Ways to make prescribing controlled substances safer

Safer controlled substance prescribing begins with a thorough patient workup, diagnosis and treatment plan. Consider nonopioid options for complex conditions

Safer controlled substance prescribing begins with a thorough patient workup, an appropriate diagnosis and a comprehensive treatment plan, according to Kelly C. Cooper, M.D., an addiction medicine specialist with Norton Behavioral Medicine.

“We just tend to go for the pills first. And it’s not just as providers, it’s patients as well,” Dr. Cooper said during a recent episode of “MedChat,” a Norton Healthcare continuing medical education podcast. “It’s a lot easier to hit a button and write a prescription and hope that cures it or treats it.”

Before prescribing controlled substances such as opioids, stimulants and benzodiazepines, Dr. Cooper advocates considering other options.

For someone experiencing pain, for example, there are nonopioid medications. Also, providers should consider whether the patient needs to be treated for anxiety or depression, or for sleep issues, or whether physical therapy would be beneficial. If the patient is experiencing back pain, should the patient see an interventional radiologist?

“When you are prescribing controlled substances, generally, whatever you’re treating is probably pretty complex, and it requires a lot more pieces to put in place,” Dr. Cooper said.

With patients taking controlled substances, providers should also check a prescription drug monitoring program (PDMP) or the Kentucky All Schedule Prescription Electronic Reporting (KASPER) every three months.

Prescription drug monitoring program databases track controlled substance prescriptions and can provide timely information about prescribing and patient behaviors. Prescription drug monitoring programs also allow providers to check that their Drug Enforcement Administration controlled substance number is not being used illegally by someone else.

Providers also should test the patient’s urine at least once a year if the patient is on a chronic controlled substance. Additional urine screens may be needed if the patient requests early refills or if something else seems awry, according to Dr. Cooper. A provider also can ask to see a patient in the middle of a prescription course, rather than waiting until the end, and do a pill count as a means of checking for drug misuse.

“I strongly recommend providers not be overreactive to a urine drug screen result that you’re not expecting or a pill count that you’re not expecting,” Dr. Cooper said. “It’s really an opportunity to discuss with the patient what’s going on. Because what you don’t want to do is alienate a patient, specially someone who is suffering.”

If a patient is taking more than the prescribed amount, or if there is some other type of misuse where the drug is not being taken as prescribed, this may be a time to revamp the treatment plan, adjust the assessments and change the diagnosis.

According to Dr. Cooper, all patients on a chronic controlled substance will become dependent.

“So that means, if you take it away or stop it, they’re going to withdraw physically or mentally,” Dr. Cooper said.

If there are signs of substance abuse, such as injecting or snorting a drug, according to Dr. Cooper, a provider should work to get the patient into a treatment program.

Treatment of chronic pain or chronic conditions is a challenge for primary care providers, because mood and mental health need to be assessed as well. A practitioner should consider referring or co-managing the patient to ensure they don’t miss something in the patient’s 15-minute visit.

Access to subspeciality physician care can be challenging in rural areas, but telehealth can help fill the gap.

“We do a lot of our mental health and addiction work through telehealth. It’s really lifesaving for [patients] that they don’t have to travel, especially folks with transportation issues,” Dr. Cooper said.

Providers who inherit a patient on an opiate dosage that seems high should question the dosage but resist automatically not prescribing or de-prescribing the medication, according to Dr. Cooper. A referral to pain management can help assess the patient’s need.

“Before I would cut somebody off or taper them down, I would get some other options in place or co-managing from some other folks to assess the patient. If they think there’s an addiction problem, send them over to get an assessment for addiction. If there’s a mental health issue, send them over to get that addressed,” Dr. Cooper said.

Tapering or discontinuing a medication comes with severe risks, including withdrawal issues, for which the prescribing practitioner needs to be prepared. However, tapering is appropriate as a patient gets older, because their metabolism slows down, meaning the amount of drug in their body goes up.

According to Dr. Cooper, tapering needs to be done slowly, 10% per week or per month depending on how well the patient tolerates it.

“Opioids are easier to come off than benzos. I think benzos are very, very difficult, and so I usually do 10% a month for those patients — and hope I can get them off in two years,” Dr. Cooper said.

The Controlled Substances Act classified the drugs into five categories, or schedules, depending on the acceptable medical use and abuse or dependency potential, according to the Drug Enforcement Administration. Schedule I drugs have the most potential for addiction and use disorder, while Schedule V drugs have the least.

Schedule I

Schedule I drugs are considered to have no currently accepted medical use and a high potential for abuse. Schedule I drugs include heroin, lysergic acid diethylamide (LSD), marijuana, ecstasy, methaqualone and peyote.

Schedule II

Schedule II drugs have a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Schedule II drugs include Vicodin, cocaine, methamphetamine, methadone, Dilaudid, oxycodone (OxyContin), fentanyl, Dexedrine, Adderall and Ritalin.

Schedule III

Schedule III drugs have a moderate to low potential for physical and psychological dependence. Schedule III drugs include Tylenol with codeine, ketamine, anabolic steroids, testosterone.

Schedule IV

A schedule IV controlled substance has a low potential for abuse and low risk of dependence. Examples include Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien and tramadol.

Schedule V

A schedule V controlled substance contains limited quantities of certain narcotics. They include cough medicines with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin.

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