BCACP Pain Management and Opioid Stewardship — Questions and Answers
Question 1: A patient on morphine 30 mg oral every 4 hours (180 mg/day) requires conversion to oxycodone due to adverse effects. Using standard equianalgesic conversion (oral morphine to oral oxycodone ratio of 1.5:1), what is the approximate total daily oxycodone dose?
- 90 mg/day
- 120 mg/day (Correct answer)
- 180 mg/day
- 270 mg/day
Correct answer: 120 mg/day
The equianalgesic ratio is oral morphine 30 mg = oral oxycodone 20 mg (ratio 1.5:1). Therefore, 180 mg morphine/day ÷ 1.5 = 120 mg oxycodone/day. In clinical practice, a 25–33% dose reduction is typically applied when rotating opioids to account for incomplete cross-tolerance, making the practical starting dose even lower, but the direct equianalgesic conversion yields 120 mg/day.
Question 2: Which validated tool is MOST commonly used in ambulatory care to assess a patient's risk for opioid misuse or aberrant drug-related behaviors BEFORE initiating long-term opioid therapy?
- PHQ-9 (Patient Health Questionnaire-9)
- ORT (Opioid Risk Tool) (Correct answer)
- AUDIT-C (Alcohol Use Disorders Identification Test)
- CAGE questionnaire
Correct answer: ORT (Opioid Risk Tool)
The Opioid Risk Tool (ORT) is a brief, validated 5-item screening tool specifically designed to predict aberrant drug-related behaviors in patients prescribed opioids for chronic pain. It stratifies patients as low, moderate, or high risk. PHQ-9 screens for depression. AUDIT-C and CAGE screen for alcohol use disorder. While all may provide useful clinical context, the ORT is the tool designed specifically for pre-opioid prescribing risk assessment.
Question 3: A pharmacist is counseling a patient on naloxone use. The patient's caregiver asks when to administer naloxone. Which clinical sign is the MOST important indicator of opioid overdose requiring immediate naloxone administration?
- Nausea and vomiting after taking opioids
- Excessive sedation and miosis (pinpoint pupils)
- Slow, shallow respirations (fewer than 12 breaths per minute) with unresponsiveness (Correct answer)
- Constipation and urinary retention
Correct answer: Slow, shallow respirations (fewer than 12 breaths per minute) with unresponsiveness
The hallmark indication for naloxone administration is respiratory depression — specifically slow, shallow breathing (fewer than 12 breaths/min) combined with unresponsiveness or unconsciousness. This represents life-threatening opioid toxicity. Sedation and miosis are expected opioid effects and do not alone require naloxone. Nausea and constipation are common opioid side effects, not overdose signs. The opioid overdose triad is: pinpoint pupils + respiratory depression + unconsciousness.
Question 4: According to the CDC Clinical Practice Guideline for Prescribing Opioids (2022), which of the following is the recommended approach for a patient with chronic non-cancer pain who is opioid-naive?
- Begin with a long-acting opioid to provide consistent analgesia throughout the day
- Prescribe the highest dose needed to achieve complete pain relief as the primary goal
- Start with non-opioid therapies; if opioids are used, begin with the lowest effective dose of immediate-release opioids (Correct answer)
- Opioids are absolutely contraindicated in all chronic non-cancer pain and should never be initiated
Correct answer: Start with non-opioid therapies; if opioids are used, begin with the lowest effective dose of immediate-release opioids
The 2022 CDC guideline emphasizes that non-opioid therapies (physical therapy, NSAIDs, SNRIs, anticonvulsants, cognitive behavioral therapy) are preferred for chronic non-cancer pain. If opioids are initiated, the guideline recommends the lowest effective dose of immediate-release opioids, starting low and titrating cautiously. Long-acting opioids are not recommended as initial therapy. Complete pain elimination is not a realistic or recommended goal; functional improvement is the target.
Question 5: A patient with chronic low back pain and depression is seeking pharmacological treatment that may address both conditions. Which non-opioid analgesic class has dual evidence for both chronic musculoskeletal pain and depression?
- SNRIs (e.g., duloxetine) (Correct answer)
- COX-2 inhibitors (e.g., celecoxib)
- Gabapentin
- Topical diclofenac
Correct answer: SNRIs (e.g., duloxetine)
SNRIs such as duloxetine (Cymbalta) are FDA-approved for both major depressive disorder and chronic musculoskeletal pain conditions including chronic low back pain, diabetic peripheral neuropathy, and fibromyalgia. This dual mechanism (norepinephrine and serotonin reuptake inhibition) provides analgesic and antidepressant effects. COX-2 inhibitors and topical diclofenac have analgesic but no antidepressant properties. Gabapentin treats neuropathic pain but is not approved for depression.
Question 6: A patient on long-term opioid therapy for chronic pain presents for a routine monitoring visit. Which of the following is a recommended component of ongoing monitoring according to opioid prescribing guidelines?
- Monthly complete blood count to monitor for opioid-induced cytopenias
- Urine drug screening and prescription drug monitoring program (PDMP) check (Correct answer)
- Weekly liver function tests due to opioid hepatotoxicity risk
- Routine cardiac stress testing due to QTc prolongation from all opioids
Correct answer: Urine drug screening and prescription drug monitoring program (PDMP) check
CDC guidelines and state-level opioid prescribing policies recommend urine drug testing (to verify adherence and screen for undisclosed substance use) and checking the Prescription Drug Monitoring Program (PDMP) at each visit or at minimum at the start of therapy and periodically thereafter. CBCs and LFTs are not routinely indicated for opioid monitoring. QTc monitoring is specific to methadone, not all opioids.
