<div class="yourchoice"><strong>You chose: </strong>Interview regarding pain</div>
<div class="container">
<div class="inner">
<div class="summary">The provider starts to interview Ms. Davis regarding her pain: </div>
<div class="dialogue-container">
<div class="provider-dialogue"><p>That looks pretty sore. Can you describe the pain for me?</p></div>
<div class="patient-dialogue"><p> Sure. It's pretty severe, like a 9 out of 10, and that's with the ibuprofen plus acetaminophen I took about 6 hours ago. I took the maximum recommended dose of each, so I guess it's starting to wear off. It's a sharp, constant, and severe pain. It's getting stiff as it swells up. The ice helps some. </p></div>
<div class="provider-dialogue"><p> Thanks. And is the pain staying the same or getting better or worse?</p></div>
<div class="patient-dialogue"><p> It's been pretty much the same for the past couple of hours and now that the medication is wearing off, it's getting worse. Can you give me some intravenous morphine while I'm here? </p></div>
</div>
</div>
<div class="navigation">
<div class="question">What is your next course of action?</div>
<div class="continue">[[Administer morphine to treat her pain while she is in the clinic]] </div>
<div class="continue">[[Offer acetaminophen until you can complete your evaluation]]</div>
<div class="continue">[[III. Evaluation]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Obtain Additional History - Question</p><div class="chapter"><strong>Ch 2 |</strong> Additional History</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong>Interview about past medical history</div>
<div class="container">
<div class="inner">
<div class="dialogue-container">
<div class="provider-dialogue"><p> We don't have any past records for you. What can you tell me about your past medical problems?</p></div>
<div class="patient-dialogue"><p> Just what I put on the intake form - a broken wrist and miscarriage when I was younger. That's it. </p></div>
<div class="provider-dialogue"><p> Nothing else? Psychological, sleep, or breathing problems of any kind?</p></div>
<div class="patient-dialogue"><p> No.</p></div>
<div class="provider-dialogue"><p> Kidney, liver?</p></div>
<div class="patient-dialogue"><p> No.</p></div>
<div class="provider-dialogue"><p> And you don't ever take other medications, sedatives?</p></div>
<div class="patient-dialogue"><p> No.</p></div>
<div class="provider-dialogue"><p> Thank you.</p></div>
</div>
<div class="summary"><strong>Discussion:</strong><br/>
The ICSI guidelines for acute pain management and opioid prescribing (Thorson et al., 2014) recommend precautions in opioid prescribing for the following conditions (Acronym - ABCDPQRS)<br/><ul><li>Alcohol use - "There is no known safe dose of alcohol for a patient on opioids"</li><li>Benzodiazepines - Should not be combined with opioids</li><li>Clearance - Many opioids are metabolized via the kidney, but severe hepatic metabolism can affect opioid metabolism and require a dose adjustment. Lower or avoid acetaminophen dose with impaired liver function.</li><li>Delirium, Dementia - Increase risk of falls and accidental overdose. Risk of opioids precipitating delirium.</li><li>Psychiatric disorders - Opioids have anxiolytic properties which can make opioids attractive for relief of psychic symptoms. </li><li>Query Prescription Monitoring Program - often uncovers more than one prescription for the same acute pain condition </li><li>Respiratory Insufficiency and Sleep Apnea - Increase risk of respiratory problems or arrest with opioids</li><li>Safe driving, work, storage, disposal - Unsafe to drive on new or increased opioid prescription. </li></ul>
</div>
</div>
<div class="navigation"><div class="question">
Would you like to return to Obtain Additional History or continue on to Evaluation?</div>
<div class="return">[[II. Obtain Additional History]] </div>
<div class="continue">[[III. Evaluation]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Obtain Additional History - Question</p><div class="chapter"><strong>Ch 2 |</strong> Additional History</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong> Substance use screening</div>
<div class="container">
<div class="inner"></div>
<div class="navigation">
<div class="question">Please select a screening tool to evaluate Ms. Davis' substance use or do an interview (You will have a chance to select other options later)</div>
<div class="continue">[[CAGE AID for alcohol or drug use]]</div>
<div class="continue">[[Patient interview about substance use]]</div>
<div class="continue">[[No screening needed for a medical student]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Evaluation - Question</p><div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong> CAGE AID for alcohol or drug use</div>
<div class="container">
<div class="inner"><div class="feedback correct">Correct. CAGE-AID is a good quick screen for drugs and alcohol use problems.</div>
<div class="dialogue-container">
<div class="provider-dialogue"><p>It helps me to understand your use of tobacco, alcohol, and drugs. Could I get you to answer this short questionnaire?</p></div>
<div class="patient-dialogue"><p> Sure, no problem.</p></div></div>
<div class="summary"><strong>Jessica Davis (Today's Date) CAGE-AID Screening</strong>
When thinking about drug use, include illegal drug use, as well as the use of prescription drugs other than prescribed.<br/>
<strong>Have you ever felt that you ought to cut down on your drinking or drug use?</strong> No.<br/>
<strong>Have people annoyed you by criticizing your drinking or drug use?</strong> No.<br/>
<strong>Have you ever felt bad or guilty about your drinking or drug use?</strong> No.<br/>
<strong>Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?<br/></strong> No.<br/>
<strong>Interpretation Guide:</strong> Each affirmative response earns one point. Even just one point indicates a possible problem. Two points indicate a probable problem. However, Ms. Davis scored 0, suggesting no problem. <br/>
(Reproduced with permission from Dr. Richard L. Brown, MD, MPH)
</div></div>
<div class="navigation">
<div class="question"> Would you like to return to Substance use screening, return to Evaluation, or continue to Impressions?</div>
<div class="return">[[Substance use screening]]</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Diagnostic Impressions]] </div>
</div></div>
<div class="footer"><p class="small">You are here: Evaluation - Discussion </p><div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong> No screening needed for a medical student</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
<div class="summary">Incorrect. All patients should be screened regarding their substance use, including alcohol, drugs (both illicit drugs and prescription drugs), and tobacco. Substance use disorder is generally recognized as one of the best predictors of risk in prescribing opioids (Chou et al. 2009).<br/>
Medical students are certainly not immune to substance use disorder. While there are few recent studies, several report current rates of cocaine and amphetamine use among medical students, as well as a 33% rate of excessive alcohol use in the past 30 days (Dumitrascu, 2015).<br/>
32.4% of medical students surveyed met the diagnostic criteria for alcohol abuse/dependence (n=4400). Contributing factors to use were depression, burn-out, and mental/emotional pressures (Jackson et al. 2016).<br/>
Together with a Urine Drug Test, a substance use screening instrument helps determine risk in prescribing opioids, and is indicated, even for medical students.<br/>
Had you used the substance use screening instrument, the CAGE-AID, you would have learned the following:<br/>
Ms. Davis CAGE-AID results were negative for risk of substance use disorder.
</div></div>
</div>
<div class="navigation">
<div class="question"> Would you like to return to Substance use screening, return to Evaluation, or continue to Impressions?</div>
<div class="return">[[Substance use screening]]</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Diagnostic Impressions]] </div>
</div>
</div>
<div class="footer"><p class="small">You are here: Evaluation - Discussion</p><div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>
<div class="yourchoice"><strong>You chose: </strong>Urine drug testing</div>
<div class="container">
<div class="inner"><div class="feedback neutral">
Possibly. Clinical guidelines on treating chronic pain recommend a baseline Urine Drug Testing when treating a patient with chronic opioid therapy, however, they do not specify one way or the other regarding acute, limited opioid prescriptions (Chou et al., 2009). </div><div class="summary">Ms. Davis' urine drug test results are below:
<ul><li>Amphetamines (AMP) - Negative</li><li>Cocaine (COC) - Negative</li><li>MDMA (MDMA) - Negative</li><li>Methamphetamine (mAMP) - Negative</li><li>Opiate (OPI) - Negative</li><li>THC (THC) - Negative</li></ul>
</div></div>
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<div class="question">Would you like to return to Evaluation, or continue on to Impressions?</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Diagnostic Impressions]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Evaluation - Question</p><div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose:</strong> IV. Diagnostic Impressions</div>
<div class="container">
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</div>
<div class="navigation">
<div class="question">Based on what you have learned so far, what is the likelihood that Ms. Davis is seeking opioids for recreational purposes or diversion?</div>
<div class="continue">[[No risk of opioid abuse or overdose]]</div>
<div class="continue">[[Low risk of opioid misuse or overdose]]</div>
<div class="continue">[[Cannot determine risk of opioid abuse or diversion]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: IV. Impressions</p><div class="chapter"><strong>Ch 4 |</strong> Impressions</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Review medical history</div>
<div class="container">
<div class="inner">
<div class="ehr">
<div class="header patientimg"><h4>Electronic Medical Record</h4><div class="patientname"></div></div>
<div class="content">
<strong>Patient:</strong> Jessica Davis<br/>
<strong>Medical History</strong><br/>
<strong>Past Medical History:</strong> Fractured left wrist age 10<ul><li>Second trimester miscarriage, age 17</li></ul>
<strong>Surgical History: </strong>None<br/>
<strong>Family/Social History:</strong>
<ul><li>Relatives: Both parents have controlled HTN</li><li>Marital/ Family Status: Single, lives with 3 other medical students; no children, parents live in another state</li><li>Substance Use:<ul><li>Tobacco Use: Never smoked</li><li>Recreational Drug Use: Denies use</li><li>Alcohol Use: 2-3 pre-mixed "alcopop" drinks/night, Friday/Saturday only</li></ul></li></ul>
</div></div></div>
<div class="navigation"><div class="question">Return to Review Medical Record, or Continue on to Obtain Additional History?</div>
<div class="return">[[I. Review Medical Record]] </div>
<div class="continue">[[II. Obtain Additional History]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Review Medical Record - Question</p><div class="chapter"><strong>Ch 1 |</strong> Medical Record</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Review medications</div>
<div class="container">
<div class="inner">
<div class="ehr">
<div class="header patientimg"><h4>Electronic Medical Record</h4><div class="patientname"></div></div>
<div class="content">
<strong>Current Medications:</strong><br/>
Condition Treated: Crushed right index finger<br/>
(Today's date) Ibuprofen 500 mg qid<br/>
(Today's date) Acetaminophen 1000 mg qid<br/>
<strong>Past Medications:</strong><br/>
No information available
</div>
</div>
</div>
<div class="navigation"><div class="question">Return to Review Medical Record, or Continue on to Obtain Additional History?</div>
<div class="return">[[I. Review Medical Record]]</div>
<div class="continue">[[II. Obtain Additional History]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Review Medical Record - Question</p><div class="chapter"><strong>Ch 1 |</strong> Medical Record</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Order Prescription Drug Monitoring Report</div>
<div class="container">
<div class="inner"><div class="ehr"><div class="header patientimg"><h4>Prescription Report</h4><div class="patientname"></div></div>
<div class="content">
<strong>Date:</strong> (Today's Date)<br/>
<strong>Prescription History Report for:</strong> <br/>
<strong>ID:</strong> 55-555 <strong>Name:</strong> Davis, Jessica <strong>DOB:</strong> 7/7/1986<br/>
No data for this patient in this state.<br/>
Note that with the current policy of having separate data bases by state, a negative drug monitoring report does not guarantee that the patient does not have a problematic record in another state. Some states have agreements with adjacent states permitting review of their prescription data bases as well as the local one.
</div>
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<div class="navigation"><div class="question">
Would you like to return to Obtain Additional History or continue on to Evaluation?</div>
<div class="return">[[II. Obtain Additional History]]</div>
<div class="continue">[[III. Evaluation]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Obtain Additional History - Question</p><div class="chapter"><strong>Ch 2 |</strong> Additional History</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Physical Exam Results</div>
<div class="container">
<div class="inner">
<div class="summary">
<strong>Summary:</strong><br/>
<em>Significant positive findings in physical exam:</em><br/>
<strong>General Appearance:</strong> Well developed well nourished, dressed in gym clothes, in some distress from current pain<br/>
<strong>Extremities:</strong> <span style="background: yellow;">SIGNIFICANT</span><br/>
Crushed, swollen, bruised right index finger tip, distal phalanx
Physical exam otherwise unremarkable.
</div>
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<div class="question">Would you like to return to Evaluation, or continue on to Impressions?</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Diagnostic Impressions]] </div>
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<div class="yourchoice"><strong>You chose: </strong> III. Evaluation</div>
<div class="container">
<div class="inner">
<div class="content">Instructions: To evaluate the patient, you have the opportunity to interview the patient or use validated questionnaire instruments to conduct relevant screenings for substance use problems and depression, review the results summary from a physical exam, and order labs. Select blue buttons in each passage then navigate to the next step, by clicking the orange Navigation buttons at the bottom of the passage.
<div class="object">[[Substance use screening]]</div>
<div class="object">[[Physical exam results]]</div>
<div class="object">[[Depression screening]]</div>
<div class="object">[[Urine drug testing]]</div>
</div></div>
<div class="navigation">
<div class="question">Continue on to IV. Diagnostic Impressions</div>
<div class="continue">[[IV. Diagnostic Impressions]]</div>
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<div class="footer"><p class="small">You are here: III. Evaluation</p>
<div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong> No risk of opioid abuse or diversion</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
<div class="summary">Incorrect. The CDC's evidence review found that there is no threshold dose of opioids below which there is no risk of overdose (Dowell et al., 2016). So there is always at least a low risk. Similarly, they found that the accuracy of risk assessment instruments was somewhat limited or the data for their effectiveness was inconsistent. So risk of opioid misuse or diversion cannot be ruled out by an assessment.<br/>
Therefore, it is important to take precautions and provide patient education for all patients as if there is at least a low risk of opioid misuse or overdose.
</div></div>
</div>
<div class="navigation"><div class="question"> Would you like to return to Impressions or continue to Treatment Planning? </div>
<div class="return">[[IV. Diagnostic Impressions]] </div>
<div class="continue">[[V. Treatment Planning]]</div>
</div>
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<div class="footer"><p class="small">You are here: Impressions - Question</p><div class="chapter"><strong>Ch 4 |</strong> Impressions</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Cannot determine risk of opioid abuse or diversion</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
<div class="summary">Not the best choice. The CDC's evidence review found that the accuracy of risk assessment instruments for risk in prescribing opioids was somewhat limited or the data for their effectiveness was inconsistent (Dowell et al., 2016). The CDC's evidence review also found that there is no threshold dose below which there is no risk of overdose. So there is always at least a low risk. Therefore, it is important to take precautions and provide patient education for all patients as if there is at least a low risk of opioid abuse or overdose. You do have some information about her risk level however. Her CAGE-AID was negative as was a substance use interview. However, her request for I.V. morphine instead of additional acetaminophen, is a little concerning, however, this is a very painful injury. The acetaminophen appears to have been providing at least some pain relief, since the worsening of her pain corresponds to the acetaminophen dose wearing off. Therefore, low risk seems to describe Ms. Davis' risk level based on the evidence so far. </div></div>
</div>
<div class="navigation"><div class="question"> Would you like to return to Impressions or continue to Treatment Planning? </div>
<div class="return">[[IV. Diagnostic Impressions]]</div>
<div class="continue">[[V. Treatment Planning]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Impressions - Question</p><div class="chapter"><strong>Ch 4 |</strong> Impressions</div><div class="progress chapter4"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong> Low risk of opioid abuse or overdose</div>
<div class="container">
<div class="inner"><div class="feedback correct">
<div class="summary">Correct. The CDC's evidence review found that there is no threshold dose of opioids below which there is no risk of overdose (Dowell et al., 2016). So there is always at least a low risk. Similarly, they found that the accuracy of risk assessment instruments was somewhat limited or the data for their effectiveness was inconsistent. So risk of opioid misuse or diversion cannot be ruled out by an assessment. <br/>
Therefore, it is important to take precautions and provide patient education for all patients as if there is at least a low risk of opioid misuse or overdose. <br/>
<strong>Specific Risk for Ms. Davis</strong><br/>
Ms. Davis prescription monitoring report is negative for this state. However, she is a student from out of state and might have a significant report in another state. Her CAGE-AID is negative for substance use problems. Her response to an interview about substance use was also essentially negative. However, her request for I.V. morphine instead of additional acetaminophen, is a little concerning, however this is a very painful injury. The acetaminophen appears to have been providing at least some pain relief, since the worsening of her pain corresponds to the acetaminophen dose wearing off. Therefore, low risk seems to describe Ms. Davis' risk level based on the evidence so far.
</div></div>
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<div class="return">[[IV. Diagnostic Impressions]]</div>
<div class="continue">[[V. Treatment Planning]]</div>
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<div class="yourchoice"><strong>You chose: </strong>V. Treatment Planning</div>
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<div class="summary">In this chapter you will develop a treatment plan including making any referrals needed. Following that, you will have the opportunity to provide patient education.
</div></div>
<div class="navigation"><div class="question">Current options (You will have the opportunity to return to each option later):</div>
<div class="continue">[[Prescribe pain medication]]</div>
<div class="continue">[[Non pharmacological treatment]]</div>
<div class="continue">[[Follow Up Plan]]</div>
</div>
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</div>
<div class="yourchoice"><strong>You chose: </strong> Non pharmacological treatment</div>
<div class="container">
<div class="inner"><div class="feedback correct">
<div class="summary">Correct. It is important that non pharmacological treatments or immobilization, ice, and elevation be continued and that opioids only be used to the extent that these and non-narcotic pain medications are not sufficient to manage the pain.</div></div>
</div>
<div class="navigation"><div class="question"> Would you like to return to Treatment Planning or continue to Treatment Summary? </div>
<div class="return">[[V. Treatment Planning]]</div>
<div class="continue">[[Treatment Summary]]</div>
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<div class="yourchoice"><strong>You chose: </strong> Prescribe acetaminophen</div>
<div class="container">
<div class="inner"> <div class="feedback correct">
<div class="summary">Correct as an adjunct and for later pain management. Acetaminophen is a good choice for pain management in the acute phase of pain management. Unlike NSAIDs, there is no risk of interfering with the healing process.<br/>
However, Ms. Davidson's pain is severe despite trying over-the-counter pain medication and so it does qualify for a limited opioid prescription. Use of acetaminophen as an adjunctive pain treatment will help minimize the opioid dose needed.
</div></div></div>
<div class="navigation"><div class="question"> Would you like to return to Prescribe pain medication, return to Treament Planning, or continue on to Treatment Summary? </div>
<div class="return">[[Prescribe pain medication]]</div>
<div class="return">[[V. Treatment Planning]]</div>
<div class="continue">[[Treatment Summary]]</div>
</div>
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<div class="yourchoice"><strong>You chose: </strong> Treatment Summary</div>
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<div class="inner">
<div class="summary">
The final treatment plan for Ms. Davis involved continued application of ice and elevation, immobilization in a sleeve splint. Her pain management plan included: <ol><li>Oxycodone 5 mg qid prn pain, supplemented by over-the-counter acetaminophen in the first 48 hours. This is to be followed by over-the-counter NSAIDs with supplemental acetaminophen as needed prn pain. </li><li>Amount prescribed: 3 day supply.</li><li>Recommend primary care followup in 2-3 weeks; sooner if symptoms worsen or pain is not managed by this plan.</li></ol>
<strong>Discussion:</strong><br/>
The selected dose is the lowest dose sufficient to manage severe pain in an opioid-naive patient. The supply of 3 days covers the likely duration for which opioids are needed for severe pain in most cases according to CDC guidelines for opioid prescribing (Dowell et al., 2016). The lowest possible dose is recommended, which according to product information is 5 to 15 mg. Dosages of 50 to 100 MME/day increase overdose risk by 1.9 to 4.6 compared to doses that are <20 MME/day; above 100 MME the risk is 2.0 to 8.9 times that of <20 MME/day. 5 mg of oxycodone would translate to around 7.5 mg. of morphine.<br/>
A tamper resistant formulation was prescribed. This is generally good practice, especially in acute pain when the patient, and therefore their risk for illicit drug use, is not well known. Although determined drug users may circumvent tamper resistant formulations, they do provide some deterrence. Ms. Davis' request for IV morphine adds to the reasons to be careful.
</div>
</div>
<div class="navigation">
<div class="question">Continue to:</div>
<div class="continue">[[VI. Patient Education]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Treatment Planning - Summary - ABC</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div>
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<div class="yourchoice"><strong>You chose: </strong> Follow up plan</div>
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<div class="navigation"><div class="question">
Which of the following follow up plans seems appropriate for Ms. Davis? (You will be able to choose other options later)</div>
<div class="continue">[[Referral to primary care if severe pain continues]]</div>
<div class="continue">[[Call if more opioids are needed]]</div>
<div class="return">[[V. Treatment Planning]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Question</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong> Referral to primary care if severe pain continues</div>
<div class="container">
<div class="inner"><div class="feedback correct">
<div class="summary">Correct. Evaluation in primary care would fulfill the recommendation that the continued need for opioids be determined before writing a prescription.
</div></div>
</div>
<div class="navigation"><div class="question"> Would you like to return to Referral, return to Treatment Planning, or continue to Treatment Summary? </div>
<div class="return">[[Follow Up Plan]]</div>
<div class="return">[[V. Treatment Planning]] </div>
<div class="continue">[[Treatment Summary]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Discussion</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Case Summary</div>
<div class="container">
<div class="inner">
<div class="summary"><strong>Key Points</strong>
<ol><li>Assure that acute pain is severe enough to warrant an opioid prescription and has not responded to non-opioid pain management</li><li>Assess risk for opioid misuse and overdose, especially no history of overdose and not taking benzodiazepines</li><li>Limit the supply of opioids for acute pain to 3 days for most acute pain and no more than 7 days.</li><li>Keep the dose under the 50 morphine milligram equivalent (MME) dose; above that the risk of overdose increases significantly. Most opioids prescribed for acute or chronic pain are stronger than morphine and so the dose to avoid overdose risk will be lower than 50 mg.</li><li>Recommend primary care followup if it seems the supply of opioids is insufficient in order to assure that any further prescriptions for opioids will be based on documented continued need.</li></ol>
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<div class="question">Continue to:</div>
<div class="continue">[[References]]</div>
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</div><div class="footer"><p class="small">You are here: Case Summary</p> <div class="chapter"><strong>Case Summary |</strong> Finish Case</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
<div class="yourchoice"><strong>You chose: </strong>Call if more opioids are needed</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
<div class="summary">Not the best choice. Extending the prescription based on a phone call is not recommended. Evaluation in primary care would fulfill the recommendation that the continued need for opioids be determined before writing a prescription. </div>
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<div class="navigation"><div class="question"> Would you like to return to Referral, return to Treatment Planning, or continue to Treatment Summary? </div>
<div class="return">[[Follow Up Plan]]</div>
<div class="return">[[V. Treatment Planning]] </div>
<div class="continue">[[Treatment Summary]]</div>
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</div><div class="footer"><p class="small">You are here: Treatment Planning - Discussion</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong> VI. Patient Education</div>
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<div class="dialogue-container">
<div class="provider-dialogue"><p> While you are taking opioids, do not use alcohol or other sedating medications as it can be dangerous. You probably know that the combination can lead to life threatening respiratory impairment and overdose. I see that you drink several alcopops per night on weekends.</p></div>
<div class="patient-dialogue"><p> Yes. But both the alcohol and the opioids you are prescribing are kind of weak, though.</p></div>
<div class="provider-dialogue"><p> The ICSI guidelines for opioid prescribing for acute pain say there is no safe dose of opioids with alcohol (Thorson et al., 2014). So, to play it safe, I recommend no alcohol while taking opioids. Also, opioids can be sedating, especially since you are not used to them so avoid driving or other activities that could be dangerous when sedated, including childcare.</p></div>
<div class="patient-dialogue"><p>Okay. No problem.</p></div>
</div>
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<div class="question"> Would you like to provide further patient education?</div>
<div class="continue">[[Further patient education is needed]]</div>
<div class="continue">[[No further patient education is needed]]</div>
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<div class="footer"><p class="small">You are here: Vb. Patient Education</p><div class="chapter"><strong>Ch 6 |</strong> Patient Education</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>
<div class="yourchoice"><strong>You chose: </strong> Prescribe pain medication</div>
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<div class="navigation"><div class="question">
What pain medications would you prescribe? (You will be able to return to select more than one)</div>
<div class="continue">[[Prescribe an opioid]]</div>
<div class="continue">[[Prescribe acetaminophen]]</div>
<div class="continue">[[Prescribe NSAIDs]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Question</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Radiology report</div>
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<div class="inner"><div class="ehr"><div class="header patientimg"><h4>Patient Information</h4><div class="patientname"></div></div>
<div class="content">
<strong>Patient:</strong> Jessica Davis (Today's Date)<br/>
<strong>Radiology Summary:</strong> Comminuted fracture of the right index finger distal phalanx due to a crush injury.
</div>
</div>
</div>
<div class="navigation"><div class="question">Return to Review Medical Record, or Continue on to Obtain Additional History?</div>
<div class="return">[[I. Review Medical Record]]</div>
<div class="continue">[[II. Obtain Additional History]] </div>
</div>
</div><div class="footer"><p class="small">You are here: Review Medical Record - Question</p><div class="chapter"><strong>Ch 1 |</strong> Medical Record</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>Resources</div><div class="container">
<div class="inner">
<div class="references">
<strong>Screening Tools:</strong><br/>
<a href="http://www.drugabuse.gov/nmassist/" target="_blank" rel="noopener noreferrer" data-raw=""> NIDA Quick Screen - Online</a>
<a href="http://www.integration.samhsa.gov/images/res/CAGEAID.pdf" target="_blank" rel="noopener noreferrer" data-raw="">CAGE-AID</a><br/>
<strong>Provider Resources</strong><br/>
Thorson D, Biewen P, Epstein H. et al. Acute pain assessment and opioid prescribing protocol. Health care protocol. AHRQ National Quideline Clearinghouse. Developed by Institute for Clinical Systems Improvement. Available at: <a href="https://www.guideline.gov/content.aspx?id=47765" target="_blank" rel="noopener noreferrer" data-raw="">https://www.guideline.gov/content.aspx?id=47765</a>. Accessed: 3/31/16. <br/>
</div>
</div>
<div class="navigation"><div class="question">END OF CASE. You may elect to return to the start.</div>
<div class="return">[[Case Overview]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Resources</p><div class="chapter"><strong>Resources |</strong> Finish Case</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
<div class="yourchoice"><strong>You chose: </strong> Depression Screening</div>
<div class="container">
<div class="inner"><div class="feedback correct">Correct. A quick depression screening is indicated before prescribing narcotics and when treating pain.</div>
<div class="dialogue-container">
<div class="provider-dialogue"><p> Mood is a very important part of longstanding pain like you have. Can I ask you a few questions?</p></div>
<div class="patient-dialogue"><p>Sure.</p></div>
</div>
<div class="summary">The provider asks Ms. Davisto complete the Patient Health Questionnaire (PHQ9) depression screening. She reports no incidences over the last two weeks where she's had any of the symptoms on the list. <br/>
Total Score=0 Interpretation: No depression (Range 0)</div>
</div>
<div class="navigation">
<div class="question">Would you like to return to Evaluation, or continue on to Impressions?</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Diagnostic Impressions]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Evaluation - Question</p><div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>II. Obtain Additional History</div>
<div class="container">
<div class="inner"><div class="content"><br/>Instructions: Select blue History Information buttons to review available information. After you have explored all History Information, choose where to navigate to next in the case scenario, by clicking the orange Navigation buttons at the bottom.
<h4>History Currently Available:</h4>
<div class="object">[[Order Prescription Drug Monitoring Report]]</div>
<div class="object">[[Interview regarding pain]]</div>
<div class="object">[[Interview about past medical history]]</div>
<div class="object">[[Contact primary care physician]]</div>
<strong>Instructions:</strong> When you have completed review of the history section, scroll down to navigate to the next section.<br/><br/>
</div></div>
<div class="navigation"><div class="question">When you have finished obtaining the history, continue to evaluate the patient.</div>
<div class="continue">[[III. Evaluation]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Obtain Additional History</p><div class="chapter"><strong>Ch 2 |</strong> Additional History</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong>I. Review Medical Record</div>
<div class="container">
<div class="inner"><div class="ehr"><div class="header patientimg"><h4>Patient Information</h4><div class="patientname"></div></div>
<div class="content"><br/>
<strong>Patient Name:</strong> Jessica Davis<br/>
<strong>Vital Signs:</strong> BP: 116/72; Pulse: 70; Resp: 12; BMI: 24<br/>
<strong>Age/Occupation:</strong> 30 y/o 4th year medical student<br/>
<strong>Chief Complaint:</strong> Requests treatment and pain management for crushed right index finger<br/>
<Strong>Relevant History:</strong> Dropped a weight on finger in health club 8 hours ago. Immediately applied ice and elevation and took over-the-counter pain medication. Noted subungual hematoma.<br/>
Instructions: Select blue Case Information buttons at the start of each section of this patient encounter to review available information. In this scene, you may view content in the patient record to prepare to see your patient. After you have explored all available information, make choices or navigate to the next step by clicking the orange buttons at the bottom of each page.
<h4>Medical Record Information Currently Available:</h4>
<div class="object">[[Review medical history]]</div><br/>
<div class="object">[[Review medications]]</div><br/>
<div class="object">[[Radiology report]]</div><br/>
<strong>Instructions:</strong> When you have completed review of this information, scroll down to navigate to the next section via the orange buttons.<br/><br/> </div></div>
</div> <div class="navigation">
<div class="question">When you have reviewed this section of the medical record, continue on to obtain additional patient history.</div> <div class="continue">[[II. Obtain Additional History]]</div>
</div> </div>
<div class="footer"><p class="small">You are here: Review Medical Record</p><div class="chapter"><strong>Ch 1 |</strong> I. Review Medical Record</div><div class="progress chapter1"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong>Contact primary care physician</div>
<div class="container">
<div class="inner"><div class="feedback neutral">
<div class="summary">Sorry, their office is closed.</div>
</div>
</div>
<div class="navigation"><div class="question">Would you like to return to Obtain Additional History or continue on to Evaluation?</div>
<div class="return">[[II. Obtain Additional History]] </div>
<div class="continue">[[III. Evaluation]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Obtain Additional History - Question</p><div class="chapter"><strong>Ch 2 |</strong> Additional History</div><div class="progress chapter2"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
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<div class="yourchoice"><strong>You chose: </strong> Prescribe an opioid</div>
<div class="container">
<div class="inner">
</div>
<div class="navigation"><div class="question">Please choose the appropriate duration for this prescription:</div>
<div class="continue">[[3 day supply]]</div>
<div class="continue">[[7 day supply]]</div>
<div class="continue">[[14 day supply]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Discussion</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong> Further patient education is needed</div>
<div class="container">
<div class="inner"><div class="feedback correct">
Correct. Any time you prescribe opioids, it is important to inform the patient that the duration of taking them should not be extended and that they should be stored and disposed of properly. </div>
<div class="dialogue-container">
<div class="provider-dialogue"><p> I am prescribing a 3 day supply to cover just the time period that you are likely to need something for severe pain. I recommend combining them with acetaminophen to keep your opioid dose low. After three days, let's see how you do with just acetaminophen for pain. If that's not enough, you should see your primary care physician. It is important that you stop taking opioids when they are no longer needed for severe pain. </p></div>
<div class="patient-dialogue"><p>Okay. Sounds good.</p></div>
<div class="provider-dialogue"><p> Make sure you keep them locked up, so that no children, pets, or other adults have access. And if you don't take all of them, be sure to dispose of them safely, like through a community take-back program such as the one offered through the police station.</p></div>
<div class="patient-dialogue"><p> Okay. I didn't know the police station had that. </p></div>
<div class="provider-dialogue"><p>Yes, it's a locked box in the lobby. You just drop your bottle in and leave. No questions are asked. We're lucky because many communities have no way to safely dispose of opioids or just an occasional program. Drug stores sometimes offer this service, too. </p></div>
<div class="patient-dialogue"><p> Interesting.</p></div>
</div></div>
<div class="navigation">
<div class="question">Continue to:</div>
<div class="continue">[[Case Summary]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Patient Education - Question</p><div class="chapter"><strong>Ch 6 |</strong> Patient Education</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>
<div class="yourchoice"><strong>You chose: </strong> No further patient education is needed</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
Incorrect. Any time you prescribe opioids, it is important to inform the patient that the duration of taking them should not be extended and that they should be stored and disposed of properly.
</div>
<div class="dialogue-container">
<div class="provider-dialogue"><p>I am prescribing a 3 day supply to cover just the time period that you are likely to need something for severe pain. I recommend combining them with acetaminophen to keep your opioid dose low. After three days, let's see how you do with just acetaminophen for pain. If that's not enough, you should see your primary care physician. It is important that you stop taking opioids when they are no longer needed for severe pain. </p></div>
<div class="patient-dialogue"><p>Okay. Sounds good.</p></div>
<div class="provider-dialogue"><p> Make sure you keep them locked up, so that no children, pets, or other adults have access. And if you don't take all of them, be sure to dispose of them safely, like through a community take-back program such as the one offered through the police station. </p></div>
<div class="patient-dialogue"><p> Okay. I didn't know that police station had that. </p></div>
<div class="provider-dialogue"><p> Yes, it's a locked box in the lobby. You just drop your bottle in and leave. No questions are asked. We're lucky because many communities have no way to safely dispose of opioids or just an occasional program. Drug stores sometimes offer this service, too. </p></div>
<div class="patient-dialogue"><p> Interesting.</p></div>
</div></div>
<div class="navigation">
<div class="question">Continue to:</div>
<div class="continue">[[Case Summary]]</div>
</div>
</div>
<div class="footer"><p class="small">You are here: Patient Education - Question</p><div class="chapter"><strong>Ch 6 |</strong> Patient Education</div><div class="progress chapter6"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>
<div class="yourchoice"><strong>You chose: </strong> 3 day supply</div>
<div class="container">
<div class="inner"><div class="feedback correct">
<div class="summary">Correct only if her pain does not respond to acetaminophen. The CDC's 2016 guidelines for opioid prescribing recommend using first line medications first. So she should be advised to take acetaminophen and after the acute phase, NSAIDs. She should have no more than a 3 day supply for most acute pain conditions. The supply should only cover the anticipated duration of pain severe enough to require an opioid for pain management and not more than 7 days without re-evalauation. A combination with non-opioid medications should be used to spare the use of opioids if possible.
</div></div>
</div>
<div class="navigation"><div class="question">To follow current guidelines for using the lowest possible dose and minimize risk of overdose, but still provide adequate pain relief, you want to be sure to keep Jessica's prescription for oxycodone less than:</div>
<div class="continue">[[13 mg]]</div>
<div class="continue">[[26 mg]]</div>
<div class="continue">[[52 mg]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Discussion</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong> 7 day supply</div>
<div class="container">
<div class="inner"><div class="feedback neutral">
<div class="summary">This much is probably not needed. The CDC's 2016 guidelines for opioid prescribing recommend using first line medications first. So she should be advised to take acetaminophen and after the acute phase, NSAID. However, if her pain does not respond to acetaminophen, a brief course of opioids can be used. She should have no more than a 3 day supply for most acute pain conditions. The supply should only cover the anticipated duration of pain severe enough to require an opioid for pain management and not more than 7 days without re-evalauation. A combination with non-opioid medications should be used to spare the use of opioids if possible. </div>
</div>
</div>
<div class="navigation"><div class="question">
To follow current guidelines for using the lowest possible dose and minimize risk of overdose, but still provide adequate pain relief, you want to be sure to keep Jessica's prescription for oxycodone less than:</div>
<div class="continue">[[13 mg]]</div>
<div class="continue">[[26 mg]]</div>
<div class="continue">[[52 mg]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Discussion</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong>14 day supply</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
<div class="summary">Incorrect. The CDC's 2016 guidelines for opioid prescribing recommend using first line medications first. So she should be advised to take acetaminophen and after the acute phase, NSAID. However, if her pain does not respond to acetaminophen, a brief course of opioids can be used. She should have no more than a 3 day supply for most acute pain conditions. The supply should only cover the anticipated duration of pain severe enough to require an opioid for pain management and not more than 7 days without re-evalauation. A combination with non-opioid medications should be used to spare the use of opioids if possible.
</div></div>
</div>
<div class="navigation"><div class="question">To follow current guidelines for using the lowest possible dose and minimize risk of overdose, but still provide adequate pain relief, you want to be sure to keep Jessica's prescription for oxycodone less than:</div>
<div class="continue">[[13 mg]]</div>
<div class="continue">[[26 mg]]</div>
<div class="continue">[[52 mg]]</div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Discussion</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong> 13 mg</div>
<div class="container">
<div class="inner"><div class="feedback correct">
<div class="summary">This is the correct maximum dose of oxycodone to avoid risk of overdose, however, since she is opioid naive, she can be prescribed even less. See discussion.
The CDC's evidence review found no threshold dose under which there is no risk of overdose (Dowell et al., 2016). However, doses under 20 MME have lower overdose risk than doses of 50 to 100 MME, and doses under 100 have less risk of overdose than doses over 100 MME. Therefore keeping the dose under 20 MME in an opioid naive patient will help reduce risk of overdose. However, consider that most opioids prescribed are stronger (exception - hydrocodone is similar to morphine in strength). Oxycodone is 1.5 times more potent than morphine, so 20 MME translates to only 13.3 mg of oxycodone.<br/>
<strong>Oxycodone Product Information</strong><br/>
Note that risk of overdose increases with increasing opioid dose.
Starting dose of oral oxycodone is 5 to 15 mg q 4 to 6 h
Oxcodone to morphine mg equivalent (MME) conversion factor is around 1.5.<br/>
Following the CDC guideline recommendations of using the lowest possible dose, starting with 5 mg in this opioid naive patient is appropriate if first line treatments have failed. Oxycodone is 1.5 times more potent than morphine so 5 mg of oxycodone is equivalent to 7.5 mg of morphine.
</div>
</div></div>
<div class="navigation"><div class="question"> Would you like to return to Prescribe pain medication, or continue to Treatment Summary? </div>
<div class="return">[[Prescribe pain medication]]</div>
<div class="continue">[[Treatment Summary]] </div>
</div>
</div><div class="footer"><p class="small">You are here: Treatment Planning - Discussion</p><div class="chapter"><strong>Ch 5 |</strong> Treatment Planning</div><div class="progress chapter5"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div></div>
</div>
<div class="yourchoice"><strong>You chose: </strong>26 mg</div>
<div class="container">
<div class="inner"><div class="feedback incorrect">
<div class="summary">Incorrect. This is too much for an opioid naive patient. The CDC's evidence review found no threshold dose under which there is no risk of overdose (Dowell et al., 2016). However, doses under 20 MME have lower overdose risk than doses of 50 to 100 MME, and doses under 100 have less risk of overdose than doses over 100 MME. Therefore keeping the dose under 20 MME in an opioid naive patient will help reduce risk of overdose. However, consider that most opioids prescribed are stronger and so require a lower dose than morphine to keep the risk for overdose relatively low (exception - hydrocodone is similar to morphine in strength). Oxycodone is 1.5 times more potent than morphine, so 20 MME translates to only 13.3 mg of oxycodone. <br/>
<strong>Oxycodone Product Information</strong><br/>
Note that risk of overdose increases with increasing opioid dose.
Starting dose of oral oxycodone is 5 to 15 mg q 4 to 6 h
Oxcodone to morphine mg equivalent (MME) conversion factor is around 1.5.<br/>
Following the CDC guideline recommendations of using the lowest possible dose, starting with 5 mg in this opioid naive patient would be appropriate if first line therapies are not sufficient. Oxycodone is 1.5 times more potent than morphine so this dose is equivalent to 7.5 mg of morphine.
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<div class="yourchoice"><strong>You chose: </strong> 52 mg</div>
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<div class="inner"><div class="feedback incorrect">
<div class="summary">Incorrect! This is far too much for an opioid naive patient. The CDC's evidence review found no threshold dose under which there is no risk of overdose (Dowell et al., 2016). However, doses under 20 MME have lower overdose risk than doses of 50 to 100 MME, and doses under 100 have less risk of overdose than doses over 100 MME. Therefore keeping the dose under 20 MME in an opioid naive patient will help reduce risk of overdose. However, consider that most opioids prescribed are stronger and so require a lower dose than morphine to keep the risk for overdose relatively low (exception - hydrocodone is similar to morphine in strength). Oxycodone is 1.5 times more potent than morphine, so 20 MME translates to only 13.3 mg of oxycodone. <br/>
<strong>Oxycodone Product Information</strong><br/>
Note that risk of overdose increases with increasing opioid dose.
Starting dose of oral oxycodone is 5 to 15 mg q 4 to 6 h
Oxcodone to morphine mg equivalent (MME) conversion factor is around 1.5.<br/>
Following the CDC guideline recommendations of using the lowest possible dose, starting with 5 mg in this opioid naive patient would be appropriate after first line treatments have been tried. Oxycodone is 1.5 times more potent than morphine so this dose is equivalent to 7.5 mg of morphine.
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<div class="yourchoice"><strong>You chose: </strong>Prescribe NSAIDs</div>
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<div class="summary">Correct, but you might consider delaying NSAIDs in favor of acetaminophen. Some evidence supports avoiding NSAIDs in the acute inflammatory phase of fractures as it can lead to poor fracture healing and may also delay soft tissue healing (Patel & Adrian, 2011). NSAIDs could be used for pain management later, avoiding their use in at least the first 48 hours. <br/>
Reference<br/>
Pater DS, Adrian BA. Do NSAIDs impair healing of musculoskeletal injuries? Rheumatology Network. June 6, 2011. Available at: http://www.rheumatologynetwork.com/articles/do-nsaids-impair-healing-musculoskeletal-injuries. Accessed 3/30/2016.
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<div class="return">[[Prescribe pain medication]]</div>
<div class="return">[[V. Treatment Planning]]</div>
<div class="continue">[[Treatment Summary]]</div>
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<div class="yourchoice"><strong>You chose: </strong> Patient interview about substance use</div>
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<div class="inner"><div class="feedback correct">Correct. Interviewing the patient is a good approach to screening for drugs and alcohol use.</div>
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<div class="provider-dialogue"><p> It helps me to understand your use of alcohol and drugs before planning how to treat your pain and make sure we do it safely and avoid potentially dangerous drug interactions. Could I ask a few questions about that?</p></div>
<div class="patient-dialogue"><p> Sure, no problem.</p></div>
<div class="provider-dialogue"><p> Have you had any drug use, illegal or prescription drugs for non-medical reasons, now or in the past?</p></div>
<div class="patient-dialogue"><p> I smoked some weed before I got in medical school. That's about it. </p></div>
<div class="provider-dialogue"><p> And no drugs currently?</p></div>
<div class="patient-dialogue"><p> No</p></div>
<div class="provider-dialogue"><p> And I see you drink a few alcoholic beverages on weekends only? Ever drink more than that?</p></div>
<div class="patient-dialogue"><p> No. I just drink alcopops. You know, those sweet drinks with hardly any alcohol in them. </p></div>
<div class="provider-dialogue"><p> Would you have any problems going without it?</p></div>
<div class="patient-dialogue"><p> Sure.</p></div>
<div class="provider-dialogue"><p> Have you ever taken opioids medically or not?</p></div>
<div class="patient-dialogue"><p> I may have had morphine when I broke my wrist. I'm not sure.</p></div>
<div class="provider-dialogue"><p> Have you ever taken benzodiazepines, like Xanax or Valium?</p></div>
<div class="patient-dialogue"><p> No.</p></div>
<div class="provider-dialogue"><p> Okay. I appreciate your answering these questions. </p></div>
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<div class="question"> Would you like to return to Substance use screening, return to Evaluation, or continue to Impressions?</div>
<div class="return">[[Substance use screening]]</div>
<div class="return">[[III. Evaluation]]</div>
<div class="continue">[[IV. Diagnostic Impressions]] </div>
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<div class="footer"><p class="small">You are here: Evaluation - Discussion</p><div class="chapter"><strong>Ch 3 |</strong> Evaluation</div><div class="progress chapter3"><div class="inner"></div><div class="chaptermark1"></div><div class="chaptermark2"></div><div class="chaptermark3"></div><div class="chaptermark4"></div><div class="chaptermark5"></div><div class="chaptermark6"></div></div></div>
<div class="yourchoice"><strong>You chose: </strong> Administer morphine to treat her pain while she is in the clinic</div>
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<div class="inner"><div class="feedback neutral">
<div class="summary">Possibly, under certain circumstances and with caution. This is not the best option unless the pain "overwhelms the patient's ability to contribute to the assessment process." Guidelines in acute pain management by ICSI (Thorson et al., 2014) recommend considering "judicious use of opioids" in the emergency setting if that was the case, but it does not appear to be the case for Jessica. The reason to do an evaluation is to determine what pain management is indicated and safe. For example, you want to be sure that she is not taking benzodiazepines or using alcohol, which could interact harmfully with opioids. </div></div>
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Would you like to return to Obtain Additional History or continue on to Evaluation?</div>
<div class="return">[[II. Obtain Additional History]] </div>
<div class="continue">[[III. Evaluation]] </div>
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<div class="yourchoice"><strong>You chose: </strong>Offer acetaminophen until you can complete your evaluation</div>
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<div class="inner"><div class="feedback neutral">
<div class="summary">Partly correct. This would be a good option if she hadn't already taken some acetaminophen. You would learn that if you asked her first. The reason to do an evaluation is to determine what pain management is indicated and safe. For example, you want to be sure that she is not taking benzodiazepines which could interact with opioids. However, guidelines in acute pain management by ICSI (Thorson et al., 2014) recommend considering "judicious use of opioids" in the emergency setting if the pain "overwhelms the patient's ability to contribute to the assessment process." </div></div></div>
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<div class="return">[[II. Obtain Additional History]] </div>
<div class="continue">[[III. Evaluation]] </div>
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<div class="yourchoice"><strong>You chose: </strong>References</div><div class="container">
<div class="inner">
<div class="references">
Chou R, Fanciullo G, Fine P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. J Pain. 2009; 10(2): 113-130. Available at: <a href="http://www.jpain.org/article/S1526-5900(08)00831-6/abstract" target="_blank" rel="noopener noreferrer" data-raw="">http://www.jpain.org/article/S1526-5900(08)00831-6/abstract</a> Accessed 02/13/2019.
Dumitrascu CD, Mannes PZ, Gamble LJ, Selzer JA. Substance use among physicians and medical students. MSRJ. 2014: 03 (Winter): 26-35. Available at: <a href="http://msrj.chm.msu.edu/wp-content/uploads/2014/04/MSRJ-Winter-2014-Substance-Use-Among-Physicians-and-Medical-Students.pdf" target="_blank" rel="noopener noreferrer" data-raw="">http://msrj.chm.msu.edu/wp-content/uploads/2014/04/MSRJ-Winter-2014-Substance-Use-Among-Physicians-and-Medical-Students.pdf</a> Accessed 02/13/2019.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016; ePub: March 2016: DOI: <a href="http://dx.doi.org/10.15585/mmwr.rr6501e1er" target="_blank" rel="noopener noreferrer" data-raw="">http://dx.doi.org/10.15585/mmwr.rr6501e1er</a>. Available at: <a href="http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm?s_cid=rr6501e1er_w" target="_blank" rel="noopener noreferrer" data-raw="">http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm?s_cid=rr6501e1er_w</a> Accessed 02/13/2019.
Drug Enforcement Administration. State Prescription Drug Monitoring Programs. U.S. Department of Justice. 2011. Available at: <a href="http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm" target="_blank" rel="noopener noreferrer" data-raw="">http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm</a> Accessed 02/13/2019.
Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burnout and Alcohol Abuse/Dependence Among U.S. Medical Students. Acad Med. 2016. Available at: <a href="http://www.ncbi.nlm.nih.gov/pubmed/26934693" target="_blank" rel="noopener noreferrer" data-raw="">http://www.ncbi.nlm.nih.gov/pubmed/26934693</a> Accessed on: 2016-03-31.
Physicians for Responsible Opioid Prescribing. Petition to FDA. July 25, 2012. Available at: <a href="http://www.citizen.org/documents/2048.pdf" target="_blank" rel="noopener noreferrer" data-raw="">http://www.citizen.org/documents/2048.pdf</a> Accessed 02/13/2019.
Thorson D, Biewen P, Epstein H. et al. Acute pain assessment and opioid prescribing protocol. Health care protocol. AHRQ National Guideline Clearinghouse. Developed by Institute for Clinical Systems Improvement. Available at: <a href="https://www.guideline.gov/content.aspx?id=47765" target="_blank" rel="noopener noreferrer" data-raw="">https://www.guideline.gov/content.aspx?id=47765</a> Accessed 02/13/2019.
Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician. 2009; 12: 507-515. Available at: <a href="http://www.ncbi.nlm.nih.gov/pubmed/19461820" target="_blank" rel="noopener noreferrer" data-raw="">http://www.ncbi.nlm.nih.gov/pubmed/19461820</a> Accessed 02/13/2019.
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<div class="header">Your Next Patient</div>
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<strong>Jessica Davis</strong>
<p>"My finger is really hurting!"</p>
<div class="continue">[[Case Overview]]</div>
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<div class="yourchoice"><strong>You Chose:</strong> Case Overview</div>
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<div class="report"><h4 class="title">Case Overview</h4><div class="patient-overview"><div class="patientimg"></div>
<div class="name">Jessica Davis</div><div class="age">Age 30</div><div class="occupation">4th year medical student</div><div class="complaint">"My finger is really hurting!"</div></div>
<p>Your next patient is Jessica Davis, a medical student who presents to an urgent care clinic. She is in severe pain after dropping a weight on her finger while working out at her health club. She knew to apply ice and to elevate the finger, but after 8 hours finds the pain is severe despite taking over-the-counter pain medications.</p>
<p>This case will challenge you to follow the latest guidelines when prescribing opioids for severe acute pain in terms of indications and contraindications, dosage, quantity, and patient education.</p>
<p>In this clinical simulation, you will make choices as Ms. Davis' primary care provider and experience outcomes based on the choices you make. You will be challenged to: </p>
<ul><li>Evaluate patient's need for opioid therapy to manage acute pain</li>
<li>Assess the safety of prescribing opioids for acute pain in the context of urgent care with an unknown patient</li>
<li>Follow current guidelines when prescribing opioids for acute pain in terms of dosage and amount prescribed</li>
<li>Provide targeted patient education regarding opioids for patients in the context of being treated for acute pain in urgent care</li>
</ul>
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<div class="continue">[[I. Review Medical Record]]</div>
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