Controlled Substances

Question 1

What are schedule I substances?

Answer 1

high potential for abuse & no accepted medical use in the US

Question 2

What are schedule II substances?

Answer 2

substances that have high abuse potential with severe liability for psychic or physical dependence, but in general are substances that are approved by the FDA fro a therapeutic use

Question 3

What are schedule III & IV substances?

Answer 3

include drugs with decreasing levels of abuse potential

Question 4

What type of registration do you need to prescribe controlled substances?

Answer 4

MO-DNDD (mo-specific)
DEA

Question 5

What are the four criteria for a legitimate prescription?

Answer 5

• practitioner has to be registered
• patient has to desire treatment for a legitimate illness
• practitioner has to establish a legitimate need through pertinent technical diagnostic modalities
• must be reasonable correlation between drug prescribed & the patient’s needs

Question 6

What are the components for a legitimate prescription?

Answer 6

• dated & signed on date when issued
• patient’s full name & address
• practitioner’s full name, address & DEA registration number
• drug name
• drug strength
• drug dosage
• quantity prescribed
• directions for use
• number of refills authorized
• if a substitution is permitted

Question 7

A practitioner must document reasoning for prescribing opiates over what number of days for acute pain?

Answer 7

7-day limit

Question 8

What are the limitations in the mode of prescribing for a schedule II drug?

Answer 8

• signed in original ink of written
• verbal in an emergency by doctor only
• faxed if injectable to LTCF or hospice
• electronics per DEA guidelines
• mid-levels have 5 day supply hydrocodone only

Question 9

What are the limitations in refills for schedule II drug?

Length of prescription validity?

Answer 9

no refills allowed; partial dispensing allowed

6 month validity

Question 10

What are the quantity limitations for prescribing for a schedule II drug?

Answer 10

• 30 days for most
  
  • over 30 days requires medical reason
  • max is 90 day supply
• can write multiple & separate Rx w/ “do not fill until” date written on bottom
  
  • can’t exceed 90 day supply

Question 11

What are the limitations in the mode of prescribing for a schedule III & IV drug?

Answer 11

• signed in original ink if written
• phoned in or faxed
• electronic per DEA guidelines
• midlevels may prescribe
  
  • 30 day supply buprenophine w/o refill for substance abuse treatment only

Question 12

What are the limitations in refills for schedule III/IV drug?

Length of prescription validity?

Answer 12

max refill of 5 w/in 6 months of issuing prescription

6 month validity

Question 13

What are the quantity limitations for prescribing for a schedule III / IV drug?

Answer 13

90 days

Question 14

What are the limitations in the mode of prescribing for a schedule V drug?

Answer 14

• signed in original ink if written
• oral phoned-in
• faxed
• electronic per DEA guidelines

Question 15

What are the limitations in refills for schedule V drug?

Length of prescription validity?

Answer 15

as authorized by the physician, can be refilled PRN as prescriber allows for 1 yr

one year validity

Question 16

According to CDC guidelines, when should you consider opioid therapy for chronic pain?

Answer 16

if expected benefits for both pain & function are anticipated to outweigh the risks to the patients

if opioids are used - should be combined with nonpharmacologic therapy as appropriate

Question 17

Before starting opioid therapy for chronic pain, clinicians should establish what treatment goals with patients?

Answer 17

realistic goals for pain & function

should how therapy will be discontinued if benefits do not outweigh risks

should only continue if clinically meaningful improvement

Question 18

Before starting & periodically throughout opioid therapy, physicians should have what discussion with patients?

Answer 18

known risks & realistic benefits

clinician responsibility for managing therapy

Question 19

When starting opioid therapy for chronic pain, what type of opioids should be prescribed?

Answer 19

immediate-release opioids instead of extended-release/long-acting

Question 20

Opioids should be started at what dose?

Answer 20

lowest effective dose

Question 21

Clinicians should carefully reassess evidence of individual benefit & risks when increasing opioid dosage above what value? Physicians should avoid / carefully justify increasing dosage to what level?

Answer 21

reassess - >50MME

avoid - >90 MME

Question 22

What guidelines should you consider when prescribing opioids for acute pain?

Answer 22

lowest effective dose of immediate-release

no greater quantity than expected duration of pain severe enough to require opioids (usually 3 days or less; rarely > 7 days)

Question 23

Clinicians should evaluate benefits & harm within what time period of starting opioid therapy? Then how long thereafter?

What should they do if they decide benefits do not outweigh harm?

Answer 23

within 1-4 weeks

every 3 months

if benefits do not outweigh harm → work with patients to taper to lower dosage or to discontinue

Question 24

Clinicians should incorporate management plan strategies to mitigate risk, such as?

Answer 24

offering naloxone when increase factors for opioid overdose

(history of overdose, history substance abuse disorder, higher opioid dosage, concurrent benzodiazepine use)

Question 25

How should physicians review patient's history of controlled substance prescriptions?

Answer 25

state prescription drug monitoring program data (starting for chronic pain & periodically during therapy; every prescription → ever 3 month)

Question 26

When should clinicians use urine drug testing during opioid therapy?

Answer 26

when starting & consider annually throughout treatment assess for prescribed medications & other controlled prescriptions / illicit drugs

Question 27

What should clinicians offer or arrange for patients with opioid use disorder to manage chronic pain?

Answer 27

evidence-based treatment (usually w/ buprenorphine or methadone in combo w/ behavioraa therapies)

Question 28

What are the characteristics of drug-seeking patients?

Answer 28

* feign physical problems * early requests for refill * eliciting sympathy or guilt or threat * claim to be referred by another clinician * unusual behavior in waiting rooms * inconsistent signs of acute pain * unusual knowledge of controlled substances * requests a specific drug * reluctance to try another drug * demanding or abusive to staff * more than one physician * unusual appearance * cutaneous signs of drug abuse

Question 29

Wha information do you need from patients to prescribe opioids?

Answer 29

* what other practitioners they are seeing * when they were last seen * what drugs they have been previously prescribed * what drugs they are currently taking * have they ever been treated for alcohol or chemical dependency * request picture ID or SSN * call previous practitioner, pharmacist, or hospital * confirm telephone number & address * write for limited quantities

Question 30

What are strategies to prevent diversion & abuse?

Answer 30

* lock unused prescription pads * number prescription blanks * never sign blank prescriptions * write amount clearly & in arabic or roman numerals * respond to pharmacists inquiry * carbon or photocopies

Question 31

What substances are you legally unable to prescribe for yourslef?

Answer 31

all schedule controlled substances

Question 32

What are the suggestions for what you should do to keep yourself out of trouble?

Answer 32

examine and document, document, document ask questions talk to pharmacists