Questions and Answers
How useful is the Antigen test?
At this point it may be a less expensive screen for active disease but there is debate about false negative and false positive tests. The advantage is that results are available in 5 minutes. Until proven accurate probably more useful for population screening. A positive test should be repeated with PCR technology.
Is COVID recurrence a true phenomena?
There seem to be some cases of re infection but these are all small studies. In general there can be a prolonged recovery or even a chronic fatigue like syndrome. In general if new symptoms develop after 90 days and the PCR is positive re infection is a possibility.
What about food borne COVID?
Food has not been implicated in COVID transmission. Restaurants should be visited outdoors because of fellow diners and servers posing a risk.
Will routine use of gloves protect me in my office?
The risk benefit analysis suggests one time use of gloves for workers in the healthcare field. For others washed hands are generally safer. Many people wear the same gloves for hours Which poses a risk.
What about pets and COVID?
An interesting question. Dogs, cats, zoo animals and other have had PCR positive swabs. They may or may not be slightly ill. There are no documented cases of domestic animal spread but the CDC currently suggests that individuals with COVID isolate from their pets.
In response to the questions regarding escalation of opioid therapy in inpatient settings for acute pain:
When the inpatient provider deems the patient to have a medical reason for acute pain, it is appropriate to escalate opioid therapy. Patients on long-term opioids for chronic pain often experience tolerance and need higher doses to adequately control pain in acute settings such as perioperatively. Their needs should not be misconstrued as "opioid-seeking" behavior. Coordination with the outpatient Pain Management prescriber is advised.
In response to the questions regarding opioid prescribing in hospice settings:
This is also appropriate as patients with life expectancy limited to less than 6 months should be treated with a focus on pain control; concern for misuse or addiction in this situation is minimal. That said, checking the state controlled substance prescription monitoring database is always advisable as it can provide information regarding a patient's tolerance and prior treatment trials.
Comment on the benefits of transitioning patients from full opioid agonists like oxycodone to buprenorphine-naloxone (Suboxone) for chronic non-cancer pain:
Buprenorphine-naloxone (Suboxone) has strong off-label evidence for chronic pain. As a partial opioid agonist, buprenorphine is less likely than full opioid agonists to cause opioid-induced hyperalgesia. Some experts believe that opioid tolerance is largely driven by hyperalgesia. Therefore, switching a patient from a full opioid agonist to a partial one can lead to better pain control. An additional advantage is that the partial opioid agonist does not carry the risk of respiratory depression and fatal overdose seen with full opioid agonists. The naloxone component of buprenorphine-naloxone is activated only if the patient attempts to misuse their medication, either intranasally or by injection. In these situations, the activation of naloxone prevents the medication from causing euphoria. Buprenorphine-naloxone can precipitate opioid withdrawal if started too soon after the last full opioid agonist dose. However, as long as the appropriate time interval has elapsed (at least 6-10 hours after the last short-acting opioid such as oxycodone, 24 hours after the last long-acting opioid such as Oxycontin, and 48-72 hours after any methadone), patients can be safely transitioned to buprenoprine-naloxone. The transition is typically done in the outpatient setting by a provider who has been trained in prescribing buprenorphine-naloxone and has obtained their X-waiver to do so from the DEA. More information can be found at: https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner
For questions regarding duration of controlled substance prescribing and appropriate dating
It is generally advisable to dispense no more than a 4 week supply at a time to minimize the risk of diversion. That said, in patients who are stable, refills can be placed on a controlled substance prescription to allow for a patient to receive a total of a 3 months' supply before their next provider visit in accordance with federal guidelines. Writing future dates (i.e., "Not to be filled before MM/DD/YY") on prescriptions can be a helpful way to prevent early refills. Another useful practice is to always write prescriptions as a multiple of 7 days (i.e. 28 days rather than 30 days) such that the refill will always fall on the same day of the week. This practice prevents refills from being due on a weekend and refill calls to the answering service.
Regarding opioid prescribing in the elderly
Pain management in this population can be quite challenging. One reason that opioids are often used is that the Beers List has historically warned against the use of systemic NSAIDs. However, the 2019 updated criteria explicitly state that this warning should not be misinterpreted as an invitation to prescribe opioids (https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdf). Topical NSAIDs are safe and carry minimal risk of systemic absorption. For safety reasons; these should be tried before opioids are used. If long-term opioids are to be prescribed in elderly patients, this should be done with close monitoring including assessment of sedation, fall risk, and other adverse effects such as constipation. The same safety measures used with younger patients, such as having the patient sign a controlled substance prescription agreement, checking the state controlled substance prescription database, and obtaining urine toxicology screens, should also be practiced with elderly patients.