ten tips prescribing controlled substances

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Ten Tips for Prescribing Controlled Substances Charlie Reznikoff MD [email protected] Hennepin County Medical Center

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Page 1: Ten Tips Prescribing controlled substances

Ten Tips for Prescribing Controlled Substances

Charlie Reznikoff MD [email protected]

Hennepin County Medical Center

Page 2: Ten Tips Prescribing controlled substances

Tip #1: Avoid prescribing highly reinforcing

(addictive) drugs

Page 3: Ten Tips Prescribing controlled substances

Tip #1: Avoid prescribing highly reinforcing

(addictive) drugs… when other options are available

Page 4: Ten Tips Prescribing controlled substances

Highly reinforcing medications

• Alprazolam (xanax)

Page 5: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

Page 6: Ten Tips Prescribing controlled substances

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol)

Page 7: Ten Tips Prescribing controlled substances

Highly reinforcing medications

• Alprazolam (xanax) • Meperidine (demerol)

– Preferred: morphine

Page 8: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

Page 9: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

– Preferred: long acting methylphenidate (concerta)

Page 10: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

Page 11: Ten Tips Prescribing controlled substances
Page 12: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

– Preferred: long acting oxycodone (oxycontin 2.0)

Page 13: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

Page 14: Ten Tips Prescribing controlled substances

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

Page 15: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

Page 16: Ten Tips Prescribing controlled substances

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

Page 17: Ten Tips Prescribing controlled substances

Highly reinforcing medications

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

Page 18: Ten Tips Prescribing controlled substances

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

Page 19: Ten Tips Prescribing controlled substances
Page 20: Ten Tips Prescribing controlled substances
Page 21: Ten Tips Prescribing controlled substances

Conceptualize and communicate about addictive behavior as an

adverse event inherent to certain medications

Page 22: Ten Tips Prescribing controlled substances

Streetrx.com

Page 23: Ten Tips Prescribing controlled substances

Tip #2: Know which problematic controlled

substances are commonly overlooked

Page 24: Ten Tips Prescribing controlled substances

Drugs falsely believed to be safe(r)

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

Page 25: Ten Tips Prescribing controlled substances

Drugs falsely believed to be safe(r)

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

– short-acting barbiturate – Schedule III

Page 26: Ten Tips Prescribing controlled substances

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

Page 27: Ten Tips Prescribing controlled substances
Page 28: Ten Tips Prescribing controlled substances

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

Page 29: Ten Tips Prescribing controlled substances

Tramadol now sch. 4

Page 30: Ten Tips Prescribing controlled substances

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

Page 31: Ten Tips Prescribing controlled substances
Page 32: Ten Tips Prescribing controlled substances

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

Page 33: Ten Tips Prescribing controlled substances

Hydrocodone sch. 2

starting October 6,

2014

Page 34: Ten Tips Prescribing controlled substances
Page 35: Ten Tips Prescribing controlled substances

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

Page 36: Ten Tips Prescribing controlled substances

Tip #3: Avoid prescribing meds (or for

conditions) outside your training

Page 37: Ten Tips Prescribing controlled substances

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

Page 38: Ten Tips Prescribing controlled substances

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

Page 39: Ten Tips Prescribing controlled substances

Indications

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

Page 40: Ten Tips Prescribing controlled substances

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

Page 41: Ten Tips Prescribing controlled substances

Tip #4: Limit total daily doses of opioids

Page 42: Ten Tips Prescribing controlled substances

Tip #4: Limit total daily doses of opioids,

and dangerous mixes of drugs

Page 43: Ten Tips Prescribing controlled substances

120 mg morphine

equiv. per day

limit

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Page 45: Ten Tips Prescribing controlled substances

Other risks of opioid overdose death

• Concomitant alcohol • Concomitant benzodiazepine • Comorbid medical conditions

–renal, psyche, pulmonary, addiction

Page 46: Ten Tips Prescribing controlled substances
Page 47: Ten Tips Prescribing controlled substances
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Tip #5: Dispose and store of meds safely

Page 50: Ten Tips Prescribing controlled substances
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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

Page 52: Ten Tips Prescribing controlled substances

Safe disposal of fentanyl patches

• Folded upon themselves and flushed

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

Page 53: Ten Tips Prescribing controlled substances

Store controlled substances:

private safe

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

Page 54: Ten Tips Prescribing controlled substances

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

Page 55: Ten Tips Prescribing controlled substances

Tip #7: Do not negotiate with intoxicated or

withdrawing patients

Page 56: Ten Tips Prescribing controlled substances
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Heavy eyelids “Nodding off”

Page 59: Ten Tips Prescribing controlled substances
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When you determine someone to be intoxicated you have only one job…?

Page 63: Ten Tips Prescribing controlled substances

…Make sure they are getting home safely

Page 64: Ten Tips Prescribing controlled substances

Tip #8: Check the prescription monitoring

program

Page 65: Ten Tips Prescribing controlled substances

The next regulation: mandatory PMP searches for all scripts?

Page 66: Ten Tips Prescribing controlled substances

Tip #9: Do not prescribe under duress

Page 67: Ten Tips Prescribing controlled substances
Page 68: Ten Tips Prescribing controlled substances

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

Page 69: Ten Tips Prescribing controlled substances

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

Page 70: Ten Tips Prescribing controlled substances

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

Page 71: Ten Tips Prescribing controlled substances

Tip #10: Ignore pain scores and pain talk.

Assess function

Page 72: Ten Tips Prescribing controlled substances

What objective measures can we use titrating pain medications?

Page 73: Ten Tips Prescribing controlled substances

What objective measures can we use titrating pain medications?

Function (enough) Opioid toxicity (too much)

Page 74: Ten Tips Prescribing controlled substances

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

given opioids

Page 75: Ten Tips Prescribing controlled substances

Tip #11: Above all retain your relationship

with your patient

Page 76: Ten Tips Prescribing controlled substances

Healing is about relationships

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Thank you! Questions?

References following this slide