MTM Pain Management & Opioid Stewardship 3 — Questions and Answers
Question 1: A patient on chronic opioid therapy presents with constipation that has not responded to standard laxatives. Which agent is specifically FDA-approved for opioid-induced constipation (OIC) in non-cancer patients?
- Lactulose
- Methylnaltrexone (Relistor) (Correct answer)
- Docusate sodium
- Lubiprostone (Amitiza) for all indications
Correct answer: Methylnaltrexone (Relistor)
Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist (PAMORA) FDA-approved for OIC that blocks GI opioid effects without reversing central analgesia.
Question 2: Which state-level monitoring program should a pharmacist consult before dispensing a Schedule II opioid to a new patient to identify potential 'doctor shopping'?
- FDA MedWatch
- Prescription Drug Monitoring Program (PDMP) (Correct answer)
- REMS program database
- DEA ARCOS database
Correct answer: Prescription Drug Monitoring Program (PDMP)
PDMPs are state-run electronic databases that track controlled substance prescriptions, helping pharmacists identify patients obtaining opioids from multiple prescribers.
Question 3: An MTM pharmacist identifies a patient on chronic opioids who scores 15 on the COMM (Current Opioid Misuse Measure). What does a score ≥9 on this scale indicate?
- The patient is at low risk and no further action is needed
- The patient is likely currently misusing opioids and warrants further evaluation (Correct answer)
- The patient has a confirmed opioid use disorder diagnosis
- The patient requires immediate hospitalization
Correct answer: The patient is likely currently misusing opioids and warrants further evaluation
A COMM score ≥9 suggests probable current opioid misuse and should prompt the clinician to reassess the treatment plan and consider addiction specialist referral.
Question 4: Naloxone dispensed for opioid overdose reversal primarily works by which mechanism?
- Competitive antagonism at mu-opioid receptors (Correct answer)
- Stimulating respiratory drive via adenosine receptors
- Enhancing GABA-mediated sedation reversal
- Partial agonism at kappa-opioid receptors
Correct answer: Competitive antagonism at mu-opioid receptors
Naloxone competitively antagonizes mu-opioid receptors, rapidly reversing opioid-induced respiratory depression, sedation, and analgesia.
Question 5: A cancer patient requires around-the-clock opioid therapy with a short-acting agent for breakthrough pain. What is the standard recommendation for breakthrough dose as a percentage of the total daily opioid dose?
- 1–5% of the total daily dose every 1–2 hours as needed
- 10–15% of the total daily dose every 4–6 hours as needed (Correct answer)
- 25% of the total daily dose every 8 hours as needed
- 50% of the total daily dose every 12 hours as needed
Correct answer: 10–15% of the total daily dose every 4–6 hours as needed
Breakthrough doses are typically 10–15% of the total daily opioid dose (equivalent to 1/6 of the 24-hour dose), given every 1–4 hours as needed.
Question 6: Which opioid rotation strategy is recommended to reduce incomplete cross-tolerance and prevent underdosing when switching between opioids?
- Use the full equianalgesic dose of the new opioid without adjustment
- Reduce the calculated equianalgesic dose of the new opioid by 25–50% (Correct answer)
- Increase the calculated equianalgesic dose by 20% to account for tolerance
- Use a 1:1 mg ratio regardless of the opioids involved
Correct answer: Reduce the calculated equianalgesic dose of the new opioid by 25–50%
Due to incomplete cross-tolerance, the equianalgesic dose of the new opioid is typically reduced by 25–50% to avoid inadvertent overdose.
Question 7: What is the primary role of a Risk Evaluation and Mitigation Strategy (REMS) for extended-release/long-acting (ER/LA) opioids?
- To replace state PDMPs as the sole monitoring tool
- To ensure prescribers, pharmacists, and patients understand serious risks and safe use (Correct answer)
- To restrict opioid prescribing exclusively to pain management specialists
- To mandate urine drug screening at every patient visit
Correct answer: To ensure prescribers, pharmacists, and patients understand serious risks and safe use
The ER/LA Opioid Analgesics REMS requires prescriber education, patient counseling via Medication Guides, and emphasizes appropriate patient selection to mitigate risks of misuse, abuse, addiction, overdose, and death.
MTM Pain Management & Opioid Stewardship 3
A patient on chronic opioid therapy presents with constipation that has not responded to standard laxatives.
Which agent is specifically FDA-approved for opioid-induced constipation (OIC) in non-cancer patients?