MTM Pain Management & Opioid Stewardship 5 — Questions and Answers
Question 1: A pharmacist reviewing a patient's medication list notices fentanyl 50 mcg/hr patch, sertraline 100 mg daily, and tramadol 50 mg PRN. What serious drug interaction risk should be flagged?
- QTc prolongation from fentanyl and sertraline combination
- Serotonin syndrome from serotonergic activity of tramadol combined with sertraline (Correct answer)
- Additive anticholinergic toxicity
- Reduced fentanyl absorption from transdermal competition with sertraline
Correct answer: Serotonin syndrome from serotonergic activity of tramadol combined with sertraline
Tramadol inhibits serotonin reuptake and, combined with sertraline (an SSRI), significantly increases the risk of serotonin syndrome, a potentially life-threatening condition.
Question 2: What is the correct initial naloxone dose and route for reversing suspected opioid overdose in a community setting using the nasal spray formulation?
- 0.4 mg intramuscularly repeated every 5 minutes
- 4 mg intranasally into one nostril, repeated every 2–3 minutes if no response (Correct answer)
- 2 mg intravenously as a single bolus
- 8 mg intranasally divided between both nostrils simultaneously
Correct answer: 4 mg intranasally into one nostril, repeated every 2–3 minutes if no response
Narcan nasal spray 4 mg (one spray into one nostril) is the FDA-approved community dose, with repeat administration every 2–3 minutes if the patient does not respond.
Question 3: An MTM pharmacist is completing a comprehensive medication review for a 72-year-old on oxycodone 10 mg q6h. Which Beers Criteria concern is most relevant?
- Opioids are safe in all elderly patients if dosed correctly
- Opioids increase risk of falls, fractures, delirium, and respiratory depression in older adults (Correct answer)
- Only IV opioids are flagged by Beers Criteria in elderly patients
- Opioids are contraindicated by Beers only in patients with dementia
Correct answer: Opioids increase risk of falls, fractures, delirium, and respiratory depression in older adults
The AGS Beers Criteria identifies opioids as potentially inappropriate in older adults due to increased risks of falls, fractures, confusion, delirium, and respiratory depression.
Question 4: Which schedule classification does the DEA assign to hydrocodone combination products (e.g., Vicodin) as of 2014?
- Schedule III
- Schedule II (Correct answer)
- Schedule IV
- Schedule V
Correct answer: Schedule II
In 2014, the DEA reclassified hydrocodone combination products from Schedule III to Schedule II due to high abuse potential, requiring a written prescription with no refills.
Question 5: A patient with renal impairment (CrCl 20 mL/min) requires opioid analgesic therapy. Which opioid is generally preferred due to the absence of clinically significant active metabolite accumulation?
- Morphine
- Codeine
- Fentanyl (Correct answer)
- Hydromorphone
Correct answer: Fentanyl
Fentanyl is primarily metabolized to inactive metabolites and is generally preferred in renal impairment, whereas morphine, codeine, and hydromorphone have active or toxic metabolites that accumulate with decreased renal function.
Question 6: A patient expresses interest in tapering off long-term opioid therapy. What is the recommended initial taper rate to minimize withdrawal symptoms?
- Reduce the total dose by 50% immediately, then discontinue within 2 weeks
- Reduce by no more than 10% of the original dose per week, going more slowly as the dose decreases (Correct answer)
- Abruptly stop opioids if the total daily dose is below 40 MME/day
- Reduce by 25% every 3 days until the dose reaches zero
Correct answer: Reduce by no more than 10% of the original dose per week, going more slowly as the dose decreases
Slow tapers of ≤10% per week (or even slower near the end) minimize withdrawal discomfort and improve patient success in discontinuing long-term opioid therapy.
Question 7: Which of the following is a key element of an opioid treatment agreement (pain management agreement) that an MTM pharmacist should review with a patient?
- Agreement that the patient will not discuss pain management with other providers
- Expectations regarding urine drug testing, single pharmacy use, and safe storage of medications (Correct answer)
- Guarantee that opioid therapy will continue indefinitely as long as the patient is compliant
- Waiver of the patient's right to request medication changes
Correct answer: Expectations regarding urine drug testing, single pharmacy use, and safe storage of medications
Opioid treatment agreements outline patient responsibilities including urine drug testing, using a single prescriber and pharmacy, safe storage, and not sharing medications.
MTM Pain Management & Opioid Stewardship 5
A pharmacist reviewing a patient's medication list notices fentanyl 50 mcg/hr patch, sertraline 100 mg daily, and tramadol 50 mg PRN.
What serious drug interaction risk should be flagged?