ten tips prescribing controlled substances

Ten Tips for Prescribing Controlled Substances

Charlie Reznikoff MD Charlie.reznikoff@hcmed.org

Hennepin County Medical Center

Tip #1: Avoid prescribing highly reinforcing

(addictive) drugs

Tip #1: Avoid prescribing highly reinforcing

(addictive) drugs… when other options are available

Highly reinforcing medications

• Alprazolam (xanax)

Highly reinforcing medications

• Alprazolam (xanax) – Preferred: lorazepam (ativan)

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol)

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol)

– Preferred: morphine

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall)

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall)

– Preferred: long acting methylphenidate (concerta)

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro)

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro)

– Preferred: long acting oxycodone (oxycontin 2.0)

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone

– Long acting tamper proof oxycodone

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone • Gel based fentanyl patch

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone • Gel based fentanyl patch

– Embedded mesh formulation

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol) • Short acting amphetamine (adderall) • Long acting hydrocodone (zohydro) • High dose short acting oxycodone • Gel based fentanyl patch

What makes a drug reinforcing?

• Crushable (snortable, injectable) • Large dosage (gel based fentanyl patch) • Rapid cns onset (lipophilicity, absorption) • Unique receptor action (serotonin?) • Individual patient differences • Cultural preference

Conceptualize and communicate about addictive behavior as an

adverse event inherent to certain medications

Streetrx.com

Tip #2: Know which problematic controlled

substances are commonly overlooked

Drugs falsely believed to be safe(r)

• Carisoprodol (soma) – Barbiturate (eqinil) pro-drug – NOW schedule IV

Drugs falsely believed to be safe(r)

• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet)

– short-acting barbiturate – Schedule III

Drugs falsely believed to be safe(r)

• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.)

– low-potency benzodiazepine – Schedule IV – FDA lowered its dosing recommendation

Drugs falsely believed to be safe(r)

• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.) • Tramadol (ultram)

– Low potency opioid with norepi blockade – Causes seizures before respiratory depression – NOW schedule IV

Tramadol now sch. 4

Drugs falsely believed to be safe(r)

• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.) • Tramadol (ultram) • Promethazine with codeine (phenergan syrup)

– “Purple drank” – Cultural preference within southern African Americans – Schedule V

Drugs falsely believed to be safe(r)

• Carisoprodol (soma) • Butalbatol (fiorinal, fioricet) • Z-drugs e.g. zolpidem (ambien, lunesta, etc.) • Tramadol (ultram) • Promethazone with codeine (cough syrup) • Hydrocodone containing products (Vicodin,

lortab) – FULL AGONIST OPIOID – NOW schedule II

Hydrocodone sch. 2

starting October 6,

2014

These drugs all have their uses… but they are not addiction-proof!

Tip #3: Avoid prescribing meds (or for

conditions) outside your training

05/01/2014 08/01/2015

May 29

Medical Cannabis Bill

signed into law

Director of Office of Medical Cannabis

starts

Aug 13

Manufacturer application published

Manufacturer application due

Sept 5 Oct 3

Two Manufacturers

registered

Dec 1

Dosage recommendations Patient

registration

Medical Cannabis available to patients

Spring 2015 July1

Deadline to publish notice of proposed

rules

Aug 8

Manufacturer Interested Parties

Meeting

Jan 1

Medical Cannabis Timeline

Doctors providing marijuana recommendations are expected to follow the patient as the treating doctor of the qualifying condition

Indications

• Dying of cancer with pain or nausea • Dying of HIV/AIDS with pain or nausea • MS, ALS • Glaucoma • Seizure • Tourette’s syndrome

Minnesota Medical cannabis

• Limited forms • Smoking prohibited • Controlled production • Patient and doctor registry

• NOT: approval of casual marijuana use over a

wide swath of Minnesotans

Tip #4: Limit total daily doses of opioids

Tip #4: Limit total daily doses of opioids,

and dangerous mixes of drugs

120 mg morphine

equiv. per day

limit

Other risks of opioid overdose death

• Concomitant alcohol • Concomitant benzodiazepine • Comorbid medical conditions

–renal, psyche, pulmonary, addiction

Tip #5: Dispose and store of meds safely

Pill disposal

• Schedule 2– flush, pill take back site • Schedule 3-5– mix with unpalatable

substances and throw away • Fentanyl patches need special care

• www.fda.gov/Drugs/ResourcesForYou/Consu

mers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm

Safe disposal of fentanyl patches

• Folded upon themselves and flushed

• Every year toddlers and pets die from exposure to fentanyl patches

Store controlled substances:

private safe

ideally locked out of the reach of children hidden from house guests

Tip #6 Pill misuse equally affects (young Caucasian) women

Tip #7: Do not negotiate with intoxicated or

withdrawing patients

Heavy eyelids “Nodding off”

When you determine someone to be intoxicated you have only one job…?

…Make sure they are getting home safely

Tip #8: Check the prescription monitoring

program

The next regulation: mandatory PMP searches for all scripts?

Tip #9: Do not prescribe under duress

Pressure from many angles

• Productivity, time • Patient satisfaction scores • Emotional pressure: manipulation, flirting,

bullying • Your internal drive to please patients • Your internal drive to fix problems

Ways to deal with pressure

• Self Awareness • Exit the room • Discuss, debrief with a colleague • Addiction and pain are chronic diseases that

cannot be fixed in one visit

Treat the patient as you’d want a loved one treated

Tip #10: Ignore pain scores and pain talk.

Assess function

What objective measures can we use titrating pain medications?

What objective measures can we use titrating pain medications?

Function (enough) Opioid toxicity (too much)

Acute pain research shows pain scores lowered by 30% in patients

given opioids

Tip #11: Above all retain your relationship

with your patient

Healing is about relationships

Thank you! Questions?

References following this slide