Ten Tips for Prescribing Controlled Substances. Charlie Reznikoff MD Hennepin County Medical Center
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1 Ten Tips for Prescribing Controlled Substances Charlie Reznikoff MD Hennepin County Medical Center
2 Tip #1: Avoid prescribing highly reinforcing (addictive) drugs
3 Tip #1: Avoid prescribing highly reinforcing (addictive) drugs when other options are available
4 Highly reinforcing medications Alprazolam (xanax)
5 Highly reinforcing medications Alprazolam (xanax) Preferred: lorazepam (ativan)
6 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol)
7 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Preferred: morphine
8 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Short acting amphetamine (adderall)
9 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Short acting amphetamine (adderall) Preferred: long acting methylphenidate (concerta)
10 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Short acting amphetamine (adderall) Long acting hydrocodone (zohydro)
11
12 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Short acting amphetamine (adderall) Long acting hydrocodone (zohydro) Preferred: long acting oxycodone (oxycontin 2.0)
13 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Short acting amphetamine (adderall) Long acting hydrocodone (zohydro) High dose short acting oxycodone
14 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
15 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Short acting amphetamine (adderall) Long acting hydrocodone (zohydro) High dose short acting oxycodone Gel based fentanyl patch
16 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
17 Highly reinforcing medications Alprazolam (xanax) Meperidine (demerol) Short acting amphetamine (adderall) Long acting hydrocodone (zohydro) High dose short acting oxycodone Gel based fentanyl patch
18 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
19
20
21 Conceptualize and communicate about addictive behavior as an adverse event inherent to certain medications
22 Streetrx.com
23 Tip #2: Know which problematic controlled substances are commonly overlooked
24 Drugs falsely believed to be safe(r) Carisoprodol (soma) Barbiturate (eqinil) pro-drug NOW schedule IV
25 Drugs falsely believed to be safe(r) Carisoprodol (soma) Butalbatol (fiorinal, fioricet) short-acting barbiturate Schedule III
26 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
27
28 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
29 Tramadol now sch. 4
30 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
31
32 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
33 Hydrocodone sch. 2 starting October 6, 2014
34
35 These drugs all have their uses but they are not addiction-proof!
36 Tip #3: Avoid prescribing meds (or for conditions) outside your training
37 Medical Cannabis Timeline Medical Cannabis Bill signed into law Manufacturer application due Medical Cannabis available to patients Director of Office of Medical Cannabis starts Two Manufacturers registered Aug 8 Sept 5 Oct 3 Jan 1 May 29 Aug 13 Dec 1 Spring 2015 July1 05/01/2014 Manufacturer Dosage 08/01/2015 recommendations Interested Parties Meeting Patient registration Manufacturer application published Deadline to publish notice of proposed rules
38 Doctors providing marijuana recommendations are expected to follow the patient as the treating doctor of the qualifying condition
39 Indications Dying of cancer with pain or nausea Dying of HIV/AIDS with pain or nausea MS, ALS Glaucoma Seizure Tourette s syndrome
40 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
41 Tip #4: Limit total daily doses of opioids
42 Tip #4: Limit total daily doses of opioids, and dangerous mixes of drugs
43 120 mg morphine equiv. per day limit
44
45 Other risks of opioid overdose death Concomitant alcohol Concomitant benzodiazepine Comorbid medical conditions renal, psyche, pulmonary, addiction
46
47
48
49 Tip #5: Dispose and store of meds safely
50
51 Pill disposal Schedule 2 flush, pill take back site Schedule 3-5 mix with unpalatable substances and throw away Fentanyl patches need special care mers/buyingusingmedicinesafely/ensuringsaf euseofmedicine/safedisposalofmedicines/uc m htm
52 Safe disposal of fentanyl patches Folded upon themselves and flushed Every year toddlers and pets die from exposure to fentanyl patches
53 Store controlled substances: private safe ideally locked out of the reach of children hidden from house guests
54 Tip #6 Pill misuse equally affects (young Caucasian) women
55 Tip #7: Do not negotiate with intoxicated or withdrawing patients
56
57
58 Heavy eyelids Nodding off
59
60
61
62 When you determine someone to be intoxicated you have only one job?
63 Make sure they are getting home safely
64 Tip #8: Check the prescription monitoring program
65 The next regulation: mandatory PMP searches for all scripts?
66 Tip #9: Do not prescribe under duress
67
68 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
69 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
70 Treat the patient as you d want a loved one treated
71 Tip #10: Ignore pain scores and pain talk. Assess function
72 What objective measures can we use titrating pain medications?
73 What objective measures can we use titrating pain medications? Function (enough) Opioid toxicity (too much)
74 Acute pain research shows pain scores lowered by 30% in patients given opioids
75 Tip #11: Above all retain your relationship with your patient
76 Healing is about relationships
77 Thank you! Questions? References following this slide
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