Controlled substances
A practical approach to avoiding the pitfalls of prescribing
by Elizabeth S. Grace, MD, FAAFP, CPEP Medical Director
Providing care that incorporates best practices and current clinical guidelines and appropriately documenting that care will achieve the dual goals of providing safe care for your patients and protecting yourself. Here are some practical tips to help you stay on course. Note: While these tips are primarily directed at primary care physicians and other non-pain management physicians, for the most part they represent generally good approaches to care that transcend specialty.
• Independently and objectively evaluate all patients, including patients who present with established diagnoses and treatment plans. Don’t presume that the previous physician conducted a thorough evaluation and formulated a thoughtful treatment plan. Review old records.
• Assess for risk of abuse before prescribing and periodically thereafter. Several risk tools are available, such as the Opioid Risk Tool (ORT), Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), and Current Opioid Misuse Measure (COMM).
• Establish measurable functional treatment goals for chronic pain patients (e.g., to be able to walk for 15 minutes three days a week) and educate patients that pain is not likely to be completely eliminated by any treatment, including opioid therapy.
• Know your state (DORA Quad-Regulator Joint Policy for Prescribing and Dispensing Opioids) and national (CDC Guideline for Prescribing Opioids for Chronic Pain) guidelines. See links below.
• Obtain a urine drug test before prescribing and at least annually, as recommended in the CDC guidelines. Most providers will test more frequently, commensurate with the patient’s level or risk. Random testing is typically more effective in identifying aberrancies. Document/include results in the chart. These should be actual results, not just your interpretation.
• CDC guidelines also recommend that you check the prescription Drug Monitoring Program before prescribing and at least every three months thereafter. Consider checking the PDMP even before prescribing acute, short term opioids - particularly if it is for a new patient.
• Utilize controlled substance agreements to educate patients about risks and establish expectations for both parties. Having an agreement in place can make it easier for you to respond to aberrant behaviors because the patient has had fair warning of potential consequences.
• At follow-up visits, update the history and conduct physical exams at appropriate frequency. It is easy to convince oneself that an exam is not necessary for a stable patient, but periodic exam is warranted to justify ongoing treatment.
• At each follow-up visit, document the 5 As: Activity – progress toward patient-specific functional goals; Analgesia – is the medication helping?; Adverse effects – side effects of opioids such as sedation, constipation, etc.; Aberrant behaviors – requests for early refills, unexpected urine drug testing results, etc.; and Affect – mood changes, presence of depression or anxiety.
• Do not post-date prescriptions. This is prohibited by the DEA. You may issue multiple prescriptions totaling a 90-day supply for schedule II substances by writing separate prescriptions, with the date they are written, with a note on each prescription indicating the earliest date that the particular prescription can be filled (e.g., “Do not fill before June 15, 2017” on one prescription; “Do not fill before July 15, 2017” on the next, etc.)
• Update the medication list. In certain EMRs, failing to renew a medication does not automatically remove the medication from the medication list. Then, if you begin prescribing a different medication or a different dose, it may appear from the medication list that the patient is on multiple opioid medications.
• Become familiar with addiction treatment resources in your area. Patients who are drug-seeking because they have an addiction have a disease – substance use disorder – and they need treatment. They may not take you up on your offer the first time, but they may at a subsequent visit.
• Avoid concurrent prescribing of benzodiazepines and opioids. Benzodiazepine withdrawal can be dangerous, and tapering can be tricky. If appropriate, refer to an addictionologist or psychiatrist for help.
• Avoid morphine milligram equivalents (MMEs) that are considered high, based on current guidelines. Get help from consultants, including pain management specialists, addictionologists, or psychiatrists.
• Patient medical comorbidities, such as obstructive sleep apnea, can increase risk of adverse events from opioids. Consider medical comorbidities when formulating treatment plans.
• If you do prescribe higher dose opioids, or to patients at higher risk due to other factors, mitigate risk by:
o Assessing for adverse effects, for example with sleep studies or nocturnal pulse oximetry, periodically and when increasing dosing.
o Prescribe naloxone in case of overdose.
o Document carefully. Document your clinical rationale for using dosing that is considered high so that someone reading the chart will understand your decisions, and document that you have discussed the increased risks with the patient.
• If you decide to taper a patient’s opioid dosing, establish and agree upon a clear, documented tapering plan.
• Use the PDMP to provide an overview of your own prescribing. Do a query of all your controlled substances for a one-month period. Are you prescribing high doses to more patients than you realized? Are you co-prescribing benzodiazepines and opioids more often than you recalled?
• Do not prescribe controlled substances to yourself or family members. The Colorado Medical Practice Act defines prescribing, distributing or giving a controlled substance to a family member or to oneself except on an emergency basis as unprofessional conduct and grounds for discipline.
• Know your own vulnerabilities. Be self-aware if saying “no” to a demanding patient is difficult for you. Get help building these skills.
• If a patient’s family member calls to talk to you, take the call and inform the family member that you can listen, but you cannot respond or discuss any patient without their permission. You are not breaching patient confidentiality if you listen to the concerns of the family member, and it may give you some insight and help you take care of the patient. For example, “Doctor, I want you to know that my son is addicted to the medications you are prescribing and he is getting them from at least three other physicians.”
Do you want to learn more? CPEP offers the following CME courses.
• Prescribing Controlled Drugs: Critical Issues and Common Pitfalls: A three-day CME course based on curriculum developed at Vanderbilt University, this is an intensive, skill building course designed to increase skills in safe prescribing, identification of substance abuse, and how to say “no” to a patient asking for controlled substances when it is in the best interests of the patient. Approved for 22.75 AMA PRA Category 1 credit. www.cpepdoc.org/cpep-courses/prescribing-controlled-drugs/#toggle-id-7.
• Basics of Chronic Pain Management: Essentials for the Non-Pain Management Specialist: This is a one-day CME course covering the pathophysiology of chronic pain, non-pharmacologic treatment, interventional pain management, and both opioid and non-opioid medications used in the treatment of chronic pain. Approved for 8 AMA PRA Category 1 credit. www.cpepdoc.org/cpep-courses/basics-of-chronic-pain-management.
Additional resources
• DORA Quad-Regulator Joint Policy for Prescribing and Dispensing Opioids: http://www.ucdenver.edu/academics/colleges/PublicHealth/
research/centers/CHWE/Documents/DORA%20Opioid%20Policy%20
Revised%2010.15.14.pdf.
• CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016: https://www.cdc.gov/media/modules/dpk/2016/dpk-pod/rr6501e
1er-ebook.pdf.
• Pain Treatment Guidelines, Oregon Pain Guidance Group: http://www.oregonpainguidance.org/app/
content/uploads/2016/05/OPG_Guidelines_2016.pdf
• Sample controlled substance agreement: https://www.drugabuse.gov/sites/default/files/files/SamplePatient
AgreementForms.pdf.
• DEA Prescriber’s Manual: https://www.deadiversion.usdoj.gov/pubs/manuals/pract/pract_manual012508.pdf.
• Brief about benzodiazepine tapering: https://www.va.gov/PAINMANAGEMENT/docs/OSI_6_Toolkit_Taper_Benzodiazepines_Clinicians.pdf.
• Brief about tapering opioids: https://www.cdc.gov/drugoverdose/pdf/
clinical_pocket_guide_tapering-a.pdf.
Posted in: Colorado Medicine | Initiatives | Prescription Drug Abuse
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