Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170:1155-1160.
Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Medicine. 2005;69:432-442.
Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). J Pain Symptom Manage. 2006;32:287-293.
Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: Volume 1. Summary of National Findings. NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012
Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses -- a US epidemic. MMWR Morb Mort Wkly Rep. 2012:61:10-13.
National Institute on Drug Abuse. Research Report Series: Prescription Drugs: Abuse and Addiction. 2011. http://www.drugabuse.gov/sites/default/files/rrprescription.pdf
Fishbain DA, Rosomoff HL, Rosomoff RS. Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain. 1992;8:77-85.
Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patinets on opioid therapy in a large US health-care system. Addiction. 2010;105:1776-1782.
Brown J, Setnik B, Lee K, et al. Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting. J Opioid Manag. 2011;7:467-483.
Michna E, Ross EL, Hynes WL, et al. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage. 2004;28:250-258.
Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-112.
Gourlay DL, Heit HA. Universal precautions revisited: managing the inherited pain patient. Pain Med. 2009;10:S115-S123.
Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349:1943-1953.
Eisenberg E, McNicol ED, Carr DB. Efficacy and safety of opioid agonists in the treatment of neuropathic pain of nonmalignant origin: systematic review and meta-analysis of randomized controlled trials. JAMA. 2005;293:3043-3052.
Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146:116-127.
Passik SD, Kirsh KL. Assessing aberrant drug-taking behaviors in the patient with chronic pain. Curr Pain Headache Res. 2004;8:289-294.
American Medical Association. Informed Consent. American Medical Association 2012. http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.page?. Accessed 8/9/2012.
Paterick TJ, Carson GV, Allen MC, Paterick TE. Medical informed consent: general considerations for physicians. Mayo Clin Proc. 2008;83:313-319.
Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14:123-143.
McCarberg BH. A critical assessment of opioid treatment adherence using urine drug testing in chronic pain management. Postgrad Med. 2011;123:124-131.
Carroll CP, Haythornthwaite J. Maladaptive opioid use behaviors and psychiatric illness: what should we do with what we know? Curr Pain Headache Rep. 2011;15:91-93.
Miller NS, Gold MS. Opiate prescription medication dependence and pain perceptions. J Addict Dis. 2007;26(Suppl 1):65-71.
Weissman DE, Haddox JD. Opioid pseudoaddiction -- an iatrogenic syndrome. Pain. 1989;36:363-366.
Passik SD, Kirsh KL, Whitcomb L, et al. A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin Ther. 2007;26:552-561.
Smith HS, Kirsh KL. Documentation and potential tools in long-term opioid therapy for pain. Anesthesiology Clin. 2007;25:809-823.
Butler SF, Budman SH, Fernandez KC, et al. Development and validation of the Current Opioid Misuse Measure. Pain. 2007;130:144-156.
Weiss RD, Potter JS, Provost SE, et al. A multi-site, two-phase Prescription Opioid Addiction Treatment Study (POATS): rationale, design, and methodology. Contemp Clin Trials. 2010;31:189-199.
Weiss RD, Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68:1238-1246.

CME/CE

Managing Pain Patients Who Abuse Prescription Drugs

Authors: Gayathri J. Dowling, PhD; Richard A. Denisco, MD
CME/CE Released: 9/26/2012; Reviewed and Renewed: 10/2/2014
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 10/2/2015, 11:59 PM EST

Target Audience and Goal Statement

This activity is intended for primary care providers, neurologists, anesthesiologists, pain specialists, obstetrician/gynecologists, orthopedists, nurse practitioners, nurses and other healthcare practitioners who manage patients with chronic pain.

The goal of this activity is to describe the symptoms and prevalence of opioid addiction and dependence in patients with chronic pain, and the steps clinicians can take to screen for, prevent, and treat such these conditions.

Upon completion of this activity, participants will be able to:

Develop strategies to assess and monitor patients taking opioids for abuse and potential diversion of medication
Propose communication strategies to engage patients in dialog focused on treatment of prescription drug abuse or addiction
Formulate treatment management and possible referral plans to prevent and address opioid addiction in patients with a diagnosis of chronic pain

Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Author(s)

Gayathri J. Dowling, PhD

Acting Chief, Science Policy Branch, National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, Bethesda, MD

Disclosures

Disclosure: Gayathri J. Dowling, PhD has disclosed no relevant financial relationships.

Dr Dowling does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

Dr Dowling does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Richard A. Denisco, MD

Medical Officer, National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, Bethesda, MD

Disclosures

Disclosure: Richard A. Densico, MD, has disclosed no relevant financial relationships.

Dr. Denisco does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

Dr. Denisco does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editor(s)

Jane Lowers

Group Scientific Director, Medscape LLC

Disclosures

Disclosure: Jane Lowers has disclosed no relevant financial relationships.

Colleen Quinn

Clinical Editor, Medscape, LLC

Disclosures

Disclosure: Colleen Quinn has disclosed no relevant financial relationships.

Writer(s)

Lynne Kolton Schneider, PhD

Freelance writer, Boca Raton, Florida

Disclosures

Disclosure: Lynne Kolton Schneider has disclosed no relevant financial relationships.

Additional Planners/Reviewers

Robert Carroll, PhD, RN

Project director, IQ Solutions, Rockville, MD

Disclosures

Disclosure: Robert Carroll, PhD, RN, has disclosed no relevant financial relationships.

Denise Crute, MA

Director of training, IQ Solutions, Rockville, MD

Disclosures

Disclosure: Denise Crute, MA has disclosed no relevant financial relationships.

Bill H. McCarberg, MD

Primary Care Physician, Adjunct Assistant Clinical Professor, University of California, San Diego; Founder, Chronic Pain Management Program, Kaiser Permanente, San Diego, California

Disclosures

Disclosure: Bill McCarberg, MD, has disclosed the following relevant financial relationships:
Served as an advisor or consultant for: PriCara; Forest Laboratories, Inc.; Endo Pharmaceuticals; Sucampo Pharmaceuticals, Inc.; NeurogesX, Inc.; Teva Pharmaceuticals; Insys Therapeutics, Inc; QRX Pharma Ltd; Salix Pharmaceuticals, Inc.

CME Reviewer(s)

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

Nurse Planner

Laurie E. Scudder, DNP, NP

Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC

Disclosures

Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.

Accreditation Statements

For Physicians

Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Medscape, LLC designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.

Contact This Provider

For Nurses

Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Awarded 1.75 contact hour(s) of continuing nursing education for RNs and APNs; 1.75 of these credits is in the area of pharmacology.

Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

Read the target audience, learning objectives, and author disclosures.
Study the educational content online or printed out.
Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

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The following test-and-teach case is an educational activity modeled on the interactive grand rounds approach. The questions within the activity are designed to test your current knowledge. After each question, you will see whether you answered correctly and can then read evidence-based information that supports the most appropriate answer choice. Please note that these questions are designed to challenge you; you will not be penalized for answering the questions incorrectly. At the end of the case, there will be a short posttest assessment based on material covered in the activity.

Case Presentation

Edward, a 52-year-old warehouse employee, injured his back at home getting ready for a move out of state. It is now 2 months later and he is in your office as a new patient. He describes the pain at 7/10, aching in the center of the back without radiation, and no numbness or weakness and no bowel or bladder dysfunction. The pain is worse with bending, cough, or straining with bowel movements.

You have no chart, but the patient describes an initial treatment plan by a prior provider consisting of ibuprofen, tizanidine, ice, heat, stretching, and later physical therapy. He was seen by a physiatrist after a magentic resonance imaging (MRI) showed multilevel disc disease without encroachment. An epidural steroid injection under fluoroscopy did not help to alleviate his pain. Edward is now unemployed and spends much of his day in bed due to continued disabling pain, even though he's on hydrocodone/acetaminophen 10/325 mg 6 pills a day. He currently appears sleepy with diminished affect and is asking for something stronger than the hydrocodone.

The physical exam shows tight muscles in the low back with diffuse tenderness and triggering of the pain down the right leg. His range of motion is restricted by pain, with a negative neurologic exam including a normal straight leg raise. Provocative testing of the sacroiliac joint and piriformis muscle are negative.

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Disclaimer

The educational activity presented above may involve simulated case-based scenarios. The patients depicted in these scenarios are fictitious and no association with any actual patient is intended or should be inferred.

The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that support educational programming on medscape.org. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.

References

Faculty and Disclosures

Author(s)

Gayathri J. Dowling, PhD

Richard A. Denisco, MD

Editor(s)

Jane Lowers

Colleen Quinn

Writer(s)

Lynne Kolton Schneider, PhD

Additional Planners/Reviewers

Robert Carroll, PhD, RN

Denise Crute, MA

Bill H. McCarberg, MD

CME Reviewer(s)

Nafeez Zawahir, MD

Nurse Planner

Laurie E. Scudder, DNP, NP

CME/CE

Managing Pain Patients Who Abuse Prescription Drugs

Target Audience and Goal Statement

Disclosures

Author(s)

Gayathri J. Dowling, PhD

Richard A. Denisco, MD

Editor(s)

Jane Lowers

Colleen Quinn

Writer(s)

Lynne Kolton Schneider, PhD

Additional Planners/Reviewers

Robert Carroll, PhD, RN

Denise Crute, MA

Bill H. McCarberg, MD

CME Reviewer(s)

Nafeez Zawahir, MD

Nurse Planner

Laurie E. Scudder, DNP, NP

Accreditation Statements

For Physicians

For Nurses

Instructions for Participation and Credit

Managing Pain Patients Who Abuse Prescription Drugs

Case Presentation