Study Points

Strategies for Appropriate Opioid Prescribing: The Florida APRN/PA Requirement

Course #91152 - $18 -

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. 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.

    DEFINITIONS

    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 [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 opioid prescribing is thorough patient assessment, treatment 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 patients with pain, and how these potentially problematic behavioral responses to opioids both resemble and differ from physical dependence and pseudo-addiction. 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]. For example, a 2013 survey measuring 200 primary care physicians' understanding of opioids and addiction found that [3]:

    • 35% admitted knowing little about opioid addiction.

    • 66% and 57% viewed low levels of education and income, respectively, as causal or highly contributory to opioid addiction.

    • 30% believed opioid addiction "is more of a psychologic problem," akin to poor lifestyle choices rather than a chronic illness or disease.

    • 92% associated prescription analgesics with opioid addiction, but only 69% associated heroin with opioid addiction.

    • 43% regarded opioid dependence and addiction as synonymous.

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  2. The aging population contributes to the increasing prevalence of chronic pain in the United States.

    EPIDEMIOLOGY OF CHRONIC PAIN AND OPIOID MISUSE

    There is a widespread misperception that opioid analgesic prescribing and overdose continues to grow, fueling an opioid epidemic [13,14,15,16,17]. Data from a 2019 Centers for Disease Control and Prevention (CDC) surveillance report show that between 2006 and 2018, the annual prescribing rate per 100 persons decreased from 72.4 to 51.4 for all opioids, an overall reduction of 29.0% [18]. (Opioid prescriptions, including codeine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, propoxyphene, tapentadol, tramadol, and buprenorphine, were identified using the National Drug Code. Cough and cold formulations containing opioids were not included.) The rate for all opioid prescriptions initially increased annually by 1.9% from 2006 to 2012, but then decreased annually by 5.2% from 2012 to 2016, and continued to decrease annually by 12.4% from 2016 to 2018 [18].

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  3. In the absence of other risk factors, a patient prescribed opioids for chronic pain who has no personal or family history of alcohol or substance abuse is considered at medium risk for developing problematic opioid behavioral responses.

    INITIATION AND MANAGEMENT OF THE PATIENT WITH PAIN

    RISK STRATIFICATION FOR PATIENTS PRESCRIBED OPIOIDS

    Low Risk
    No past or current personal history of alcohol/substance use disorder (AUD/SUD)
    No or minimal co-occurring psychiatric disorders
    No family history of alcoholism or substance abuse
    Medium Risk
    Past history of AUD or SUD
    Moderate concomitant psychiatric disorders
    Family history of alcoholism or substance abuse/addiction
    Patient history of physical, emotional or sexual abuse, especially in childhood
    High Risk
    Patient actively addicted to or abusing opioids, illicit drugs or alcohol
    Untreated or poorly controlled major psychiatric disorder
    History of diversion, prescription forgery, selling their prescription drugs
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  4. The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) consists of five items.

    INITIATION AND MANAGEMENT OF THE PATIENT WITH PAIN

    The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a patient-administered, 24-item screen with questions addressing history of alcohol/substance use, psychologic status, mood, cravings, and stress. Like the ORT, the SOAPP-R helps assess risk level of aberrant drug-related behaviors and the appropriate extent of monitoring [66,67].

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  5. When implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function.

    INITIATION AND MANAGEMENT OF THE PATIENT WITH PAIN

    When implementing a chronic pain treatment plan that involves the use of opioids, the patient should be frequently reassessed for changes in pain origin, health, and function [1]. This can include input from family members and/or the state PDMP. During the initiation phase and during any changes to the dosage or agent used, patient contact should be increased. At every visit, chronic opioid response may be monitored according to the "5 A's" [75]:

    • Analgesia

    • Activities of daily living

    • Adverse or side effects

    • Aberrant drug-related behaviors

    • Affect (i.e., patient mood)

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  6. For patients considered at medium risk for misuse of prescription opioids, urine drug testing should be completed every month.

    INITIATION AND MANAGEMENT OF THE PATIENT WITH PAIN

    PATIENT RISK LEVEL AND FREQUENCY OF MONITORING

    Monitoring Tool Patient Risk Level
    Low Medium High
    Urine drug testEvery 1 to 2 yearsEvery 6 to 12 monthsEvery 3 to 6 months
    State prescription drug monitoring programTwice per year3 times per year4 times per year
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  7. There are no universal recommendations for the proper disposal of unused opioids.

    INITIATION AND MANAGEMENT OF THE PATIENT WITH PAIN

    There are no universal recommendations for the proper disposal of unused opioids, and patients are rarely advised of what to do with unused or expired medications [83]. According to the Office of National Drug Control Policy, most medications that are no longer necessary or have expired should be removed from their containers, mixed with undesirable substances (e.g., cat litter, used coffee grounds), and put into an impermeable, nondescript container (e.g., disposable container with a lid or a sealed bag) before throwing in the trash [84]. Any personal information should be obscured or destroyed. The FDA recommends that certain medications, including oxycodone/acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl (Duragesic Transdermal System), be flushed down the toilet instead of thrown in the trash [85]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so and no other disposal method is appropriate [85].

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  8. The Office of National Drug Control Policy is responsible for formulating federal standards for the handling of controlled substances.

    COMPLIANCE WITH STATE AND FEDERAL LAWS

    The DEA is responsible for formulating federal standards for the handling of controlled substances. In 2011, the DEA began requiring every state to implement electronic databases that track prescribing habits, referred to as PDMPs. Specific policies regarding controlled substances are administered at the state level.

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  9. All clinicians who prescribe or dispense controlled substances are required to report the action to the Electronic Florida Online Reporting of Controlled Substances Evaluation (E-FORCSE) within one business day.

    COMPLIANCE WITH STATE AND FEDERAL LAWS

    All clinicians who prescribe or dispense controlled substances are required to report the action to E-FORCSE as soon as possible, but no later than the close of the next business day [39]. This should be repeated each time the substance is dispensed. This reporting requirement is waived in certain circumstances, including for [103]:

    • The dispensing of a controlled substance in the healthcare system of the Department of Corrections

    • The dispensing of a controlled substance to a person younger than 16 years of age

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  10. Injecting medications meant for oral use is suggestive of an emerging opioid use disorder.

    IDENTIFICATION OF DRUG DIVERSION/SEEKING BEHAVIORS

    In addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [82,107,108]:

    • Selling medications

    • Prescription forgery or alteration

    • Injecting medications meant for oral use

    • Obtaining medications from nonmedical sources

    • Resisting medication change despite worsening function or significant negative effects

    • Loss of control over alcohol use

    • Using illegal drugs or non-prescribed controlled substances

    • Recurrent episodes of:

      • Prescription loss or theft

      • Obtaining opioids from other providers in violation of a treatment agreement

      • Unsanctioned dose escalation

      • Running out of medication and requesting early refills

    Behaviors with less association with opioid misuse include [82,107,108]:

    • Aggressive demands for more drug

    • Asking for specific medications

    • Stockpiling medications during times when pain is less severe

    • Using pain medications to treat other symptoms

    • Reluctance to decrease opioid dosing once stable

    • In the earlier stages of treatment:

      • Increasing medication dosing without provider permission

      • Obtaining prescriptions from sources other than the pain provider

      • Sharing or borrowing similar medications from friends/family

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.