SCOPE of Pain: Safe & Competent Opioid Prescribing Education

Your medical director states that over the next six months, all patients on opioids must be decreased below 90 morphine milligram equivalents as per the mandate of the CDC guideline. What does the CDC guideline say about a dosing threshold of 90 morphine milligram equivalents?

A patient is afraid receiving postoperative opioid analgesics will result in opioid addiction. How will you educate this patient about the risks and benefits of opioids for managing her postoperative pain?

A patient with a twisted ankle requests a prescription for oxycodone. How will you respond to his request for opioids for his acute pain?

How will you manage a patient's chronic pain and likely opioid use disorder after her opioid overdose?

Your medical director states all patients on chronic opioid therapy should be tapered, as there's no evidence opioids are effective for chronic pain. What is the actual efficacy of opioids for chronic pain?

How do you educate your medical director about the importance and benefits of offering medications, such as buprenorphine for the treatment of patients with opioid use disorder?

Your surgical colleague asks if your patient who is taking buprenorphine for his opioid use disorder should stop before hip replacement surgery and requests your guidance on how to manage postoperative pain in this patient. What will you recommend?

You get an anonymous phone call stating your patient, who you've been treating with chronic opioids for chronic pain for the past six months, is selling his opioids. How will you respond to this concerning, anonymous call regarding potential opioid diversion by your patient?

A patient treated with long-term high-dose opioids for chronic pain insists on having her opioid dose increased to improve her pain management and refuses to consider adding other non-opioid medications or accepting referrals to other forms of pain treatment, including physical therapy, cognitive behavioral therapy or acupuncture. How will you respond to this patient's lack of interest in other chronic pain management strategies?

Your patient, who you've been treating with chronic opioids for chronic painful diabetic neuropathy for the past 11 months calls the on-call service asking for an early refill. She states her pain has worsened, she took extra tablets and has run out early.

When discussing tapering a patient's opioids due to lack of benefit and apparent harm, she continues to request a higher opioid dose. She states her pain is so severe she's unable to get out of bed most days. She angrily says if you don't increase her dose, she's going to report you to the board of medicine for abandoning her. How will you respond to this patient's response to your plans for an opioid taper?

A new patient has been treated with high-dose opioids, extended-release morphine, (100 mg twice per day) for chronic back pain after multiple failed surgeries. His previous primary care physician recently retired and gave him enough opioid until his visit with you today. He's requesting an opioid prescription at today's visit. How will you respond?

Your long-term patient who is stable on chronic low-dose opioids for chronic pain complains he feels the front desk and lab staff treat him like a heroin addict. How do you address this patient's concerns?

When discussing tapering your patient's opioid due to lack of benefit, functional decline and apparent harm (she fell asleep while smoking), she angrily states, "I thought you trusted me. I thought we had a good relationship," and then asks, "Can you give me enough until I find a new doctor?"

Your patient, who has been stable on chronic low-dose opioids for chronic pain, discloses he started buying cannabis from his friend to treat his pain and help him sleep. What changes will you make in his treatment plan and how will you communicate with the patient about his cannabis use?

Your patient, who has been stable on chronic, low-dose opioids for chronic pain for the past three years with excellent pain and functional improvements, has an unexpected urine drug test, which is negative for the prescribed opioid. How will you assess this finding, and what changes will you make in his treatment plan?

Your patient on chronic opioids for post-traumatic chronic knee pain for the past two years has achieved very good pain relief and excellent functional benefits, including working full time. At yesterday's visit, he denied illicit drug use, but his urine drug test returned positive for cocaine, along with his prescribed opioid.

When discussing the need for routine urine drug testing with your patient who is on chronic opioids for chronic back pain, she becomes visibly upset and asks, "Why are you treating me like a drug addict?" How will you respond?

When assessing a new patient's chronic pain from bilateral knee osteoarthritis, he states his pain is a 20 on a 0 to 10 pain scale. Why is this patient reporting pain above the 10-point scale? And how will you respond?

Dr. Daniel Alford – Professor of Medicine and course director for Boston University Chobanian & Avedisian School of Medicine's SCOPE of Pain safer opioid prescribing program – shares more than 20 years' experience as a general internist along with his personal understanding of the complexities, communication challenges, risks, and benefits of prescribing opioids for patients with chronic pain in this exclusive series.