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OUD

CE / CME

Module 6: Opioid Use Disorder

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurses: 1.00 Nursing contact hour

ABIM MOC: maximum of 1.00 Medical Knowledge MOC point

Optometrists: 1.00 COPE CE credit 

ABP MOC: maximum of 1.00 MOC point

ABS MOC: maximum of 1.00 Continuous Certification credit

ABOHNS MOC: maximum of 1.00 Part II Self-Assessment Credit

ABPath MOC: maximum of 1.00 Lifelong Learning point

Dental Professionals: 1.00 ADA CERP credit

Physicians: maximum of 1.00 AMA PRA Category 1 Credit™

Released: May 31, 2023

Expiration: May 30, 2026

Timothy Atkinson
Timothy Atkinson, PharmD, BCPS, CPE
CME/CE Information

Activity

Progress
1 2 3
Course Completed

Meet Ryan


Let’s look at a case study. This is Ryan. He is 45 years old and has a history of reporting lost or stolen medications. He frequently requests early renewals for his pain medications and frequently visits the emergency department for pain. He has a 15-year history of low back pain after multiple surgeries. The last one was an L2 to L5 fusion requiring instrumentation. He consistently denies any abuse or misuse.

He is a construction worker, working 40-50 hours per week. He has no consistent exercise regimen and does not adhere to a healthy diet. He smokes 1 pack of cigarettes per day, drinks 2 beers daily, and denies any illicit drug use, but he also has poor sleep. In addition to his back surgeries, his medical history includes hypertension, hyperlipidemia, sleep apnea, anxiety, depression, and insomnia. 

From a pain perspective, he has significant pain history from all of the surgeries, but he mainly experiences axial pain with some radicular pain. He describes the pain mostly as stiffness, throbbing, and shooting. It appears to be musculoskeletal inflammatory pain combined with neuropathic pain. His current pain medication regimen includes gabapentin 600 mg 3 times per day, duloxetine 60 mg daily, and a lidocaine patch that he applies daily. He also takes controlled-release oxycodone 20 mg twice daily and immediate-release hydromorphone 4 mg 4 times daily as needed.

Patient Case Ryan: Treatment Concerns

Ryan now requests an early refill of his pain medications. Each time he does this, he says he has been instructed to contact the clinic at least 1 week early to make sure that the clinic has time to get the refill from the providers. He denies any overuse or misuse. When he is questioned about the emergency department visits, he reports that his back pain has been considerably worse and he is considering another surgery. We are concerned because the emergency department notes indicate that he asks about getting more medication while he is there. There is also a history of reports of lost or stolen prescriptions.

We have asked him for a current pill count, and we have allotted 48 hours to come in for the pill count and a urine drug screen. We are concerned that something is going on that he is not admitting. 

When he presents for the pill count, he says that the pills have once again been lost or stolen.

Patient Case Ryan

Ryan’s urine drug screen result is positive for opiates and benzodiazepine. Although we would expect that it would be positive for oxycodone, we have some concern because he is not prescribed benzodiazepines.

What is the best treatment option for Ryan? How do we proceed with this case?

Patient Case Ryan

At this point, we plan a brief intervention with Ryan.

We express concern for what we have witnessed: the request for early refills of his medication, the emergency department visits, the claim of lost or stolen medications, the unexplained discrepancy in his pill count. We review the results of his urine drug screen and we express the intent to run confirmatory tests.

An important part of making clinical decisions based on test results is that they are definitive results. So, we plan to send his urine drug stream for a confirmatory panel to be sure that the benzodiazepine result we saw in the first test was not a false positive. In this second panel, the opiates portion of the test comes back with a surprising result: the positive test result for opiates is not hydromorphone or oxycodone but rather morphine, for which he does not have a prescription. In addition, the benzodiazepine result is confirmed as alprazolam.

Patient Case Ryan: Resolution

At this point, we must discuss future plans with Ryan. We need to bring our findings to his attention and relate that we have concerns about his behavior. We ask him if opioids have become a problem. We review the DSM-5 criteria for OUD, making sure he understands that OUD is a spectrum disorder. Ryan does agree that opioids have become a problem. We discuss that he can be treated for co-occurring OUD and pain with good supervision. We describe how that can be done in our clinic. He voices a preference at this point to continue treatment with his primary care provider.

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