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250-510 - Administration of SymantecTM Data Loss Prevention 10.5 - BETA - Dump Information

Vendor : Symantec
Exam Code : 250-510
Exam Name : Administration of SymantecTM Data Loss Prevention 10.5 - BETA
Questions and Answers : 196 Q & A
Updated On : Click to Check Update
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250-510 Questions and Answers

Pass4sure 250-510 Dumps with Real Questions & Practice Test


D. The Detection server communicates directly to the Oracle database as well as indirectly via Enforce server


Answer: C


QUESTION: 190

Which default port is used for communication between the Detection server and Enforce server?


  1. 8000

  2. 8100

  3. 8300

  4. 8080


Answer: B


QUESTION: 191

Which two server types are affected by Incident.Detection.TrialMode in the advanced server settings? (Select two.)


  1. ICAP Prevent

  2. Protect

  3. Discover

  4. Enforce

  5. Network Monitor


Answer: AB


QUESTION: 192

What information can a user collect from the Enforce Console when troubleshooting issues with detection servers?


  1. A user can only collect Operational Logs one server at a time

  2. A user must collect Operational Logs by collecting them manually

  3. A user can collect Operational Logs, Debug Logs and Configuration files from all detection servers at once

  4. A user can collect Operational Logs, Debug Logs and Configuration files from all

    detection servers one at a time

  5. A user can only collect configuration files one server at a time


Answer: CD


QUESTION: 193

Which file or folder is unique to running command line ECU without options on Enforce versus on Monitor?


  1. monitorSettings

  2. HostFileLog.txt

  3. ErrorLog.txt

  4. ECUoutput.txt


Answer: A


QUESTION: 194

What is shown on an aggregated basis (rather than per protocol) on the Traffic Report Cumulative Statistics page?


  1. Discarded Packets

  2. Incidents

  3. Messages

  4. Unprocessable Components


Answer: A


QUESTION: 195

Which two diagnostic log settings are available for the Enforce server on the logs configuration page? (Select two.)


  1. Custom Attribute Lookup Logging

  2. Incident Persister Logging

  3. Monitor Controller Logging

  4. Vontu Manager Logging

  5. Reporting API SOAP Logging


Answer: AE


QUESTION: 196

Which command line utility generates custom authentication keys to improve the security of the data that is transmitted between the Enforce server and detection servers?


  1. DBPasswordChanger

  2. keytool

  3. servertool

  4. sslkeytool


Answer: D


QUESTION: 197

Which command line diagnostic utilities would give a user the operating system (OS) version of the detection servers?


  1. ECU

  2. LCU

  3. normalizationconfigcheck

  4. SC


Answer: A


QUESTION: 198

Which statistic from the Systems > Servers > Overview page would be available for the Enforce Server on a three-tier installation?


  1. Messages (Last 10 sec)

  2. Messages (Today)

  3. Incidents (Today)

  4. Incident Queue


Answer: D


Symantec 250-510 Exam (Administration of SymantecTM Data Loss Prevention 10.5 - BETA) Detailed Information

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The exams are computer-based and delivered at Pearson VUE testing centers. Pearson VUE provides computer-based testing for information technology, academic, government and professional testing programs around the world. Pearson VUE provides a full suite of services from test development to data management, and delivers exams through the world’s most comprehensive and secure network of Test Center Locations in 175 countries. Pearson VUE is a business of Pearson (NYSE: PSO; LSE: PSON), the international media company, whose businesses include the Financial Times Group, Pearson Education and the Penguin Group.
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How much time is allowed to take an exam?
Allotted exam time varies by exam length. It typically takes one minute to complete each exam question.
How will I be notified that I have passed an exam?
Pearson VUE provides you with instant results at the completion of your exam. A score report will be printed and given to you before you leave the testing center. Candidates are also able to view exam progress by logging into CertTracker.
How will Symantec be notified that I have passed an exam?
Symantec receives candidate exam results daily via file transfers from Pearson VUE to CertTracker Be sure you keep your personal information in your CertTracker profile up-to-date so that you receive proper credit for exams passed and certifications earned.
What score must I achieve to pass an exam?
Passing scores vary by exam. For more information on specific certifications in each category, please see the certification exam details within your selected product solution training path.
Who sees my exam score(s)?
You, Symantec, and your company (if you designate).
If I do not pass an exam, can I find out which questions I got wrong?
No. Symantec maintains this policy to ensure security over the exam questions.
How many times can I take an exam, is there a waiting period, and is there a cost to retake an exam?
If you do not pass an exam on your first attempt, you must wait at least 3 days (72 hours) before a second attempt. If you do not pass an exam on your second attempt, then you must wait at least 2 weeks (14 days) between each additional attempt. If you need to retake an exam that you have already passed in order to fulfill a certification track requirement, you may do so after 3 months. The same cost applies whether you take an exam once or many times.
How can I find out what topics an exam will cover?
Certification requirements, sample exams, exam objectives, recommended training and registration is available for each certification and corresponding exam. For more information on specific certifications in each category, please see the certification exam details within your selected product solution training path.
Are the exams based on current Symantec product versions?
Exams are developed for the current version of the Symantec product release at the time of development. Exams may be updated after significant new versions are released. New exams may not always correspond to the software release schedule.
How do I know what software release version an exam covers?
For more information on specific certifications in each category, please see the certification exam details within your selected product solution training path.
Are practice or sample exams available?
Sample exams are available. Each sample exam consists of multiple-choice items. Some items may have a supporting exhibit which you will be directed to view before answering the item. The sample exams are not timed, however, you should attempt to complete them as quickly as you can. Certification requirements, sample exams, exam objectives, study guides, recommended training, and registration is available for each certification and corresponding exam. For more information on specific certifications in each category, please see the certification exam details within your selected product solution training path.
Why does Symantec list a range of questions for exams?
Symantec regularly conducts statistical analyses of certification exam results for exam maintenance purposes. In doing so, Symantec publishes a range of questions per exam to account for “unscored” questions. In order to ensure the value of the Symantec certification program, Symantec routinely updates exams with new questions on an unannounced basis. Those new questions are initially delivered as “unscored” so that Symantec can evaluate the performance in the field/on the released exam. The “unscored” questions do not count towards your passing score and additional time is already incorporated into the total exam duration to answer these questions.
Symantec also regularly updates exam questions where the actual number of questions per exam may vary from time to time as these unannounced updates occur.
How are the exams developed?
Symantec end users, both internally and in the field, are studied to define the job performance requirements. The results determine the minimum level of competence required for the defined job performance and is tested in the exams. Symantec follows industry standards for “high stakes” exam development.
How are passing scores established?
Although it is intuitive to think that an appropriate passing score for an examination should be 70 or 75 percent correct based on personal experiences taking classroom tests, these arbitrary values may not reflect the performance level expected of the “minimally qualified candidate” given the difficulty of the test. For example, if the examination is very easy, a passing score of 70 may be too low. However, if the examination is very difficult, this same value may be too high.
Establishing passing scores requires the application of systematic procedures that consider the defined performance level definition of the “minimally qualified candidate” and the difficulty of the examination. Before the final passing scores are established, they are evaluated to ensure that the available validity evidence supports their use for the intended purpose of distinguishing the “minimally qualified candidates” from those who are not yet qualified. This systematic method is used to establish and maintain the fairness, validity and reliability of exams.
In order to ensure the value of the Symantec certification program, Symantec routinely updates exams with new questions. In these cases the passing percentage could change per exam from time to time as these unannounced updates occur
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Am i able to obtain contact data of 250-510 certified? The association time for 250-510 exam become surely a nice experience for me. easily passing, I have found outthe way to pass all the further tiers. because of killexams.com questions and answers for all of the assistance. I had constrained time for preparation but killexams.com brain dumps became out to be a help for me. It had vast question and answers that made me plan in a quick compass. Administration of SymantecTM Data Loss(R) Prevention 10.5 - BETA certification Rational Use of Opioids for management of continual Nonterminal ache | 250-510 Real Questions and VCE Practice Test Opioid prescribing for chronic nonterminal ache has expanded in recent years, despite the fact facts for its long-term effectiveness is weak and its potential for harm is tremendous. Nonmedical use of prescription opioids, diversion, and overdose deaths have additionally elevated sharply, sparking subject concerning the safeguard of those medicines. Physicians for the reason that initiation or continuation of opioid remedy for a affected person with continual nonterminal ache may still first use a structured strategy that comprises a biopsychosocial comparison and a medicine plan that encourages patients to set and reach useful desires. There should be a complete comparison for the cause of ache, assessment for possibility of opioid issues (including misuse and addiction), and a detailed medication history, including a evaluate of clinical records and statistics from the state prescription monitoring program. Opioids may still be prescribed on a trial foundation, to be persisted simplest if development towards useful dreams is validated. long-performing morphine is the favored initial drug, although a number of alternatives are available. Ongoing monitoring for safety and effectiveness is standard, together with usual review of purposeful progress or preservation, urine drug checking out, and surveillance of records from the state prescription monitoring software. Ineffective, hazardous, or diverted opioid therapy should still be promptly tapered or stopped. continual pain impacts about one-third of U.S. adults, and 5 p.c get hold of opioid treatment1; effective opioids are prescribed in up to 9 p.c of all office visits.2 unless the Nineties, physicians often restricted opioid medicine to patients with acute or melanoma-related pain. however, studies showed that every kind of ache have been undertreated; due to this fact, pain schooling, advocacy, and policy initiatives resulted in an increase in opioid prescribing for sufferers with persistent nonterminal pain. greater expansive prescribing of opioids for continual nonterminal ache has been accompanied by means of expanding costs of excessive-dose, continuous therapy.36 despite the fact some sufferers may also benefit from such medicine, others could have big physiologic and practical compromise. continuous opioid therapy for as little as two weeks can produce drug tolerance in some sufferers. For different sufferers, dosages as little as 30 mg per day of morphine or its equivalent had been shown to lower ache thresholds and create opioid-prompted hyperalgesia, by which pain satirically worsens as opioid doses are accelerated.79 Many sufferers event nausea, vomiting, constipation, depressed temper, and respiratory melancholy, and tolerance to these toxicities may additionally enhance slowly or no longer at all. a ten-year observe-up look at confirmed that patients who take prescription opioids have a lessen nice of lifestyles and better fees of depression and health care utilization.10 expanded opioid prescribing has additionally resulted in caring trends of misuse, abuse, and diversion on the market. Between 1997 and 2006, earnings of oxycodone (Roxicodone) expanded well-nigh eightfold, and earnings of methadone improved ninefold.11 Fifteen % of twelfth graders document that they have got taken hydrocodone/acetaminophen (Vicodin) or oxycodone, usually received from members of the family or chums.11 From 2004 to 2008, visits to emergency departments for nonmedical use of opioids tripled.12 The centers for disease manage and Prevention reported an almost sevenfold boost in methadone-related fatalities in 2009.12 standard, the nonmedical use of controlled prescription medicine now exceeds illicit drug use. These records have raised serious issues amongst state and federal law enforcement, regulatory, and legislative officers, and have sparked efforts to enhance prescription oversight.13,14 during this atmosphere, prescribers must ensure that opioid therapy is acceptable, secure, and advantageous. This review offers a framework for approaching opioid remedy for patients with persistent nonterminal pain, including patient option; structured trials of opioid therapy; monitoring; and tapering, when indicated. more details and apply equipment can be found on-line (http://guidelines.gov/content material.aspx?identification=25657&search=managing+chronic+ache).15 amplify Print type: KEY recommendations FOR observe medical recommendationEvidence ratingReferences sufferers with chronic nonterminal pain should still obtain a complete assessment, together with assessment for skills opioid responsiveness and opioid possibility. C 4, 6, 18 continual nonterminal ache requires remedy of physical and psychological modalities, prescription of nonopioid analgesics, medicine of comorbid temper disorders, and restoration of sleep. C 18, 19 Tricyclic antidepressants or selective serotonin-norepinephrine reuptake inhibitors may still be blanketed in sufferers with chronic nonterminal pain with a neuropathic element. A 13, 15, 20 Opioid remedy should still be averted in sufferers with continual relevant or visceral ache syndromes comparable to fibromyalgia, complications, or belly pain. C 11, 17 Opioids should still be initiated as a trial, to be endured if progress is documented towards useful desires, and if there isn't any proof of complications, together with misuse or diversion. C 6, 15, 18 Opioid dosages exceeding one hundred mg of morphine or its equivalent might also boost the risk of overdose, and will immediate consideration of tapering or referral to a ache subspecialist. C 13, 27 style: KEY concepts FOR follow medical recommendationEvidence ratingReferences patients with persistent nonterminal pain should still acquire a comprehensive evaluation, together with assessment for competencies opioid responsiveness and opioid chance. C 4, 6, 18 persistent nonterminal pain requires remedy of actual and psychological modalities, prescription of nonopioid analgesics, medicine of comorbid temper issues, and restoration of sleep. C 18, 19 Tricyclic antidepressants or selective serotonin-norepinephrine reuptake inhibitors may still be protected in sufferers with chronic nonterminal ache with a neuropathic part. A 13, 15, 20 Opioid remedy should still be averted in patients with persistent critical or visceral ache syndromes similar to fibromyalgia, complications, or belly pain. C eleven, 17 Opioids should still be initiated as a trial, to be continued if progress is documented towards practical goals, and if there is no facts of issues, including misuse or diversion. C 6, 15, 18 Opioid dosages exceeding one hundred mg of morphine or its equal may additionally raise the possibility of overdose, and may on the spot consideration of tapering or referral to a ache subspecialist. C 13, 27 realizing persistent ache persistent ache is different from acute ache, and ought to be approached differently. Acute pain is a symptom that plays a purposeful role in body defenses and resolves with tissue recovery. it is transmitted alongside intact neural pathways which are effectively modulated via opioids to decrease pain perception. In contrast, persistent pain has no such practical function, does not resolve with tissue recovery, and may turn into a main prognosis. chronic pain involves advanced vital nervous equipment signaling that may also be amplified through stressors akin to relationship issues, economic issues, or underlying psychiatric diagnoses. This can lead to the belief of worse pain, and an expanded probability of compromised social functioning.10,16,17 for that reason, continual nonterminal ache is a biopsychosocial condition that requires a complete, multidisciplinary approach to contrast and administration. continuing commonplace cures for acute painincluding opioid remedymay also be ineffective or unsafe in sufferers with chronic ache. popular approach to the affected person with chronic Nonterminal pain constructive management of persistent nonterminal pain requires more than prescribing medicine.13,15,18 Any skills focal or treatable pain generators may still be recognized and treated first. consideration may still then flip to actual and psychological modalities, prescription of nonopioid and adjuvant analgesic drugs, multimodal remedy of temper issues, and restoration of sleep.18,19 most effective after these measures are optimized may still a trial of opioid remedy, or continuation of current opioid remedy, be considered. A finished method is printed in desk 1.13,15,18,20 amplify Print desk 1. remedy of chronic pain determine and treat specific local ache generators, if latest Cutaneous stimulators (e.g., transcutaneous electrical nerve stimulation) local medicine (e.g., actual remedy, manipulation, therapeutic massage, warmth) Minor interventions (e.g., anesthetic or steroid joint injection) surgery Topical anesthetics (e.g., lidocaine ointment or patches) Promote match behaviors actual pastime Weight manage fix sleep counting on coexisting complications, beneficial agents may additionally consist of trazodone, tricyclic antidepressants, gabapentin (Neurontin), pregabalin (Lyrica), mirtazapine (Remeron), melatonin, or quetiapine (Seroquel); use of benzodiazepines or their analogs should be prevented on account of tolerance and abuse talents beginning adjuvant pain medicinal drugs (listed in order of informed cures) Tricyclic antidepressants are indicated for neuropathic ache; nortriptyline (Pamelor), desipramine (Norpramin), amitriptyline, and doxepin are also useful for localized or generalized pain with coexisting headache, depression, panic sickness, or tobacco dependancy Serotonin-norepinephrine reuptake inhibitors are indicated for neuropathic ache; duloxetine (Cymbalta) and milnacipran (Savella) are most beneficial for localized or generalized pain with melancholy or nervousness, venlafaxine (Effexor) much less so; doses for medication of ache are typically better than those for melancholy Pregabalin is accredited via the U.S. meals and Drug Administration for neuropathic ache and fibromyalgia; gabapentin has identical effectiveness, is attainable generically, and is greater typical, nonetheless it is sedating, and dosing is advanced; may well be synergistic when mixed with tricyclic antidepressants Anticonvulsants; carbamazepine (Tegretol) is a first-line agent for trigeminal neuralgia, but third-line (with oxcarbazepine [Trileptal] and lamotrigine [Lamictal]) for different neuropathic ache Migraine chemoprophylaxis (e.g., beta blockers, calcium channel blockers, tricyclic antidepressants, topiramate [Topamax]) treat comorbid psychiatric disease Use of pharmacologic and psychotherapeutic measures is essential for growth of signs and function often associated problems include anxiousness, depression, posttraumatic stress sickness in folks who've experienced physical, sexual, or emotional trauma; medication should include psychotherapy, biofeedback, mindfulness training, posttraumatic stress sickness therapy, relationship counseling, social and monetary counseling, and substance abuse counseling Trial of opioid remedy (initiation or continuation) sufferers should don't have any contraindications for opioid therapy sufferers with diffuse, centralized pain or headache are much less likely to benefit from opioid remedy and might be harmed with the aid of opioid toxicities opt for sufferers with certain somatic, peripheral, or neuropathic ache can also benefit from low-dose opioid remedy in mixture with different treatments medication may still produce demonstrable purposeful development, now not in basic terms a discount in ache scores, or opioids should still be tapered or discontinued desk 1. remedy of continual pain identify and treat particular native ache generators, if existing Cutaneous stimulators (e.g., transcutaneous electrical nerve stimulation) native medication (e.g., actual therapy, manipulation, massage, heat) Minor interventions (e.g., anesthetic or steroid joint injection) surgical procedure Topical anesthetics (e.g., lidocaine ointment or patches) Promote match behaviors actual recreation Weight manage fix sleep counting on coexisting issues, useful brokers might also include trazodone, tricyclic antidepressants, gabapentin (Neurontin), pregabalin (Lyrica), mirtazapine (Remeron), melatonin, or quetiapine (Seroquel); use of benzodiazepines or their analogs should be avoided as a result of tolerance and abuse knowledge delivery adjuvant ache medications (listed so as of informed treatments) Tricyclic antidepressants are indicated for neuropathic pain; nortriptyline (Pamelor), desipramine (Norpramin), amitriptyline, and doxepin are also useful for localized or generalized pain with coexisting headache, depression, panic ailment, or tobacco addiction Serotonin-norepinephrine reuptake inhibitors are indicated for neuropathic pain; duloxetine (Cymbalta) and milnacipran (Savella) are most helpful for localized or generalized pain with melancholy or anxiety, venlafaxine (Effexor) less so; doses for treatment of pain are usually bigger than these for depression Pregabalin is authorised with the aid of the U.S. food and Drug Administration for neuropathic pain and fibromyalgia; gabapentin has equivalent effectiveness, is obtainable generically, and is greater prevalent, but it is sedating, and dosing is complex; may well be synergistic when mixed with tricyclic antidepressants Anticonvulsants; carbamazepine (Tegretol) is a first-line agent for trigeminal neuralgia, but third-line (with oxcarbazepine [Trileptal] and lamotrigine [Lamictal]) for other neuropathic pain Migraine chemoprophylaxis (e.g., beta blockers, calcium channel blockers, tricyclic antidepressants, topiramate [Topamax]) deal with comorbid psychiatric affliction Use of pharmacologic and psychotherapeutic measures is fundamental for improvement of indicators and function commonly associated disorders consist of anxiousness, depression, posttraumatic stress ailment in men and women who've experienced actual, sexual, or emotional trauma; medication should encompass psychotherapy, biofeedback, mindfulness practising, posttraumatic stress disorder remedy, relationship counseling, social and fiscal counseling, and substance abuse counseling Trial of opioid remedy (initiation or continuation) sufferers should still have no contraindications for opioid therapy patients with diffuse, centralized pain or headache are less more likely to benefit from opioid therapy and might be harmed by opioid toxicities select patients with specific somatic, peripheral, or neuropathic ache can also benefit from low-dose opioid therapy in mixture with different treatments medicine should produce demonstrable useful improvement, not in simple terms a discount in ache ratings, or opioids should still be tapered or discontinued Opioid Use and Precautions initial affected person alternative protected and positive opioid therapy requires careful affected person alternative. In universal, chronic somatic or neuropathic pain (e.g., musculoskeletal ache, peripheral neuropathy, postherpetic neuralgia) is as a minimum partially aware of opioids. youngsters, persistent visceral or principal pain syndromes (e.g., belly or pelvic pain, fibromyalgia, complications) are less responsive or nonresponsive.11,17,21,22 patients with these circumstances may have greater antagonistic outcomes than benefits from continual opioid remedy. The affected person's risk of opioid misuse or abuse must be assessed. a few validated equipment are available, together with the Opioid chance device (table 2).23 risks may still be mentioned overtly and managed, on every occasion possible, before prescribing opioids. although no particular cutoffs had been established, patients with scores of eight or more on the Opioid chance device should be prescribed opioids best after all different medication modalities have been exhausted, below shut supervision, and ideally in session with a ache or dependancy subspecialist. Opioids should no longer be prescribed to patients who're actively the use of illicit components, as detected all over assessment or on pretreatment urine checking out. magnify Print desk 2. Opioid possibility tool merchandise ranking (ladies) ranking (males) household history of substance abuse Alcohol 1 3 Illicit medication 2 3 Prescription medicine 4 4 personal background of substance abuse Alcohol three 3 Illicit medication four 4 Prescription medicine 5 5 Age 16 to forty five years 1 1 historical past of preadolescent sexual abuse 3 0 Psychological condition ADHD, obsessive-compulsive disorder, bipolar disease, schizophrenia 2 2 depression 1 1 complete ranking table 2. Opioid chance device item ranking (adult females) rating (males) household historical past of substance abuse Alcohol 1 3 Illicit medicine 2 3 Prescription medicine 4 4 very own historical past of substance abuse Alcohol 3 3 Illicit drugs four four Prescription medication 5 5 Age 16 to forty five years 1 1 background of preadolescent sexual abuse three 0 Psychological situation ADHD, obsessive-compulsive disorder, bipolar ailment, schizophrenia 2 2 melancholy 1 1 complete score After careful screening, opioid therapy can be initiated on a trial basis. assistance for all phases of opioid prescribingdetermination, initiation, renovation, and taperingis given in desk three.13,15,18,19,24 These steps may still be followed in all patients as part of a regular precautions method. managed medications should still no longer be prescribed on a primary consult with as a result of power from the affected person or a way of duty to deal with. magnify Print desk 3. Phases of Opioid Prescribing determination part ensure that patient is aware that purpose of remedy is more advantageous feature, not pain scores monitor for indications (prior a success raise in function, localizable ache generator) screen for precautions and contraindications in all sufferers proof of multisourcing of controlled medicines (verify state prescription monitoring provider) clinical comorbidities that boost risk (e.g., coronary heart failure, persistent lung disorder, sleep apnea) very own historical past of alcohol, illicit drug, or prescription drug abuse; use CAGE Questionnaire, Opioid chance tool (desk 2), and urine drug checking out with enzyme-linked immunoassay and gasoline chromatography/mass spectrometry (interpretation requires tremendous care) pink-flag behaviors (e.g., misplaced or stolen prescriptions, requests for early refills, abusive behaviors) Urine drug checking out the usage of enzyme-linked immunoassay for illicit medication and gas chromatography/mass spectroscopy for prescribed medications; interpretation requires tremendous care Uncontrolled psychiatric comorbidities (e.g., anxiety, depression, posttraumatic stress disorder, psychosis) Initiation agree with sustained-free up preparations for extra constant drug tiers; affected person demands for brief-appearing medicine should still be puzzled; fentanyl (Duragesic) patches and oxycodone (Roxicodone) have excessive potential for abuse or diversion; methadone is doubtlessly high chance, however easily monitored; sublingual or transdermal buprenorphine is advantageous, includes lessen risk, and has less abuse skills Consolidate every other opioid therapy into one remedy the use of an equianalgesic calculator (e.g., http://www.narculator.com); total dosages exceeding a morphine equal of a hundred mg per day should prompt further caution and consideration of referral to a ache administration subspecialist Stabilize affected person with one opioid; avoid polypharmacy with distinct opioids or cotreatment with benzodiazepines (may additionally raise possibility of overdose) Use a managed substance settlement; patients often do not object, but doing so is a possible purple flag prevent continuous use of short-performing opioids for breakthrough remedy, or limit their use to the initiation section of therapy upkeep part verify state prescription monitoring software earlier than any prescription refills are issued document the exact doses, pill counts, expected duration of the prescription, and situations below which refills are to be received Reassess goals for renovation or development of function, not simply analgesia; taper therapy if useful desires are not completed Repeat urine drug trying out with enzyme-linked immunoassay and fuel chromatography/mass spectrometry as a minimum each year (greater commonly if the patient has dependancy or diversion chance, or has regarding behaviors) schedule face-to-face visits as a minimum every three months (more frequently throughout titration or if misuse is suspected) Write prescriptions that indicate the exact dates they will also be crammed When to cease, taper, or are looking for session cease prescribing instantly if affected person tests tremendous for illicit drug use or displays threatening conduct, or in the experience of forgery or intoxication Taper if practical goals are not done, antagonistic outcomes are extreme, or medicine is misused trust referral if purposeful dreams are not done, or for multidisciplinary pain or addiction remedy desk three. Phases of Opioid Prescribing determination part ensure that patient knows that purpose of remedy is more desirable function, no longer pain scores monitor for indications (prior successful raise in characteristic, localizable pain generator) reveal for precautions and contraindications in all patients facts of multisourcing of managed medications (check state prescription monitoring service) clinical comorbidities that increase risk (e.g., coronary heart failure, continual lung ailment, sleep apnea) personal history of alcohol, illicit drug, or prescription drug abuse; use CAGE Questionnaire, Opioid possibility device (table 2), and urine drug checking out with enzyme-linked immunoassay and gas chromatography/mass spectrometry (interpretation requires wonderful care) purple-flag behaviors (e.g., misplaced or stolen prescriptions, requests for early refills, abusive behaviors) Urine drug testing using enzyme-linked immunoassay for illicit medication and gasoline chromatography/mass spectroscopy for prescribed medications; interpretation requires first rate care Uncontrolled psychiatric comorbidities (e.g., anxiousness, depression, posttraumatic stress sickness, psychosis) Initiation consider sustained-liberate preparations for extra constant drug tiers; patient calls for for brief-acting treatment should still be wondered; fentanyl (Duragesic) patches and oxycodone (Roxicodone) have excessive competencies for abuse or diversion; methadone is potentially high risk, however without problems monitored; sublingual or transdermal buprenorphine is useful, incorporates reduce risk, and has much less abuse potential Consolidate every other opioid remedy into one remedy the use of an equianalgesic calculator (e.g., http://www.narculator.com); total dosages exceeding a morphine equal of a hundred mg per day should instantaneous additional warning and consideration of referral to a ache administration subspecialist Stabilize patient with one opioid; avoid polypharmacy with diverse opioids or cotreatment with benzodiazepines (may additionally increase possibility of overdose) Use a controlled substance contract; patients commonly don't object, but doing so is a potential pink flag avoid continuous use of short-performing opioids for step forward remedy, or limit their use to the initiation part of remedy preservation section check state prescription monitoring application before any prescription refills are issued document the accurate doses, pill counts, anticipated duration of the prescription, and circumstances beneath which refills are to be got Reassess goals for maintenance or development of feature, not in basic terms analgesia; taper remedy if purposeful desires aren't accomplished Repeat urine drug trying out with enzyme-linked immunoassay and gas chromatography/mass spectrometry at least every year (more regularly if the patient has addiction or diversion chance, or has concerning behaviors) time table face-to-face visits at least each three months (greater frequently all the way through titration or if misuse is suspected) Write prescriptions that point out the exact dates they can be filled When to stop, taper, or searching for consultation cease prescribing immediately if patient checks high quality for illicit drug use or displays threatening habits, or in the event of forgery or intoxication Taper if purposeful desires are not performed, antagonistic consequences are extreme, or remedy is misused trust referral if useful goals aren't finished, or for multidisciplinary ache or dependancy medicine If an preliminary comparison raises questions on even if opioid therapy is applicable, the physician may still brazenly well known these issues with the patient and decide to treat the pain comprehensively via different potential. If opioids don't seem to be applicable in a patient who is already taking them, remedy may still not be continued because of concerns about withdrawal. even though it is uncomfortable, opioid withdrawal is generally not life-threatening, and the affected person can also be spoke of an dependancy subspecialist for management. consult with CHECKLISTS talk over with checklists will also be used to consider whether initiation or continuation of opioid remedy is acceptable. items should consist of facts or absence of development towards ache relief and practical goals, proof of crimson-flag behaviors (e.g., lost prescriptions, typical early requests for refills), and the presence of uncontrolled psychiatric disease or medical comorbidities. Such checklists, if used mechanically, may well be specifically beneficial in group practices where dissimilar physicians might also care for the identical patients. URINE trying out All sufferers should still endure urine drug trying out earlier than opioid remedy is initiated, after which at least every year except affected person conduct suggests the need for extra common trying out. An enzyme-linked immunoassay for drugs of abuse (e.g., amphetamine, marijuana, cocaine) and gas chromatography/mass spectrometry to notice prescribed agents should still be ordered. The opioid portion of most enzyme-linked immunoassays reliably detects only morphine or codeine, and misses hydrocodone, oxycodone, hydromorphone (Dilaudid), oxymorphone, fentanyl (Duragesic), methadone, and buprenorphine. These medicine are detected by fuel chromatography/ mass spectrometry, particularly if the laboratory is asked to check for these or other selected medication in sufferers normal to be prescribed one or extra of them. both tests may additionally produce false-fine or false-terrible effects, so care must be taken to prevent misinterpretation of patient adherence. Concise publications to verify interpretation can be found.13,15,25 PRESCRIPTION MONITORING Many states have based prescription monitoring classes (http://www.painpolicy.wisc.edu/home/pmp.htm). on-line entry is available in most states and can establish a patient's managed prescriptions for the previous 12 months by way of drug identify, strength, volume, date of prescription, date prescription changed into stuffed, prescriber, and pharmacy used. office body of workers can routinely gain this guidance before visits through sufferers receiving opioid therapy. WRITTEN AGREEMENTS Many pattern pain and managed medicine agreements can be found (e.g., http://www.aapainmanage.org/literature/Articles/OpioidAgreements.pdf). These agreements define applicable intervals for follow-up, fill up policies, participation in any indicated multimodal administration plan (e.g., actual remedy, psychological medication), use of only 1 prescriber and one pharmacy for all managed drugs, and prohibition of illicit substance use or prescription diversion. As with urine checking out and prescription monitoring application reporting, written agreements may still be a part of an ongoing medication plan for all sufferers receiving chronic opioid remedy, thereby heading off reliance on health care provider judgment, suspicion, or bias. choosing an preliminary Opioid Morphine should still be the first option for continual mighty opioid therapy. legitimate, low-priced, lengthy-acting oral morphine preparations can be found for patients receiving continual therapy. If the affected person have to later be switched to one other treatment, morphine doses are the units on which opioid equianalgesic calculations are based mostly. standard adversarial outcomes consist of constipation, nausea, pruritus, and drowsiness, all of which are greater standard than morphine allergic reaction. Morphine should be used with caution (exceptionally its lengthy-performing preparations) in patients with renal failure. Oxycodone is an option for sufferers with morphine intolerance or allergy. although, it might have a better possibility of abuse and will be used with caution in sufferers with bigger risk rankings. lengthy-acting oxycodone isn't counseled for sufferers with continual pain since it isn't in fact long-performing, is costly, and has a excessive road price. Transdermal fentanyl could be a stronger choice, although it is costly and may produce tolerance enormously directly. Fentanyl is lipophilic, and absorption is affected in sufferers with little subcutaneous fats and in those vulnerable to edema at utility websites. Methadone can also be advantageous for many patients and can produce much less tolerance than other opioids. it's competitively priced, long-acting, and has a mix of opioid and N-methyl-d-aspartate receptor recreation that may additionally make it a good selection for patients with blended somatic and neuropathic ache. however, physicians who prescribe methadone ought to be popular with its unique pharmacokinetics: it has a very long elimination half-life, and its morphine-equivalent equianalgesic conversion ratio raises as dosages increase. beginning dosages in opioid-naive patients are 2.5 to 5 mg two or 3 times per day. Dosages should be titrated slowly and no more than once per week. Methadone can lengthen the QT interval, primarily in sufferers who are taking different QT-prolonging drugs. Serum drug ranges can also be used for monitoring. Methadone does not interfere with urine checking out for other opioids. Buprenorphine is a partial opioid agonist this is much less likely to produce tolerance.26 it is beneficial for remedy of ache, has reduce abuse skills, and is conveniently monitored. however, it's high priced, and its use requires special prescriber training (other than the transdermal patch). leap forward Dosing brief-acting opioids (e.g., morphine, oxycodone, hydromorphone) may well be used all through initiation of lengthy-performing opioids, however should still no longer be used perpetually as simple or step forward medicine. breakthrough dosing has now not been proven to enhance outcomes and may increase the chance of overdose, misuse, and additional opioid tolerance.24 because of the excessive road cost of many brief-appearing opioids, requests for step forward doses may still be resisted; if they are prescribed, most effective small quantities should still receive (e.g., 10 doses monthly). diverse Opioids and excessive-Dose remedy the use of numerous opioids may still be averted each time possible; equianalgesic conversions can also be used to consolidate healing procedures (a device is purchasable at http://www.narculator.com). total opioid doses exceeding 100 mg of morphine or its equal are associated with an improved risk of overdose and may immediate consideration of tapering or referral to a pain subspecialist.13,27 The want for such referral should be framed as an argument of treatment protection and effectiveness, no longer suspicion or judgment of sufferers or their conduct. Tapering or Discontinuing remedy Opioid remedy should still be reassessed for protection and effectiveness in all sufferers at least quarterly. considerations of patient safeguard or illegal undertaking should still on the spot discontinuation (table four). enlarge Print table 4. signals for Tapering or Discontinuing Opioids instant discontinuation Belligerent or threatening behavior toward physician or group of workers confirmation of diversion, multisourcing, or prescription forgery confirmation of illicit drug use, including marijuana Overdose rapid tapering typical requests for early refills, regardless of adequate titration of long-acting opioids main opposed outcomes or intoxication (e.g., somnolence, slurred speech, altered sensorium) Opioid-brought about hyperalgesia different nonadherence to ache treatment agreement Gradual tapering functional goals now not met Morphine equal dosage better than one hundred mg per day, without clear benefit to function or ache Persistent antagonistic outcomes despite opioid rotation (e.g., pruritus, nausea, refractory constipation) desk four. signals for Tapering or Discontinuing Opioids instant discontinuation Belligerent or threatening behavior toward health practitioner or workforce affirmation of diversion, multisourcing, or prescription forgery confirmation of illicit drug use, together with marijuana Overdose fast tapering typical requests for early refills, regardless of satisfactory titration of long-appearing opioids main adverse effects or intoxication (e.g., somnolence, slurred speech, altered sensorium) Opioid-brought on hyperalgesia different nonadherence to pain remedy contract Gradual tapering practical goals not met Morphine equivalent dosage more desirable than a hundred mg per day, devoid of clear advantage to feature or pain Persistent adverse effects regardless of opioid rotation (e.g., pruritus, nausea, refractory constipation) earlier than tapering, all opioid therapy may still be consolidated into a single lengthy-acting medication the usage of equianalgesic calculations. Dose discount should then proceed at a cost that avoids opioid withdrawal indicators, lack of affected person self assurance, or ache escalation,28 and may continue unless signs or function is superior. Gradual tapering can be completed by means of decreasing the usual total opioid dose by means of 10 % every one to four weeks except 20 p.c of the customary complete dose continues to be, then decreasing by way of 5 p.c of the common dose unless it is discontinued. swift tapering can also be accomplished via cutting back the long-established dose by means of 25 % every three to seven days; this can stay away from extreme withdrawal signs. despite tapering, some patients may have withdrawal indicators when opioids are absolutely discontinued. These signs should still be managed supportively; typical withdrawal administration drugs reminiscent of clonidine (Catapres), tramadol (Ultram), and muscle relaxants are generally ineffective, despite the fact brief use of nonbenzodiazepine sleep aids may also be effective. comply with-up visits may still be scheduled often for ongoing multimodal ache administration and encouragement that characteristic will increase over weeks to months. facts Sources: Searches of the human, English literature have been conducted in Medline, Cochrane reviews, and the country wide tenet Clearinghouse for scientific trials and guidelines posted from January 1, 2000, via April 25, 2011, the usage of the most important key words of persistent pain, non-malignant, non-melanoma, and non-terminal. terms used for particular subject searches covered ache assessment, psychiatric comorbidities, dependancy chance, opioid abuse, emergency branch visits, pain mechanisms, opioid-prompted hyperalgesia, opioid tolerance, opioid taper, long-term consequences, and buprenorphine. 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