Clinical Opioid Risk Activity

Authors

As an ACCME accredited provider of continuing medical education, Clinical Tools, Inc.complies with the Standards for Commercial Support issued by the ACCME and requires disclosure of and resolution of any conflicts of interest for those in control of content.
Clinical Tools, MD, MD (Company, CTI)Clinical Tools, Inc. (CTI) is a small, physician-run business dedicated to harnessing the potential of the Internet to create scalable, usable, and broadly available tools to improve the ability of physicians and other health care providers to care for patients. We achieve this goal by providing education and training to students and professionals and creating Web-based support tools for clinicians, researchers, and consumers. Information technology can and should serve as a stable framework that supports researchers and clinicians in their roles. We provide dissemination and management tools that empower clinicians and consumers to understand and control the vast amount of information related to making individual health choices. We serve our clients creatively, effectively, and with the highest quality of service.
Disclosure: Has disclosed no relevant financial relationships.

Audience and Accreditation

Audience:

Health care professional clinical level students, interns, and residents

A letter of completion for up to 2 hour(s) is available for non-physicians.
A score of 70% on the post-test is required to complete the activity.

Overview

Goal: To enhance clinical skills of health professional trainees in treating pain safely and effectively while reducing the risk of addiction/abuse/misuse of opioids and other prescribed controlled substances and also in recognizing and addressing addiction/substance abuse/misuse in patients being treated for pain.

Professional Practice GapsClinical guidelines for the use of chronic opioid therapy in chronic noncancer pain, developed by professional organizations of pain specialists based on an extensive review of the literature, include recommendations for a practice plan designed to reduce risk of addiction and other substance abuse (Chou et al, 2009). According to national surveys, physicians do not follow key elements of that plan (CASA, 2005; Adams, et al. 2001). The need for education/skills training in order to be able to follow the guidelines with respect to planning chronic opioid therapy is evident from national physician surveys (CASA, 2005; CASA, 2000; Morley-Forster, et al. 2003). Based on the overall results of their physician survey on the problem of drug diversion, CASA concluded that physicians should receive more continuing medical education related to prescribing and administering controlled substances and identifying, diagnosing, and treating substance abuse and addiction (CASA, 2005). References Adams NJ, Plane MB, Fleming MF, et al., Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage 2001; 22 pp. 791–796. CASA: The National Center on Addiction and Substance Abuse at Columbia University (CASA). Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. July 2005. Available at: http://www.casacolumbia.org/addiction-research/reports/under-the-counter-diversion-abuse-controlled-perscription-drugs. Accessed July 11, 2008. CASA: The National Center on Addiction and Substance Abuse at Columbia University. National Survey of Primary Care Physicians and Patients on Substance Abuse. April, 2000. Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009a; 10(2): 113-130. Morley-Forster PK, Clark AJ, Speechley M, Moulin DE. Attitudes toward opioid use for chronic pain: a Canadian physician survey. Pain Res Manage. 2003;8: 189–94
References:
Attitudes toward opioid use for chronic pain: a Canadian physician survey. Pain Research and Management. 2003; 8(4): .
Clinical guidelines for the use of chronic opioid therapy for chronic noncancer pain. J of Pain. 2009; 10(2): 113-130.
National Survey of Primary Care Physicians and Patients on Substance Abuse. The National Center on Addiction and Substance Abuse at Columbia University. 2000.
Opioids and the treatment of chronic pain in a primary care sample. Journal of Pain Symptom Management. 2001; 22(3): 791-796.
Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S.. National Center on Addiction and Substance Abuse at Columbia University. 2005. Available at: http://www.casacolumbia.org/addiction-research/reports/under-the-counter-diversion-abuse-controlled-perscription-drugs Accessed on: 2014-06-03.
This activity is designed to change: Competence.

Educational Objectives:

After completing this activity participants will be able to:
  • Review basic pain history, assessment, and diagnosis

  • Describe the main pharmacological and non-pharmacological categories of pain treatments used as first-line treatment for different categories of pain and common pain conditions

  • Collaborate with colleagues in a multi-dimensional/multidisciplinary approach to pain management with a medical “home”

  • Recognize when opioid therapy is indicated based on pain severity, functioning, and risk of addiction or abuse, and potential harm from side effects

  • Develop an opioid medication treatment plan that minimizes risk of addiction, misuse, overdose, and side effects

Modules in this Training Activity

  • Pain Clinical Module 1: Integrated Approach to Pain Using First-Line Treatments

  • Pain Clinical Module 2: Risks and Benefits of Opioid Pain Treatment: Effective Prescribing and Monitoring

  • Pain Clinical Module 3: Advanced Opioid Pain Treatment Concepts for Medical Residents

Practice Gap References:

"We Don’t Carry That”-Failure of pharmacies in predominately nonwhite neighborhoods to stock opioid analgesics. New Engl J Med. 2000; 342: 1023-1026.
Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. Journal of Consulting and Clinical Psychology. 2008; 76: 397-407.
Acute vs. Chronic Pain. Treatments & Procedures. 2008. Available at: http://my.clevelandclinic.org/services/pain_management/hic_acute_vs_chronic_pain.aspx Accessed on: 2012-01-06.
Antidepressants in the treatment of chronic pain. Practical Pain Management. 2011. Available at: http://www.practicalpainmanagement.com/treatments/pharmacological/non-opioids/antidepressants-treatment-chronic-pain?page=0,0 Accessed on: 2012-12-03.
Appendix C: Physical Functional Ability Questionnaire (FAQ5). Institute for Clinical Systems Improvement. 2010; 14: . Available at: http://www.generationsprimarycare.com/assets/pain-contract.pdf Accessed on: 2012-04-23.
Behavioral treatment for chronic low back pain: A systematic review within the framework of the Cochrane Back Review Group. Spine. 2000; 25: 2688-2699.
Blueprint for Prescriber Continuing Education Program. http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM277916.pdf. 2011. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM277916.pdf Accessed on: 2012-05-17.
Blueprint for Provider Education Program. FDA. 2015; Osctober 25, 2011: . Available at: http://fda.org/ Accessed on: 2014-09-02.
Burroughs VJ, Maxey RW, Levy RA. Racial and ethnic differences in response to medicines: Toward individualized pharmaceutical treatment. J National Medical Assoc. 2002; 9(10): . Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594139/ Accessed on: 2014-07-31.
Cautious Evidence Based Opioid Prescribing. Physicians for Responsible Opioid Prescribing. 2011. Available at: http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf Accessed on: 2012-05-09.
Challenges in using opioids to treat pain in persons with substance use disorders. 2008 Available at: Accessed on: 2009-11-16. Addiction Science & Clinical Practice. 2008; 4(2): 4-25. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18497713 Accessed on: 2011-01-12.
Chronic Pain Relief: New Treatments. WebMD. 2011. Available at: http://www.webmd.com/pain-management/features/chronic-pain-relief-new-treatments Accessed on: 2011-03-10.
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, Md: Center For Substance Abuse Treatment . Treatment Improvement Protocol Series, No. 40, USDHHS Publication (SMA) 04-3939.. 2004.
Clinical guidelines for the use of chronic opioid therapy for chronic noncancer pain. J of Pain. 2009; 10(2): 113-130.
Clinical pharmacokinetics of morphine. Ther Drug Monit. 1991; 13: 1-23.
Confusion with Acetaminophen: Case & Commentary. Agency for Healthcare Research and Quality. 2006. Available at: https://psnet.ahrq.gov/webmm/case/115/confusion-with-acetaminophen Accessed on: 2012-05-22.
Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995; 94: 135-140.
Crossing the quality chasm: A new health system for the 21st century. National Academy Press. Washington, DC.. 2001. Available at: http://www.nap.edu/read/10027/chapter/1 Accessed on: 2011-12-12.
Current status of pain management in children. JAMA. 2003; 290(18): 2464-2469.
Definitions related to the use of opioids for the treatment of pain. Available at: http://www.painmed.org/pdf/definition.pdf. 2001. Accessed on: 2008-04-14.
Depression and anxiety associated with three pain conditions: results from a nationally representative sample. Pain. 2004; 111(1-2): 77-83. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15327811 Accessed on: 2012-12-03.
Development and validation of the current opioid misuse measure. Pain. 2007; 130(1-2): 144-156.
Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. American College of Physicians. 2007; 147(7): 478-491.
Dose-related effects of methadone on QT prolongation in a series of patients with torsade de pointes. Pharmacotherapy. 2003; 23: 802-805.
Effectiveness of opioids in the treatment of chronic non-cancer pain. Pain Physician. 2008; 11: S181-200. Available at: http://www.researchgate.net/profile/Andrea_Trescot/publication/5408045_Effectiveness_of_opioids_in_the_treatment_of_chronic_non-cancer_pain/links/00463522fd188c0194000000.pdf Accessed on: 2012-01-10.
Effects of smoking on neuropathic pain in two people with spinal cord injury. Journal of Spinal Cord Medicine. 2005; 28(4): 330-332.
EXALGO(TM) Risk Evaluation & Mitigation Strategy. EXALGO(TM) Risk Evaluation & Mitigation Strategy. 2011.
Foundations of Opioid Risk Management. Clinical Journal of Pain. 2007; 23(2): 103-118.
Gourlay D, Heit H, Caplan Y. Urine Drug Testing in Primary Care: Dispelling the Myths & Designing Strategies. California Academy of Family Physicians. 2002. Available at: http://www.alaskaafp.org/udt.pdf Accessed on: 2005-03-15.
Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series . Board on Health Care services. 2006. Available at: http://books.nap.edu/openbook.php?record_id=11470&page=78#p2000e8e19970078001 Accessed on: 2011-01-24.
Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. NCHS Data Brief, no. 22. Hyattsville, MD: National Center for Health Statistics. 2009. Available at: http://www.cdc.gov/nchs/data/databriefs/db22.pdf Accessed on: 2011-01-13.
Increases in poisoning and methadone-related deaths: United States, 1999-2005.. . Available at: f Accessed on: 2010-03-05.. National Center for Health Statistics (NCHS). 2008. Available at: http://www.cdc.gov/nchs/data/hestat/poisoning/poisoning.pd Accessed on: 2011-01-13.
Interventional pain management practice policies. ASIPP.org. 2002. Available at: http://www.asipp.org/documents/ASIPP_Guidelines%20II.PDF Accessed on: 2010-10-01.
Long-term opioid management for chronic non-cancer pain. Cochrane Database of Systematic Reviews. 2010; 1: .
Long-term pediatric opioid based pain control. Case reports. Schmerz. 2005; 19(5): 418-25.
Management of fibromyalgia syndrome in adults. National Guideline Clearinghouse. 2009. Available at: http://f.i-md.com/medinfo/material/8d0/4eb2854244ae46d1d13648d0/4eb2855d44ae46d1d13648d3.pdf Accessed on: 2010-10-07.
Management of fibromyalgia syndrome. JAMA. 2004; 292: 2388-2395.
Managing Chronic Pain With Opioids in Primary Care. The PainEDU.org Manual. 2010; 2nd ed: . Accessed on: 2012-05-21.
Migraine headache. National Pain Foundation, Inc. 2009. Available at: http://www.nationalpainfoundation.org/cat/97/migraine-headache Accessed on: 2009-06-25.
Migraine. Mayo Clinic Health Information. 2012. Available at: http://www.mayoclinic.org/diseases-conditions Accessed on: 2014-07-31.
Migraines & Headaches Health Center . WebMD. 2012. Available at: http://www.webmd.com/migraines-headaches/guide/default.htm Accessed on: 2012-11-28.
Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study.. Pain. 2008; 134(3): . Accessed on: 2011-12-21.
Model policy for the use of controlled substances for the treatment of pain.. Federation of State Medical Boards of the United States, Inc.. 2004. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16061467 Accessed on: 2014-07-31.
NSAID prescribing precautions. Am Fam Physician. 2009; 80(12): 1371-8.
Occupational Outlook Handbook: Physical Therapists. U.S. Bureau of Labor Statistics. 2009. Available at: http://www.bls.gov/ooh/Healthcare/Physical-therapists.htm Accessed on: 2010-07-20.
Opioid contracts in chronic nonmalignant pain management: objectives and uncertainties. Am J Med. 2006; 119: 292-296.
Opioid overdose. BMJ Best Practice. 2011; October 27: . Available at: http://bestpractice.bmj.com/best-practice/monograph/339.html Accessed on: 2012-05-21.
Opioid prescriptions for chronic pain and overdose: a cohort study. Annals of Internal Medicine. 2010; 152(2): 85-92.
Opioid pseudoaddiction—An iatrogenic syndrome. J Pain. 1989; 36(3): 363-366.
Opioid Rotation in the Management of Chronic Pain: Where Is the Evidence?. Pain Practice. 2010; 10(2): 85-93. Available at: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CGcQFjAA&url=http%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpubmed%2F20070552&ei=MuOrT8nUGpKe8gTjpaAa&usg=AFQjCNEhpLO_YtUigrtTbcia06Gm8BYSvw Accessed on: 2012-05-10.
Opioid Rotation. Pain Management Today eNewsletter series. 2011. Available at: http://newsletter.qhc.com/JFP/JFP_pain032411.htm Accessed on: 2012-05-18.
Opioid therapy for chronic pain. N Engl J Med. 2003; 349(20): 1943-53.
Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids. Pain Pract. 2008; 8(4): 287-313.
Opioids for chronic noncancer pain: tailoring the therapy to fit the patient and the pain. Postgrad Med. 2004; 116(3): 37-40, 43-44.
Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) guidelines. Pain. 2008; 11: S5-S62. Available at: http://www.painphysicianjournal.com/current/pdf?article=OTgy&journal=42 Accessed on: 2015-09-01.
Opioids in the patient with chronic nonmalignant pain: a retrospective review. J Opioid Manag. 2006; 2: 31-34.
Osteoarthritis: a review of treatment options. Formulary. 2009; 44: 143-151.
Overdose deaths demand a new paradigm for opioid rotation. Pain Med. 2012; 13(4): 571-4. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22458858 Accessed on: 2012-11-02.
Pain Management: Physical Therapy. WebMD's online Pain Management Health Center. 2007. Available at: http://www.webmd.com/pain-management/physical-therapy Accessed on: 2010-07-20.
Pharmacological Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society. 2009; 57(8): 1331-1346.
Policies and strategies to promote social equity in health. Stockholm: Institute of Future Studies. 1991.
Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Medicine. 2005; 6(6): 432-442.
Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. Journal of Pain and Symptom Management. 2004; 28(3): 250-258.
Pregnancy outcome in women who use opiates. Eur J Obstet Gynecol Reprod Biol. 2006; 126: 170-175.
Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011; 30(3): 185-94. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21745041 Accessed on: 2012-11-14.
Principles of Opioid Management References Principles of Opioid Management has been created.. Hospice Palliative Care Program. 2006. Available at: http://www.fraserhealth.ca/media/16FHSymptomGuidelinesOpioid.pdf Accessed on: 2012-05-09.
Proper Disposal of Prescription Drugs . White House Drug Policy . 2009. Available at: http://www.whitehouse.gov/ondcp Accessed on: 2013-04-23.
Psychological factors as predictors of opioid abuse and illicit drug use in chronic pain patients. Journal of Opioid Management. 2007; 3(2): 89-100.
Racial injustice in health care. N Engl J Med. 2000; 342: 1045-1047.
Recognizing and Preventing Medication Diversion. Family Practice Management. 2001; 8(9): 37-41.
Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Medicine. 2012; June early e-publications: 1-11. Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2012.01414.x/abstract Accessed on: 2012-06-18.
Smoking and chronic pain: A real-but-puzzling relationship. Minnesota Medicine. 2011; March: . Available at: http://www.ncbi.nlm.nih.gov/pubmed/21485923 Accessed on: 2012-02-29.
Smoking and pain: pathophysiology and clinical implications. Anesthesiology. 2010; 113(4): 977-992.
Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2008 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-36, DHHS Publication SMA 09-4434 . 2009. Available at: http://archive.samhsa.gov/data/NSDUH/2k8nsduh/2k8Results.htm Accessed on: 2009-09-10.
Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007; 146(2): 116-127.
The American Society of Addiction Medicine. Consensus document. The American Pain Society. 2001. Available at: http://opi.areastematicas.com/generalidades/definicionesopiaceos.AAPM.pdf Accessed on: 2011-01-13.
The Faces Pain Scale - Revised: Toward a common metric in pediatric pain measurement. Pain. 2001; 93: 173-183.
The opioid contract in the management of chronic pain. J Pain Symptom Manage. 1999; 18(1): 6-8.
The role of opioid analgesics in rheumatoid disease in the elderly population. Drugs Aging. 2003; 20(8): 571-583.
The role of urine toxicology in chronic opioid analgesic therapy. Pain Manag Nurs. 2007; 8(4): 166-172.
The use of opioids in the treatment of osteoarthritis: when, why, and how?. Curr Rheumatol Rep. 2009; 11(1): 5-14.
Thorson D, Biewen P, Bonte B, et al.. Acute Pain Assessment and Opioid Prescribing Protocol. Institute for Clinical Systems Improvement. 2014. Available at: https://www.icsi.org/_asset/dyp5wm/Opioids.pdf Accessed on: 2015-12-23.
Treatment of acute migraine headache. Am Fam Physician. 2011; 83(3): 271-80. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21302868 Accessed on: 2012-11-28.
Treatment of primary headache: acute migraine treatment. Standards of care for headache diagnosis and treatment. Based on: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation. 2004: 27-39.
Trigeminal neuralgia and its management. BMJ. 2007; 334: 201-205.
Types of Pain. The Merck Manual Home Health Handbook for Patients & Caregivers. 2007. Available at: http://www.merckmanuals.com/home/brain_spinal_cord_and_nerve_disorders/pain/types_of_pain.html Accessed on: 2012-01-03.
Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S.. National Center on Addiction and Substance Abuse at Columbia University. 2005. Available at: http://www.casacolumbia.org/addiction-research/reports/under-the-counter-diversion-abuse-controlled-perscription-drugs Accessed on: 2014-06-03.
Unintentional Drug Poisoning in the United States. CDC. 2010; July: . Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5910a5.htm Accessed on: 2012-05-25.
Universal precautions in pain medicine: a rational approach to the treatment of chronic pain . Pain Med. 2005; 6: 2.
Universal Precautions Revisited: Managing the Inherited Pain Patient. Pain Medicine. 2009; 10(S2): S115-S123.
Urine drug testing in pain medicine. J Pain Symptom Manage. 2004; 27(3): 260-267.
VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. VA/DoC. 2003. Available at: http://www.ihs.gov/nc4/index.cfm Accessed on: 2009-12-01.
Validation of the brief pain inventory for chronic nonmalignant pain. The Journal of Pain. 2004; 5(2): 133-137.
What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008; 9(4): 444-459.

Review Dates

Content Review:Editorial Review:
Thu, 1/26/2012Mon, 1/30/2012

Participation Requirements

Activity Credit: Obtaining credit for participation in this activity requires that you complete the pre-assessments, work through the modules (including all in-module interactive activities), complete the post-assessments with a 70% score on the post-test, and then request credit. At the end of the activity, you will be instructed on how to print out a certificate for your records.

Time Requirement: Keep track of the amount of time it takes you to complete this activity. You will be required to spend a set amount of time in order to claim credit. You should claim credit only for the time actually spent in the activity.

Technical Requirement: To participate in this activity, you will need a computer, an Internet connection, and a Web browser. This activity requires Chrome, Firefox, and IE7 or higher.

FundingInitial development of this activity was supported by a grant from the National Institute on Drug Abuse (#1R44DA027245-01).
Training Activity References:
"We Don’t Carry That”-Failure of pharmacies in predominately nonwhite neighborhoods to stock opioid analgesics. New Engl J Med. 2000; 342: 1023-1026.
Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. Journal of Consulting and Clinical Psychology. 2008; 76: 397-407.
Acute vs. Chronic Pain. Treatments & Procedures. 2008. Available at: http://my.clevelandclinic.org/services/pain_management/hic_acute_vs_chronic_pain.aspx Accessed on: 2012-01-06.
Antidepressants in the treatment of chronic pain. Practical Pain Management. 2011. Available at: http://www.practicalpainmanagement.com/treatments/pharmacological/non-opioids/antidepressants-treatment-chronic-pain?page=0,0 Accessed on: 2012-12-03.
Appendix C: Physical Functional Ability Questionnaire (FAQ5). Institute for Clinical Systems Improvement. 2010; 14: . Available at: http://www.generationsprimarycare.com/assets/pain-contract.pdf Accessed on: 2012-04-23.
Behavioral treatment for chronic low back pain: A systematic review within the framework of the Cochrane Back Review Group. Spine. 2000; 25: 2688-2699.
Blueprint for Prescriber Continuing Education Program. http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM277916.pdf. 2011. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM277916.pdf Accessed on: 2012-05-17.
Blueprint for Provider Education Program. FDA. 2015; Osctober 25, 2011: . Available at: http://fda.org/ Accessed on: 2014-09-02.
Burroughs VJ, Maxey RW, Levy RA. Racial and ethnic differences in response to medicines: Toward individualized pharmaceutical treatment. J National Medical Assoc. 2002; 9(10): . Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2594139/ Accessed on: 2014-07-31.
Cautious Evidence Based Opioid Prescribing. Physicians for Responsible Opioid Prescribing. 2011. Available at: http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf Accessed on: 2012-05-09.
Challenges in using opioids to treat pain in persons with substance use disorders. 2008 Available at: Accessed on: 2009-11-16. Addiction Science & Clinical Practice. 2008; 4(2): 4-25. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18497713 Accessed on: 2011-01-12.
Chronic Pain Relief: New Treatments. WebMD. 2011. Available at: http://www.webmd.com/pain-management/features/chronic-pain-relief-new-treatments Accessed on: 2011-03-10.
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, Md: Center For Substance Abuse Treatment . Treatment Improvement Protocol Series, No. 40, USDHHS Publication (SMA) 04-3939.. 2004.
Clinical guidelines for the use of chronic opioid therapy for chronic noncancer pain. J of Pain. 2009; 10(2): 113-130.
Clinical pharmacokinetics of morphine. Ther Drug Monit. 1991; 13: 1-23.
Confusion with Acetaminophen: Case & Commentary. Agency for Healthcare Research and Quality. 2006. Available at: https://psnet.ahrq.gov/webmm/case/115/confusion-with-acetaminophen Accessed on: 2012-05-22.
Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995; 94: 135-140.
Crossing the quality chasm: A new health system for the 21st century. National Academy Press. Washington, DC.. 2001. Available at: http://www.nap.edu/read/10027/chapter/1 Accessed on: 2011-12-12.
Current status of pain management in children. JAMA. 2003; 290(18): 2464-2469.
Definitions related to the use of opioids for the treatment of pain. Available at: http://www.painmed.org/pdf/definition.pdf. 2001. Accessed on: 2008-04-14.
Depression and anxiety associated with three pain conditions: results from a nationally representative sample. Pain. 2004; 111(1-2): 77-83. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15327811 Accessed on: 2012-12-03.
Development and validation of the current opioid misuse measure. Pain. 2007; 130(1-2): 144-156.
Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. American College of Physicians. 2007; 147(7): 478-491.
Dose-related effects of methadone on QT prolongation in a series of patients with torsade de pointes. Pharmacotherapy. 2003; 23: 802-805.
Effectiveness of opioids in the treatment of chronic non-cancer pain. Pain Physician. 2008; 11: S181-200. Available at: http://www.researchgate.net/profile/Andrea_Trescot/publication/5408045_Effectiveness_of_opioids_in_the_treatment_of_chronic_non-cancer_pain/links/00463522fd188c0194000000.pdf Accessed on: 2012-01-10.
Effects of smoking on neuropathic pain in two people with spinal cord injury. Journal of Spinal Cord Medicine. 2005; 28(4): 330-332.
EXALGO(TM) Risk Evaluation & Mitigation Strategy. EXALGO(TM) Risk Evaluation & Mitigation Strategy. 2011.
Foundations of Opioid Risk Management. Clinical Journal of Pain. 2007; 23(2): 103-118.
Gourlay D, Heit H, Caplan Y. Urine Drug Testing in Primary Care: Dispelling the Myths & Designing Strategies. California Academy of Family Physicians. 2002. Available at: http://www.alaskaafp.org/udt.pdf Accessed on: 2005-03-15.
Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series . Board on Health Care services. 2006. Available at: http://books.nap.edu/openbook.php?record_id=11470&page=78#p2000e8e19970078001 Accessed on: 2011-01-24.
Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. NCHS Data Brief, no. 22. Hyattsville, MD: National Center for Health Statistics. 2009. Available at: http://www.cdc.gov/nchs/data/databriefs/db22.pdf Accessed on: 2011-01-13.
Increases in poisoning and methadone-related deaths: United States, 1999-2005.. . Available at: f Accessed on: 2010-03-05.. National Center for Health Statistics (NCHS). 2008. Available at: http://www.cdc.gov/nchs/data/hestat/poisoning/poisoning.pd Accessed on: 2011-01-13.
Interventional pain management practice policies. ASIPP.org. 2002. Available at: http://www.asipp.org/documents/ASIPP_Guidelines%20II.PDF Accessed on: 2010-10-01.
Long-term opioid management for chronic non-cancer pain. Cochrane Database of Systematic Reviews. 2010; 1: .
Long-term pediatric opioid based pain control. Case reports. Schmerz. 2005; 19(5): 418-25.
Management of fibromyalgia syndrome in adults. National Guideline Clearinghouse. 2009. Available at: http://f.i-md.com/medinfo/material/8d0/4eb2854244ae46d1d13648d0/4eb2855d44ae46d1d13648d3.pdf Accessed on: 2010-10-07.
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