MTM Pain Management & Opioid Stewardship 2 — Questions and Answers
Question 1: A patient on long-term opioid therapy reports their pain is well-controlled but expresses concern about dependence. Which statement best distinguishes physical dependence from addiction?
- Physical dependence means the body adapts to the drug and withdrawal occurs if stopped abruptly, while addiction involves compulsive use despite harm (Correct answer)
- Physical dependence and addiction are the same condition requiring the same treatment approach
- Physical dependence always progresses to addiction in patients on long-term opioids
- Addiction is defined solely by the need for increasing doses over time
Correct answer: Physical dependence means the body adapts to the drug and withdrawal occurs if stopped abruptly, while addiction involves compulsive use despite harm
Physical dependence is a physiological adaptation where abrupt discontinuation causes withdrawal, whereas addiction is a behavioral disorder characterized by compulsive use despite adverse consequences.
Question 2: Which opioid analgesic has the longest half-life and poses the greatest risk of accumulation in elderly patients?
- Oxycodone
- Hydromorphone
- Methadone (Correct answer)
- Tramadol
Correct answer: Methadone
Methadone has an unpredictable and prolonged half-life (8–59 hours), making it prone to accumulation and delayed toxicity, especially in elderly patients.
Question 3: Under the CDC Opioid Prescribing Guidelines, what is the recommended maximum daily morphine milligram equivalent (MME) threshold that should prompt clinician reassessment of risks?
- 50 MME/day
- 90 MME/day (Correct answer)
- 120 MME/day
- 200 MME/day
Correct answer: 90 MME/day
The CDC guideline recommends reassessing risks and benefits when doses reach or exceed 90 MME/day, as overdose risk increases significantly at this threshold.
Question 4: A pharmacist performs MTM for a patient taking oxycodone and alprazolam. What is the primary concern with this combination?
- Reduced opioid analgesic efficacy due to enzyme induction
- Synergistic CNS and respiratory depression increasing overdose risk (Correct answer)
- Increased risk of serotonin syndrome
- Reduced benzodiazepine anxiolytic effect
Correct answer: Synergistic CNS and respiratory depression increasing overdose risk
Concurrent opioid and benzodiazepine use causes additive CNS and respiratory depression, substantially increasing the risk of fatal overdose.
Question 5: Which tool is most appropriate for an MTM pharmacist to use when screening a patient for opioid misuse risk before initiating long-term opioid therapy?
- PHQ-9
- ORT (Opioid Risk Tool) (Correct answer)
- CAGE questionnaire
- GAD-7
Correct answer: ORT (Opioid Risk Tool)
The Opioid Risk Tool (ORT) is a validated 5-item screening tool used to stratify patients into low, moderate, or high risk for opioid aberrant behaviors.
Question 6: A patient is being transitioned from IV morphine to oral oxycodone. Using equianalgesic dosing, how does 10 mg IV morphine compare to oral oxycodone?
- 10 mg IV morphine ≈ 10 mg oral oxycodone
- 10 mg IV morphine ≈ 15 mg oral oxycodone (Correct answer)
- 10 mg IV morphine ≈ 20 mg oral oxycodone
- 10 mg IV morphine ≈ 30 mg oral oxycodone
Correct answer: 10 mg IV morphine ≈ 15 mg oral oxycodone
10 mg IV morphine is approximately equianalgesic to 20–30 mg oral morphine, and oral oxycodone is roughly 1.5 times as potent as oral morphine, yielding approximately 15 mg oral oxycodone.
Question 7: Which non-pharmacological intervention has the strongest evidence for chronic low back pain management as a first-line approach before initiating opioids?
- Acupuncture alone
- Cognitive behavioral therapy and exercise (Correct answer)
- TENS (transcutaneous electrical nerve stimulation)
- Massage therapy alone
Correct answer: Cognitive behavioral therapy and exercise
Cognitive behavioral therapy combined with exercise has the strongest evidence base for chronic low back pain and is recommended as first-line non-pharmacological treatment by multiple guidelines.
MTM Pain Management & Opioid Stewardship 2
A patient on long-term opioid therapy reports their pain is well-controlled but expresses concern about dependence.
Which statement best distinguishes physical dependence from addiction?