Hours
$30
Prescription Opioids and Pain Management: The Tennessee Guidelines
MDTN02TG 2 Credit Hours
$108 Palliative Care and Pain Management at the End of Life
MDTN15PC 15 Credit Hours
Note: Prices are subject to change
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_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines Prescription Opioids and Pain Management: The Tennessee Guidelines MDTN02TG — 2 CREDIT HOURS R elease D ate : 10/01/25 E xpiration D ate : 09/30/28 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: 2 ABIM MOC Points, 2 ABS MOC Points, 2 ABA MOCA Points, 2 ABPath CC Points.
3. Evaluate behaviors that may indicate drug seeking or diverting as well as approaches for patients suspected of misusing opioids. 4. Apply state and federal laws governing the proper prescription and monitoring of controlled substances. Faculty John M. Leonard, MD , Professor of Medicine Emeritus, Vanderbilt University School of Medicine, completed his post- graduate clinical training at the Yale and Vanderbilt University Medical Centers before joining the Vanderbilt faculty in 1974. He is a clinician-educator and for many years served as director of residency training and student educational programs for the Vanderbilt University Department of Medicine. Over a career span of 40 years, Dr. Leonard conducted an active practice of general internal medicine and an inpatient consulting practice of infectious diseases. Faculty Disclosure Contributing faculty, John M. Leonard, MD, 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 clinicians who may alter prescribing practices or intervene to prevent drug diversion and inappropriate opioid use. Course Objective The purpose of this course is to provide updated clinical guidance on management of chronic pain, including opioid prescription drug use that conforms with the Tennessee Department of Health recommendations and core competencies developed by the Commission on Pain and Addiction Medicine Education. Included is a discussion of clinical tools used to assess the risk of drug-seeking and drug-diverting behaviors. The goal is best practice chronic pain management while preventing the growing public health problem of drug misuse, diversion, and overdose. 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, evaluated, and treated. 2. Devise treatment plans for patients with pain that address patient needs, inform patient expectations,
and reduce the risk of drug misuse and diversion in accordance with Tennessee clinical practice guidelines.
1 Mention of commercial products does not indicate endorsement.
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Prescription Opioids and Pain Management: The Tennessee Guidelines _ ______________________________
Accreditations & Approvals
This activity has been designated for 2 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating 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. Special Approvals This course is designed to meet the Tennessee requirement for 2 hours of education on the prescribing of controlled substances, including instruction in the Tennessee Chronic Pain Guidelines. 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 integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
In support of improving patient care, 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. Designations of Credit NetCE designates this enduring material for a maximum of 2 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 participation in the evaluation component, enables the participant to earn up to 2 MOC points in the American Board of Internal 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 completion 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 participation 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 submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s ® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology 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 trademark 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 participant to earn 2 MOC points in the American Board of Pediatrics’ (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.
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included
so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.
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planning, 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. Prescriber knowledge deficit has been identified 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 [2]. The extent of recent opioid analgesic use (and abuse) in the United States is 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; by 2017, 1 in 25 adults was prescribed an opioid such as oxycodone and hydrocodone for chronic pain, and sales of opioid analgesics totaled more than $9 billion each year [3]. Between 1992 and 2003, the U.S. population increased 14%, while persons using opioid analgesics increased 94% and first-time non-medical opioid analgesic users 12 to 17 years of age increased 542% [4]. It is interesting to note that while opioid prescribing increased precipitously among adults in the United States from 1996 to 2012, the rate remained low and steady for children over the same period [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 2020 consumption of 31.2 tons (28,304 kg); 99.2% of this was consumed in the United States. Similarly, 3 tons (2,722 kg) of oxycodone were consumed globally in 1990, versus 64.9 tons (58,876 kg) in 2020, of which 44.3 tons (40,188 kg or 68.2%) were consumed in the United States [3; 101]. With only 4.5% of the world’s population, the United States annually consumes more than 80% of all opioid
INTRODUCTION Relief from pain leads the list of reasons for seeking medical care, and safe, effective relief of chronic pain is among the most challenging clinical issues in healthcare professionals’ practice. The goals of pain management are to relieve suffering, restore functional capacity, and improve quality of life while minimizing adverse effects and avoiding unintended consequences such as misuse, addiction, and overdose. Prescription opioid analgesics are approved by the U.S. Food and Drug Administration (FDA) for use in treating moderate and severe pain but can also have serious risks and side effects. Opioids are broadly accepted for managing acute pain, cancer pain, and end-of-life care, but are controversial for treatment of chronic pain not caused by a malignancy. In response to the long-standing neglect of severe pain, indications for opioid analgesic prescribing were expanded in the 1990s, followed a decade later by a trend toward inappropriate opioid prescription management and an increase in the prevalence of drug misuse, dependency, and overdose. The conundrum persists: how to provide appropriate and effective treatment of serious chronic pain while avoiding practice patterns that lead to opioid misuse, drug diversion, addiction, and overdose. Common prescription opioids include oxycodone (Oxycontin), hydrocodone (Vicodin), morphine, and methadone. Fentanyl is a synthetic opioid many times more powerful than other opioids, reserved for treatment of severe pain, such as that associated with advanced cancer. Illegally manufactured and distributed fentanyl is a major problem throughout the United States. Patients show substantial variations in opioid analgesic response and tolerability and may exhibit a range of psychological, emotional, and behavioral responses that reflect inadequate pain control, an emerging opioid use problem, or both. The delivery of best practice care to patients with pain requires appreciation of the complexities of prescription opioid use and the dual risks of inadequate pain control and inappropriate opioid use/misuse. The safe and effective use of prescription opioids requires an understanding of the prevalence, causality, and prevention of serious safety concerns attendant to the use of this important class of drugs. SCOPE OF THE PROBLEM Inappropriate prescription opioid analgesia takes several forms: failure to recognize an appropriate indication, inadequate dose titration, excessive opioid dosing, and continued prescription opioid use despite evidence that efficacy is lacking [1]. 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 prescription opioid use encompasses a thorough patient assessment, treatment
supplies, including [4; 101]: • 99% of all hydrocodone • 68% of all oxycodone • 44% of all methadone • 47% of all hydromorphone • 18% of all fentanyl
This disproportionate rate of opioid consumption reflects sociocultural and economic factors and standards of clinical medicine. OPIOID DRUG OVERDOSE In 2005 and 2011, hydrocodone and its combinations accounted for 51,225 and 97,183 emergency department visits, respectively, in the United States. Oxycodone and its combinations resulted in 42,810 visits to the emergency department in 2005; this number increased to 175,229 visits in 2011 [7; 8]. Visits for nonmedical use of all opioids increased from 217,594 to 420,040 during this six-year period.
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The age-adjusted rate of all-category drug overdose deaths increased from 8.9 deaths per 100,000 standard population in 2003 to 31.3 in 2023 [97]. This sharp increase in the rate of overdose deaths was driven by overdose and inadvertent poisoning deaths involving synthetic opioids (principally fentanyl), indicative of a worsening and expanding illicit drug use epidemic. The age-adjusted rate of drug overdose deaths involving synthetic opioids (e.g., fentanyl) was mostly stable from 2003 (0.5 deaths per 100,000) to 2013 (1.0) and then increased at different rates over time, from 11.4 per 100,000 in 2019 to 22.2 in 2023 [97]. Illicitly manufactured fentanyl and fentanyl analogs are highly potent, increasingly available across the United States, and often found in supplies of other drugs. From 2022 to 2023, drug overdose death rates decreased for non-Hispanic White people, while rates for other race and Hispanic-origin groups generally stayed the same or increased [97]. Overdose deaths involving prescription opioids are now fourfold higher than in 2000. From 1999 to 2020, more than 263,000 people died in the United States from overdoses related to prescription opioids [97]. According to the Centers for Disease Control and Prevention (CDC), 105,007 drug overdose deaths were reported in the United States in 2023, of which 79,358 (75.6%) involved prescription or illicit opioids (primarily synthetic opioids such as fentanyl, fentanyl analogs, and tramadol) [97]. The overdose death rate involving just prescription opioids has fluctuated during the past decade (15,000 to 17,000 per 100,000) before declining to 13,467 in 2023, a 22% decrease in prescription opioid-involved death rates from 2021 to 2023. PUBLIC HEALTH RESPONSE TO THE OPIOID CRISIS To assist in monitoring the public health problem associated with prescribed opioids, numerous governmental, nonprofit, and private sector agencies and organizations are involved in collecting, reporting, and analyzing data on the abuse, addiction, fatal overdose, and treatment admissions related to opioid analgesics. In the past decade, federal and state agencies have convened workgroups consisting of subject matter experts, clinicians, and patient representatives to develop clinical practice guidelines for effective and safe opioid prescription drug use. The 2022 CDC Guideline for Prescribing Opioids for Chronic Pain provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care [10]. The guideline recommendations are grouped in reference to three clinical issues: determining when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; assessing risk and addressing harms of opioid use. The CDC guideline emphasizes the importance of improved communication between providers and patients that enables informed, patient-centered decisions for safe and effective pain care.
Additional opioid prescribing guideline resources for healthcare providers, including clinical tools such as total daily opioid dosage calculators, are maintained by the CDC online at https://www.cdc.gov/overdose-prevention/hcp/clinical-care. TENNESSEE AND THE OPIOID CRISIS In 2011, the state of Tennessee had one of the highest per capita prescription rates for opioids and ranked second in the country for percentage of adult opioid abuse treatment center admissions [92]. According to a 2015 report of opioid abuse in Tennessee, an estimated 212,000 (4.35%) Tennessee adults (18 years of age and older) used pain relievers non-medically in the previous year, the second most prevalent type of drug abuse behind cannabis [93]. From 2014 to 2015, the death rate in Tennessee increased 91% for synthetic opioids (e.g., fentanyl, tramadol), 44% for heroin, and 13% for natural/semisynthetic opioids (e.g., morphine, oxycodone, hydrocodone). The death rate for natural/synthetic opioids was 9.7 per 100,000 population, more than twice the national rate (3.9 per 100,000) [92]. In 2013, the Tennessee legislature, Department of Health, and other agencies came together to address the problem of excessive opioid prescription drug use and the emerging epidemic of drug abuse and overdose. These efforts lead to the creation of a controlled substance database and monitoring program, development of clinical practice guidelines for management of pain and prescription opioid use, and mandated continuing professional education in controlled substance prescribing [94]. There are encouraging signs of progress. From 2016 to 2020, the rate of multiple provider episodes for opioid prescriptions for pain declined from 28.5 per 100,000 residents to 3.5 per 100,000, and opioid prescriptions for pain decreased from 1.98 million dispensed in 2016 to 1.24 million in 2019, representing a decrease of 35.7% [100]. However, in 2022 Tennessee ranked 6th in per capita prescription opioid dispensing rate in the United States. Drug overdose deaths in Tennessee have increased steadily over the past decade (e.g., from 1,776 in 2017 to 3,814 in 2021), and opioids were involved in 80% of these deaths in 2021 [94]. This increase in opioid overdose deaths is largely attributable to the epidemic of illicit fentanyl use and poisonings, which accounted for 2,734 of 3,043 (90%) opioid deaths in 2021, compared with 501 of 1,269 (34%) opioid deaths in 2017. Following a decline in overdose deaths from prescription opioids (e.g., a high of 739 in 2016 to 515 deaths in 2019), the annual number of overdose deaths from prescription opioids increased in 2020 (595) and 2021 (645). The 2023 CDC data summary shows that the age-adjusted prescription opioid overdose death rate in Tennessee was 5.5 per 100,000, compared with 4.1 overall (38 jurisdictions) [91]. In 2020, the number of infants born dependent to drugs, having neonatal abstinence syndrome, totaled 824 in Tennessee [94].
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TENNESSEE DEPARTMENT OF HEALTH GUIDANCE
AFTER SURGERY Perioperative pain should be managed through a combination of targeted methods that includes management of patient expectation and anxiety, activity and mobilization when appropriate, and a trial of non-opioid pain medication for mild-to-moderate pain and opioid medication for severe pain [94]. Postoperative acute or intermittent pain analgesia often requires frequent titration. A 2- to 4-hour analgesic duration with short-acting hydrocodone, morphine, or oxycodone 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 [13; 14; 15]. 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 [27]. Although experts have noted that 75% to 90% of end-of-life pain can be managed effectively, rates of pain are high, even among people receiving palliative care [27; 28; 29; 30; 31; 32; 33; 34; 35; 36]. 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 [37]. This reluctance is related to a variety of attitudes and beliefs [27; 37]: • 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 overcoming these barriers. Every member of the healthcare team should reinforce accurate information about pain management with patients and families. The clinician should initiate conversations 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 [38]. 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 in the context of opioid use for cancer pain [27]. It is also helpful to note the difference between addiction and physical dependence.
In response to the emerging substance abuse epidemic, including a growing number of unintentional drug overdose deaths and an alarming number of infants born dependent on drugs and with signs of neonatal abstinence syndrome, the Tennessee Department of Health has published the Clinical Practice Guidelines for Outpatient Management of Chronic Non-Malignant Pain, last updated in 2024 [94]. In addition to recommendations for pre-treatment evaluation, initiation of prescription opioids, and ongoing opioid therapy for chronic pain, the Tennessee guidelines document includes an Appendix on practical issues relevant to pain management. Among the topics addressed are core competencies for clinician prescribers, mental health assessment tools, women’s issues, opioids and pregnancy, risk assessment tools, and prescription drug disposal. Following a review of naloxone usage and potential benefit in reversing the effects of opioid overdosing, a section regarding co-prescribing of naloxone with opioids was added to the 2020 guidelines appendix. The Tennessee Clinical Practice Guidelines for Management of Chronic Pain, 4th Edition, is available online at https:// www.tn.gov/content/dam/tn/health/healthprofboards/pain- management-clinic/ChronicPainGuidelines.pdf. PAIN SYNDROMES AND PRESCRIPTION OPIOID USE ACUTE PAIN Acute pain is defined as sudden in onset and self-limited (a duration of less than one month), often caused by injury, trauma, musculoskeletal strain, or surgery. For initial management of common, self-limited acute pain syndromes (e.g., acute low back pain), a multimodal approach is recommended, consisting of nonpharmacologic therapies (e.g., heat, massage, physical therapy), a two- to four-week trial of nonsteroidal anti-inflammatory drugs (NSAIDs), and a trial of a non-benzodiazepine muscle relaxant, if pain persists [94]. If, and when, opioids are prescribed for acute pain, clinicians should select the lowest effective dose of immediate-release opioids in a quantity no greater than that needed for the expected duration of severe pain. In most cases, three days or less will be sufficient; more than seven days will rarely be needed [10; 94]. However, it is important to note that this recommendation is based on emergency department prescribing guidelines for non-traumatic non-surgical pain [12]. It may be necessary to prescribe for longer periods in patients with acute severe pain.
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CHRONIC NON-MALIGNANT PAIN Chronic pain is defined as unremitting or daily recurring pain lasting more than three months. The management of chronic pain is among the most prevalent and vexing of clinical issues, a challenge common to physicians and nurses in every clinical discipline of care. As a matter of public health importance, approximately one in five adults in the United States suffered from some form of chronic pain in 2019, many of whom reported “high impact” chronic pain defined as having pain on most days or every day for the past three months that limited life or work activities [10]. Nonpharmacologic therapy and non-opioid pharmacologic therapy are the preferred first- line therapies for chronic pain. If opioids are required, they should be combined with nonpharmacologic therapy and/or 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 [10]. Healthcare professionals are obligated to know and apply best practice principles to the use of prescription opioids for management of chronic pain, including knowledge of opioid prescription drug selection and dosage, the associated risks of opioids, approaches to the assessment of pain and function, and appropriate pain management modalities. 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 with an adequate trial of non- opioid therapy or nonpharmacologic pain therapy, without satisfactory pain relief, are considered to be candidates for a trial of opioid therapy [9; 10]. Initial treatment should always be considered individually determined and as a trial of therapy, not a definitive course of treatment [11].
There are several other ways clinicians can allay patients’ fears about pain medication: • 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. Clinicians’ attitudes, beliefs, and experiences also influence cancer pain management, with addiction, tolerance, side effects, and regulations being the most important concerns [27; 34; 37; 39; 40; 41]. A lack of appropriate education and training in the assessment and management of pain has been noted to be a substantial contributor to ineffective pain management [37; 39; 41; 42]. As a result, many clinicians, especially primary care physicians, do not feel confident about their ability to manage pain in their patients [37; 39]. Clinicians require a clear understanding of available medications to relieve pain, including appropriate dosing, safety profiles, and side effects. If necessary, clinicians should consult with pain specialists to develop an effective approach. Strong opioids are used for severe pain at the end of life [30; 34; 43; 44]. Morphine, buprenorphine, oxycodone, hydromorphone, fentanyl, and methadone are the most widely used in the United States [45]. Unlike non-opioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. For an opioid-naïve patient or a patient who has been receiving low doses of a weak opioid, the initial dose should be low, and, if pain persists, the dose may be titrated up daily until pain is controlled. More than one route of opioid administration will be needed by many patients during end-of-life care, but in general, opioids should be given orally, as this route is the most convenient and least expensive. The transdermal route is preferred to the parenteral route, although dosing with a transdermal patch is less flexible and so may not be appropriate for patients with unstable pain [34]. Intramuscular injections should be avoided because injections are painful, drug absorption is unreliable, and the time to peak concentration is long [34].
CREATING A TREATMENT PLAN AND ASSESSMENT OF ADDICTION RISK
PRIOR TO INITIATING OPIOID THERAPY The Tennessee Chronic Pain Guidelines enumerate several key principles to follow when initiating opioid therapy [94]. Practitioners should bear in mind that prior opioid therapy alone is not sufficient reason to continue opioids, and reasonable non-opioid treatments should be tried first. The prescriber must also assess the patient’s risk for abuse, diversion, and addiction by such means as medical history, validated assessment tool, and state-controlled substance monitoring database. When prescription opioids are considered for women of childbearing age, providers should educate the patient about the risks of opioid use during pregnancy, including the risk of physical dependence and withdrawal in the newborn; upon initiation of opioid therapy, the provider should recommend reliable contraception. A urine drug test (UDT) should be performed before initiating any opioid or benzodiazepine
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_______________________________ Prescription Opioids and Pain Management: The Tennessee Guidelines
during pregnancy [94]. A thorough clinical examination, including appropriate laboratory testing and other elements supporting the plan of care, should be documented in the medical record. When the use of controlled substances is required for management of chronic pain, patients should not be treated through telemedicine. Before deciding to prescribe an opioid analgesic, clinicians should perform and document a detailed patient assessment that includes [1; 94]: • History of the patient’s pain condition and indications for opioid therapy, including nature and intensity of the pain, and impact on functioning ability and quality of life • Past and current pain treatments and patient response • Important comorbid conditions such as COPD, sleep apnea, diabetes, or congestive heart failure • Screening co-occurring anxiety, depression, and current or past substance use disorder • Social support, housing, and employment • Home environment (i.e., stressful or supportive) • Pain impact on sleep, mood, work, relationships, leisure, and substance use • Patient history of physical, emotional, or sexual abuse • The possibility of pregnancy, initially and on each subsequent visit The initial evaluation is intended to establish a current diagnosis that justifies the need for opioid medication. After this determination is made, it is important to assess the patient’s risk for drug misuse and develop and document a treatment plan, including a discussion of treatment goals. Opioid Misuse Risk Assessment Information obtained by patient history, physical examination, and interview, from family members, a spouse, or state Controlled Substance Monitoring Database (CSMD), and According to the American Society of Interventional Pain Physicians, before starting opioid therapy, clinicians must take certain basic steps to prevent opioid abuse: distinguish individual opioid abuse risk factors; screen patients’ potential for addiction and abuse during their initial visit; categorize patients in accordance with their level of risk and implement an appropriate level of monitoring; and refrain from judgments before a thorough assessment. Combining the above strategies with point-of-care urine drug testing as a confirmatory tool have been shown to contribute significantly to the identification of inconsistencies. 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 1 ). A UDT should be performed prior to initiating opioid treatment. 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 [10; 26]. (https://www.painphysicianjournal.com/current/pdf?a rticle=NDIwNA%3D%3D&journal=103. Last accessed September 28, 2025.) Level of Evidence : Expert Opinion/Consensus Statement
If substance abuse is active, in remission, or in the patient’s history, one should consult an addiction specialist before starting opioids [1]. In the setting of active substance abuse, opioids should not be prescribed until the patient is engaged in a treatment/recovery program or other arrangement is made, such as addiction professional co-management and additional monitoring. When considering an opioid analgesic (particularly those that are extended-release or long-acting), it is important to weigh the benefits against potential risks, such as overdose, misuse, physical dependence, adverse drug interactions, and accidental exposure by children [10; 16]. Screening and assessment tools can help guide patient stratification according to risk level and inform the appropriate degree of structure and monitoring in the treatment plan. It should be noted that despite widespread endorsement of screening tool use to help determine patient risk level, most tools have not been extensively evaluated, validated, or compared to each other [17]. Information on some of the more commonly used risk assessment tools is provided in the following sections. Opioid Risk Tool (ORT) The Opioid Risk Tool (ORT) is a brief, 10-item written questionnaire completed by the patient, designed to elicit personal and family history of psychiatric illness and prior drug/alcohol abuse. The assessment is used to predict likelihood for aberrant drug-related behavior and classify patients as low-, medium-, or high-risk [18]. Screener and Opioid Assessment for Patients with Pain- Revised (SOAPP-R) The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a 24-item, patient-administered questionnaire that assesses history of alcohol/substance use, psychological status, mood, impulsivity, cravings, and stress. It uses a five-point rating scale for each response and classifies patients as low or high risk in relation to potential aberrant drug-related behaviors and the appropriate extent of monitoring [19]. CAGE and CAGE-AID The original CAGE (Cut down, Annoyed, Guilty, and Eye- opener) Questionnaire consisted of four questions designed to help clinicians determine the likelihood that a patient was misusing or abusing alcohol. These same four questions were modified to create the CAGE-AID (adapted to include drugs), revised to assess the likelihood of current substance abuse [20]. Diagnosis, Intractability, Risk, and Efficacy (DIRE) Tool The Diagnosis, Intractability, Risk, and Efficacy (DIRE) risk assessment tool is a clinician/interviewer-derived rating scale based on the patient’s history, diagnosis, personal engagement in care, and psychiatric issues. The numerical score is used to predict patient compliance with long-term opioid therapy, and patients are classified as “not a suitable candidate” or “good candidate” for long-term opioid analgesia [21].
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Mental Health Screening Tool The Mental Health Screening Tool is a five-item screen that asks about a patient’s feelings of happiness, calmness, peacefulness, nervousness, and depression in the past month [22]. A lower score on this tool is an indicator that the patient should be referred to a specialist for pain management. The Tennessee Controlled Substance Monitoring Database The Tennessee CSMD is a prescription-monitoring program designed to provide healthcare practitioners with a cumulative record of a patient’s prior controlled substance prescription history [94]. Information sent to, contained in, and reported from the database is confidential and password protected. The data are available to a prescriber or dispenser (pharmacist) of a controlled substance to the extent the information relates to a current or bona fide prospective patient. The CSMD contains prescription information from all dispensers of controlled substances in Tennessee and also those dispensers who ship to patients residing in Tennessee, including from mail-order pharmacies and some Veterans Affairs pharmacies [94]. The information that is required to be submitted includes prescriber U.S. Drug Enforcement Administration (DEA) number, patient identifier, dispensing date, controlled substance national drug code number, quantity dispensed, strength, estimated day supply, and dispenser DEA number. All data in the CSMD are reported as submitted to the data collection website by the dispenser. Therefore, if there are any questions about the data, a practitioner should contact the dispenser identified in the report. All prescribers and dispensers of controlled substances in Tennessee must register for access to the CSMD [94]. Healthcare practitioners wishing to register with the CSMD to access prescription information are required to register at https://www.tncsmd.com. A prompt will appear requesting information used to validate the provider’s statutory authority to access CSMD data. A detailed discussion of the CSMD, including access, patient report content, and prescriber self- lookup reports, is available in the Tennessee Chronic Pain Guidelines [94]. Additional information about the CSMD as well as the Data Collection Manual can be obtained at the Tennessee CSMD website at https://www.tn.gov/health/ health-program-areas/health-professional-boards/csmd-board. html. When prescribing or dispensing a controlled substance, all healthcare providers must check the CSMD at each of the following stages of treatment [94]: • Prior to prescribing an opioid, benzodiazepine, or Schedule II amphetamine to a patient at the beginning of a new episode of treatment • Prior to the issuance of each new prescription for the opioid or other controlled substance during the first 90 days of a new episode of treatment • At least every six months when opioid/controlled substances are continued for chronic care
AGREEMENTS The initial opioid prescription is preceded by a written informed consent or “treatment agreement” [1]. This agreement should address the rationale for and appropriate use of a controlled medication and the mechanism of action, expected benefit, and limitations of therapy. It should also provide information regarding potential negative effects of controlled medication, including side effects, tolerance and/or physical dependence, drug interactions, motor skill impairment, limited evidence of long-term benefit, misuse, addiction, and drug diversion. Informed consent documents should include information regarding the risk/benefit profile for the drug(s) being prescribed and common-sense rules for using controlled medications safely. The prescribing policies should be clearly delineated, including the number/ frequency of refills, early refills, and procedures for lost or stolen medications. The treatment agreement also outlines joint physician and patient responsibilities. The prescriber’s responsibility is to address unforeseen problems and prescribe scheduled refills. The patient agrees to using medications safely, refraining from “doctor shopping,” and consenting to routine UDTs. Included is the expectation that a patient will inform the provider if she wishes to avoid unintended pregnancy and if she becomes pregnant. The Tennessee practice guidelines recommend that the practitioner obtain a signature indicating that any woman who wishes to become or is at risk to become pregnant has been educated about the risks and benefits of opioid treatment during her pregnancy [94]. The provider should discuss a method to prevent unintended pregnancy with every woman of child-bearing age who has reproductive capacity before opioids are prescribed. When there is a change or discontinuation of opioid treatment, the reasons should be documented. Agreements may also include sections related to follow-up visits, monitoring, and safe storage and disposal of unused drugs. The Tennessee Department of Health provides a sample Informed Consent/Controlled Substance Agreement and Patient Agreement/Treatment Attestation form in the Appendix of the Chronic Pain Management Guidelines [94]. THE TREATMENT PLAN AND INITIATING OPIOID THERAPY The use of opioids for treatment of chronic pain should be presented as a trial approach for a pre-defined period (e.g., ≤30 days). The goals of treatment should be established with all patients prior to initiation of opioid therapy, including reasonable improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use [1; 10]. It should be emphasized to the patient that the primary goal is to reduce pain and improve functioning ability, not necessarily to alleviate pain entirely. Pain management plans should describe the selected treatment, progress measures, and other diagnostic evaluations, consultations, and therapies. The plan should establish realistic goals and expectations that will
INFORMED CONSENT AND TREATMENT
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