A 59-year-old woman comes to the office to follow up for chronic back pain caused by a motor vehicle collision. A month ago, the patient was given scheduled-dose oral morphine. Her pain level has decreased from 8 to 3 on a scale of 0-10, and pain no longer interferes with activities of daily living. There has been no drowsiness, constipation, or nausea. Other medications include naproxen, acetaminophen, and a lidocaine patch as needed. Temperature is 37 C (98.6 F), blood pressure is 114/76 mm Hg, pulse is 64/min, and respirations are 12/min. On examination, the back has greater range of motion than it did during the last visit. Which of the following would be most helpful in the early detection of prescription opioid misuse in this patient?

Question

A 59-year-old woman comes to the office to follow up for chronic back pain caused by a motor vehicle collision.  A month ago, the patient was given scheduled-dose oral morphine.  Her pain level has decreased from 8 to 3 on a scale of 0-10, and pain no longer interferes with activities of daily living.  There has been no drowsiness, constipation, or nausea.  Other medications include naproxen, acetaminophen, and a lidocaine patch as needed.  Temperature is 37 C (98.6 F), blood pressure is 114/76 mm Hg, pulse is 64/min, and respirations are 12/min.  On examination, the back has greater range of motion than it did during the last visit.  Which of the following would be most helpful in the early detection of prescription opioid misuse in this patient?

Quizplus · Accepted Answer

11ec25c8_d755_e4c5_bc81_0bac30bf3ef8_MD0003_00 Opioids account for three-quarters of all fatal prescription drug overdoses; early identification of misuse is critical in ensuring patient safety. Opioid misuse is defined as taking the medication in a way that deviates from the manner (eg, overuse, diversion) and purpose (eg, relieve anxiety) for which it was prescribed. Obtaining opioids from multiple prescribers, taking nonprescribed opioids, and concurrently using recreational drugs or other nonprescribed controlled substances also constitute misuse. The prescription drug monitoring program (PDMP) is a helpful tool for detecting misuse. The state-specific PDMP is a record of prescribed controlled substances that the patient has obtained, including the quantities, dates the prescriptions were filled, and prescriber information. The PDMP can identify patients who are receiving opioids from multiple prescribers, suggesting possible overuse or diversion. The database should be queried before each refill to help ensure appropriate use. (Choices A and B) Functional capacity (eg, range of motion) and pain level should be assessed at each visit to determine the efficacy of therapy and to guide dose adjustments when necessary. These evaluations do not provide information on misuse. (Choice C) Patient vital signs can demonstrate evidence of acute opioid intoxication (eg, bradypnea, bradycardia, hypotension) but would not indicate misuse without acute intoxication. (Choice D) Urine drug screenings can identify diversion (eg, test is negative for opioids), recreational drug use, and concurrent use of other controlled substances undivulged by the patient. However, they are best done randomly because scheduled screenings can lead to patient preparation that would misrepresent screening results. Educational objective: The prescription drug monitoring program records prescribed controlled substances that the patient received, including quantities, dates the prescriptions were filled, and prescriber information. This database can identify patients who are obtaining opioids from multiple prescribers, thereby raising concern for overuse or diversion. References: Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: evidence from the National Survey of Drug Use and Health. (http://www.ncbi.nlm.nih.gov/pubmed/28152391) Impact of prescription drug monitoring programs (PDMPs) on opioid utilization among Medicare beneficiaries in 10 U.S. states. (http://www.ncbi.nlm.nih.gov/pubmed/28498498)

A 59-Year-Old Woman Comes to the Office to Follow Up