MTM Pain Management & Opioid Stewardship 4 — Questions and Answers
Question 1: A patient with moderate hepatic impairment requires opioid therapy. Which opioid should be used with the MOST caution due to active metabolite accumulation?
- Fentanyl
- Morphine (Correct answer)
- Buprenorphine
- Hydromorphone
Correct answer: Morphine
Morphine's active metabolite morphine-6-glucuronide (M6G) accumulates with hepatic or renal impairment and can cause prolonged sedation and respiratory depression.
Question 2: Buprenorphine/naloxone (Suboxone) is used in medication-assisted treatment (MAT) for opioid use disorder. Why is naloxone included in this formulation?
- To enhance the analgesic effect of buprenorphine
- To prevent parenteral misuse by precipitating withdrawal if injected (Correct answer)
- To increase bioavailability of buprenorphine when taken sublingually
- To treat constipation caused by buprenorphine
Correct answer: To prevent parenteral misuse by precipitating withdrawal if injected
Naloxone has very low sublingual bioavailability but is rapidly absorbed if injected, precipitating immediate opioid withdrawal and deterring parenteral abuse.
Question 3: During an MTM session, a patient on long-term opioids reports new-onset fatigue, low libido, and depression. Which opioid-related endocrine effect should the pharmacist suspect?
- Opioid-induced hyperalgesia
- Opioid-induced androgen deficiency (OPIAD) (Correct answer)
- Adrenal insufficiency from cortisol overproduction
- Hypothyroidism secondary to receptor downregulation
Correct answer: Opioid-induced androgen deficiency (OPIAD)
Chronic opioid use suppresses the hypothalamic-pituitary-gonadal axis, causing opioid-induced androgen deficiency (OPIAD), which presents with fatigue, low libido, depression, and sexual dysfunction.
Question 4: Opioid-induced hyperalgesia (OIH) differs from opioid tolerance in which key way?
- OIH is managed by increasing the opioid dose, while tolerance requires dose reduction
- OIH results in increased pain sensitivity despite adequate dosing, while tolerance is reduced efficacy requiring higher doses (Correct answer)
- OIH only occurs with high-dose opioids, while tolerance occurs only at low doses
- OIH and tolerance are clinically indistinguishable and treated identically
Correct answer: OIH results in increased pain sensitivity despite adequate dosing, while tolerance is reduced efficacy requiring higher doses
OIH is a paradoxical increased pain sensitivity caused by opioids themselves, whereas tolerance is diminished analgesic effect; OIH may improve with opioid dose reduction or rotation.
Question 5: A pharmacist is counseling on safe storage and disposal of unused opioids. Which method is FDA-recommended as the preferred disposal route when a drug take-back location is unavailable?
- Flushing down the toilet for all opioids
- Mixing with coffee grounds in a sealed bag and discarding in household trash (Correct answer)
- Returning to the prescriber's office for incineration
- Dissolving in water and pouring down the sink
Correct answer: Mixing with coffee grounds in a sealed bag and discarding in household trash
The FDA recommends mixing unused opioids with an undesirable substance like coffee grounds or dirt in a sealed container and disposing in household trash when take-back programs are unavailable.
Question 6: According to the 2022 CDC Clinical Practice Guideline, what is recommended regarding the duration of opioid therapy for acute non-surgical pain?
- Opioids should not be prescribed for acute pain under any circumstances
- The lowest effective dose for the shortest duration is preferred, typically no more than a few days (Correct answer)
- A 30-day supply is standard to prevent early return visits
- Opioids should be prescribed for at least 14 days to ensure adequate analgesia
Correct answer: The lowest effective dose for the shortest duration is preferred, typically no more than a few days
The 2022 CDC guideline recommends prescribing the lowest effective opioid dose for the shortest duration needed, often just a few days, for acute non-surgical pain.
Question 7: Which adjuvant analgesic is considered first-line for neuropathic pain conditions such as diabetic peripheral neuropathy, prior to initiating opioid therapy?
- Acetaminophen
- Gabapentin or pregabalin (Correct answer)
- Ibuprofen
- Tramadol
Correct answer: Gabapentin or pregabalin
Gabapentinoids (gabapentin, pregabalin) are first-line agents for neuropathic pain per multiple guidelines, acting on alpha-2-delta calcium channel subunits to reduce aberrant neuronal firing.
MTM Pain Management & Opioid Stewardship 4
A patient with moderate hepatic impairment requires opioid therapy.
Which opioid should be used with the MOST caution due to active metabolite accumulation?