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Ten Tips for Prescribing Controlled Substances
Charlie Reznikoff MD [email protected]
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