controlled substances: a nurse practitioner’s...

Controlled Substances: A Nurse Practitioner’s Guide

3 Contact Hours

Release Date: 11/12/2015 Expiration Date: 11/12/2018

Audience The target audience for this education program is nurse practitioners who want to increase their knowledge of controlled substances and prescribing guidelines.

Purpose statement Prescribing controlled substances requires significant knowledge and skill. However, healthcare providers often receive little education regarding the prescription of controlled substances. This course is designed to help bridge such knowledge gaps. Course content includes

rationale for prescription, drug action, dose parameters, side effects, risks and benefits, patient counseling, monitoring points, and ways to deal with substance abuse or the potential for substance abuse.

Learning objectives � Summarize the differences between controlled substance schedules. � Discuss the medications in each class of controlled substance

schedules. � List the requirements for a legal controlled substance prescription. � Recall the regulations for controlled substance prescribing. � Describe the appropriate prescribing of medications for the

treatment of opiate addiction

� Perform a comprehensive initial evaluation/assessment of patient � Identify methods to monitor opioid compliance (e.g., urine drug

screens, prescription drug monitoring, etc.). � Describe methods to initiate, titrate, and monitor controlled

substance therapies. � Describe pharmacological treatment for ADHD.

How to receive credit ● Read the entire course, which requires a 3-hour commitment of

time. ● Depending on your state requirements you will asked to complete

either: ○ An attestation to affirm that you have completed the

educational activity.

○ OR completed the test and submit (a passing score of 70 percent is required).Note: Test questions link content to learning objectives as a method to enhance individualized learning and material retention.

● Provide required personal information and payment information. ● Complete the MANDATORY Self-Assessment and ● Print the Certificate of Completion.

Accreditation statementElite is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Designation of creditElite designates this continuing nursing education activity for 3.0 contact hours.

FacultyJodi Dreiling, PharmD, BCPS

Content reviewer and contributing authorAdrianne Avillion, D.Ed., RN Dani Clemmons, Copy Editor

Activity directorsJune D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner

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DisclosuresResolution of Conflict of InterestIn accordance with the ANCC Standards for Commercial Support for CNE, Elite implemented mechanisms, prior to the planning and

implementation of the CNE activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the CME activity.

Planning committee/faculty disclosuresThe following faculty and/or planning committee members have indicated they have no relationship(s) with industry to disclose relative to the content of this CNE activity.

● June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner

● Jodi Dreiling, PharmD, BCPS ● Adrianne Avillion, EdD, RN ● Tracey Foster

Disclaimer The information provided at this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

© 2015: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is

not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or p professional services expert licensed in your state. Elite Professional Education, LLC had made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and are not actual customers.

LegendMAOI: Monoamine Oxidase InhibitorQTc: Corrected QT

TCA: Tricyclic Antidepressant

IntroductionThe role of nurse practitioners has evolved over the past 50 years. The prescriptive authority for nurse practitioners has grown throughout the years. Currently, 49 states allow nurse practitioners to prescribe controlled substances, with varying autonomy [1].

Prescribing controlled substances may incur great risks. Prescribers must understand the risks and benefits of the medications they are

prescribing. Health care providers receive little education regarding the prescribing of controlled substances; however, continuing education programs help improve this education [2].

The two most commonly used controlled substances are narcotics and stimulants. The appropriate indication and use will be reviewed in this article.

Controlled Substance Act (CSA)In 1970, President Richard Nixon signed the Comprehensive Drug Abuse Prevention and Control Act into law. This legislation created the Controlled Substance Act (CSA), which regulates the manufacturing and distribution of controlled substances such as narcotics and stimulants. The CSA categorized medications into five schedules based on medical benefits and abuse potential [3].

The U.S. Drug Enforcement Agency (DEA) implements and enforces the CSA. The DEA regulates controlled substance schedules and registration of manufacturers, distributors, and dispensers of controlled substances. They also regulate the import and export of controlled substances. The DEA may prosecute anyone that violates this law [4].

CoNtroLLeD SubStANCe SCHeDuLeS [5]

Schedule I controlled substancesNursing Consideration: Nurses must be able to differentiate among the various controlled substance schedules and know what types of drugs are in each schedule. This allows nurses to adhere to legal mandates and appropriately control and monitor the distribution of such drugs and their effects on patients [5].

The substances classified as Schedule I controlled substances have no accepted medical use in the United States. They have no accepted safe use under medical supervision and a high potential for abuse. Even though tetrahydrocannabinol (THC/marijuana) is legalized in

some states for medical and recreational use, it is still a Schedule I substance.

Nursing consideration: As legalization of marijuana for medical and recreational use is under legislative review in many states, nurses must be aware of pending legislation and laws that have been passed regarding its use.

Examples of Schedule I substances: heroin, marijuana (cannabis), lysergic acid diethylamide (LSD).

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Schedule II controlled substancesSubstances with an accepted medical use and high potential for abuse are classified as Schedule II controlled substances.

Examples of Schedule II narcotics: Generic BrandCodeine

Fentanyl Abstral, Actiq, Duragesic, Fentora, Lazanda, Onsolis, Sublimaze, Subsys

Hydrocodone

Meperidine DemerolMethadone Dolophine, MethadoseMorphine MS IR, MS Contin, RoxanolOxycodone Endocet, OxyContin, OxyIR,

Percocet, Roxicodone, Roxicet

Oxymorphone Opana, Opana ERRemifentanil UltivaSufentanil Sufenta

Examples of Schedule II non-narcotics: Generic BrandAmphetamine AdderallLisdexamfetamine VyvanseMethylphenidate Concerta, Daytrana, Metadate

CD, Metadate ER, Methylin, Quilivant XR, Ritalin

Pentobarbital NembutalSecobarbital Seconal

Schedule III controlled substancesSubstances in this schedule have an acceptable medical use and less of a potential for abuse than in Schedules I or II substances. Abuse of Schedule III narcotics may lead to moderate physical dependence or high psychological dependence.

Examples of Schedule III narcotics: Generic BrandBuprenorphine Butrans, SuboxoneButalbital Fiorinal

Codeine combination products with < 90 mg/dose

Tylenol #2, #3, or #4

Examples of Schedule III non-narcotics: Generic BrandAnabolic steroids N/AKetamine KetalarTestosterone Androderm, AndroGel, Depotest

Schedule IV controlled substancesThe substances classified as Schedule IV controlled substances have a low potential for abuse compared to Schedule III controlled substances.

Examples of Schedule IV substances:Generic BrandAlprazolam XanaxArmodafinil NuvigilCarisoprodol SomaClonazepam KlonopinChlorazepate Tranxene

Diazepam ValiumEszopiclone LunestaLorazepam AtivanMidazolam VersedModafinil ProvigilPhentermine Adipex-PTemazepam RestorilTriazolam HalcionZolpidem Ambien, Edluar, Intermezzo,

Zolpimist

Schedule V controlled substancesSubstances classified as Schedule V controlled substances have a low potential for abuse relative to Schedule IV controlled substances. This schedule primarily consists of medications containing limited quantities of certain narcotics.

Examples of Schedule V substancesGeneric Brandcodeine preparations 200mg/100mL

Robitussin AC

diphenoxylate preparations Lomotillacosamide Vimpatopium preparations 100mg/100mLpregabalin Lyrica


Who may issue prescriptions [6]A prescription for a controlled substance may only be issued by a physician, dentist, podiatrist, veterinarian, mid-level practitioner, or other registered practitioner who is:

● Authorized to prescribe controlled substances by the jurisdiction in which the practitioner is licensed to practice.

● Registered with the DEA or exempted from registration (e.g., Public Health Service, Federal Bureau of Prisons, or military practitioners).

● An agent or employee of a hospital or other institution acting in the normal course of business or employment under the registration of the hospital or other institution that is registered in lieu of the individual practitioner being registered provided that additional requirements as set forth in the Code of Federal Regulation are met.

Nurse practitioners prescribing controlled substances: requirements [6]While the CSA allows nurse practitioner to prescribe controlled substances, each state has different regulations. All states except Florida allow nurse practitioners to prescribe some type of controlled substance. Each nurse practitioner should verify their state’s legal requirements and regulations for prescribing and dispensing controlled substances. There are a variety of restrictions imposed on nurse practitioners, including [1]:

● Only certain controlled substance schedules can be prescribed. ● Require controlled drug substance registration or licensure. ● Require a written agreement between physician and nurse

practitioner.

● Limit the quantity of controlled substance prescribed. ● Limit the duration of time that a controlled substance may be

prescribed. ● Have a formulary of controlled substances that may be prescribed. ● Require a certain number of controlled substance-oriented

continuing education hours.

Nursing consideration: Nurses must know from whom they may legally take medication orders. This varies from state to state. Licensed state Boards of Nursing are good sources of current information.

Writing controlled substance prescriptions [6]Laws and regulations vary from state to state, thus the prescribing practitioner must make certain that the prescription follows all requirements. When writing a prescription for a controlled substance, it must be written in indelible ink or typewritten. The prescription must be signed by the practitioner on the date that it was issued.

Nursing consideration: All nurses, not just nurse practitioners, must know about prescription requirements and follow the legal mandates of the states in which they practice [6].

Prescription requirements: ● Patient’s full name and address.

● Practitioner’s full name and address. ● Practitioner’s DEA registration number. ● Drug’s name. ● Strength. ● Dosage form. ● Quantity prescribed. ● Directions of use. ● Number of refills authorized (if any). ● Practitioner’s signature. ● Date issued.

Purpose of issue [6]To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice. The practitioner is responsible for the proper prescribing and dispensing of controlled substances. In addition, a corresponding responsibility rests with the pharmacist

who fills the prescription. Also, a prescription may not written by a practitioner to obtain controlled substances so that they may dispense the medication to individual patients. Practitioners must utilize proper ordering via wholesalers to dispense controlled substances to patients directly.

Schedule II substance regulations [6]Schedule II controlled substances require a written prescription that must be signed by the practitioner. There is no federal law stating when the prescription must be filled by after being signed by the practitioner. While some states and many insurance companies

limit the quantity of controlled substances to a 30-day supply, there is no limit of quantities of drugs dispensed via a prescription. For Schedule II controlled substances, an oral order is only permitted in an emergency situation.

Schedule II refills [6]Prescriptions written for a Schedule II controlled substance may not be refilled.

Issuance of multiple prescriptions for Schedule II substances [6]A practitioner may issue multiple prescriptions authorizing the patient to receive up to a 90-day supply of a Schedule II controlled substance provided the following conditions are met:

● Each separate prescription is issued for a legitimate medical purpose by an individual practitioner acting in the usual course of professional practice.

● The practitioner provides written instructions on each prescription indicating the earliest date on which a pharmacy may fill each

prescription. The first prescription does not need a fill date on it if the prescriber intends for that prescription to be filled immediately.

● The practitioner concludes that providing the patient with multiple prescriptions in this manner does not create a risk of diversion or abuse.

● The issuance of multiple prescriptions is permissible under applicable state laws.

● The practitioner complies with all other requirements of the CSA and any other requirements of state law.


Facsimile and oral prescriptions for Schedule II controlled substances [6]A prescriber may transmit a Schedule II prescription to the pharmacy via facsimile to expedite the filing for the prescription. The original Schedule II prescription must be presented to the pharmacist for review prior to the actual dispensing of the controlled substance.

In an emergency, a practitioner may call in a prescription for a Schedule II controlled substance to the pharmacy. The pharmacist

may dispense the prescription provided that the quantity prescribed and dispensed is limited to the amount adequate to treat the patient only during the emergency period. The prescribing practitioner must provide a written and signed prescription to the pharmacist within 7 days. The pharmacist must notify the DEA if the prescription is not received in that timeframe.

exceptions to facsimile prescriptions for Schedule II controlled substances [6]The DEA has granted three exceptions to the facsimile prescription requirements for Schedule II controlled substances. The facsimile of a Schedule II prescription may serve as the original prescription as follows:

● A practitioner prescribing Schedule II controlled substances to be compounded for the direct administration to a patient by parenteral, intravenous, intramuscular, subcutaneous, or intraspinal infusion may transmit the prescription by facsimile.

● Practitioners prescribing Schedule II controlled substances for residents of long-term care facilities (LTCF) may transmit

a prescription by facsimile to the dispensing pharmacy. The practitioner’s agent may also transmit the prescription to the pharmacy.

● A practitioner prescribing a Schedule II narcotic controlled substance for a patient enrolled in a hospice care program certified and/or paid for by Medicare under Title XVIII or a hospice program that is licensed by the state may transmit a prescription to the dispensing pharmacy by facsimile. The practitioner or the practitioner’s agent may transmit the prescription to the pharmacy and will note on the prescription that it is for a hospice patient.

Schedules III-V substance regulations [6]A prescription for controlled substances in Schedules III, IV, and V issued by a practitioner, may be communicated either orally, in writing,

or by facsimile to the pharmacist, and may be refilled if so authorized on the prescription or by call-in.

Refills [6]Schedules III and IV controlled substances may be refilled if authorized on the prescription. However, the prescription may only be refilled up to five times within 6 months after the date on which

the prescription was issued. After five refills or 6 months, whichever occurs first, a new prescription is required.

Facsimile prescriptions for Schedules III-V substances [6]Prescriptions for Schedules III-V controlled substances may be transmitted by facsimile from the practitioner, or an employee or

agent of the individual practitioner, to the dispensing pharmacy. The facsimile is considered to be equivalent to an original prescription.

telephone authorization for Schedules III-V prescriptions [6]A pharmacist may dispense a controlled substance listed in Schedules III, IV, or V pursuant to an oral prescription made by an individual practitioner and promptly reduced to writing by the pharmacist

containing all information required for a valid prescription, except for the signature of the practitioner.

Nurse practitioner prescribing controlled substance for family members [6]While the laws vary from state to state, all prescribers, including nurse practitioners should not prescribe controlled substances for a family

member. Prescribing for a family member may have legal or ethical implications.

Nurse practitioner prescribing for out-of-state patients [6]While nurse practitioners may prescribe for any patient they have a prescriber-patient relationship with, that patient may have difficulty filling the prescription. The rules regulating nurse practitioners’

prescribing vary significantly from state to state. Pharmacists who receive an out-of-state prescription by a nurse practitioner may refuse to fill the prescription as they are unsure of the rules in other states.

Prescribing medications for the treatment of opiate addiction [7]Nurse practitioners may not prescribe medications used for treating opiate addiction. Federal law restricts methadone for the treatment of dependence to legally authorized opioid treatment programs. At these sites, methadone is administered or dispensed, not prescribed to patients. Nurse practitioners are allowed to prescribe methadone for

pain if their state law permits. Federal law only allows physicians to offer office-based opioid addiction treatment using buprenorphine and buprenorphine/naloxone (Suboxone). Nurse practitioners are allowed to prescribe buprenorphine for pain if their state law permits.

opioid overviewPain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain can be acute or chronic in nature. Chronic pain is consistent pain that lasts more than 6 weeks. It has been estimated that approximately 100 million adults in the United States are affected by chronic pain. The Joint Commission on Accreditation of Health

Care Organizations declared pain to be the fifth vital sign. This led to an increase in efforts to reduce pain scores, but may result in adverse outcomes in patients [9].

The number of prescription opioids has quadrupled between 1999 and 2013. Concurrently, deaths from opioids have also quadrupled since 1999. In 2013, more than 16,000 people in the United States


died from opioid misuse. As of 2013, almost 2 million people in the United States either abused or were dependent on opioids. Despite

this substantial increase in opioid prescriptions, there has not been an overall change in the amount of pain reported [10].

opioid problemEven though the use of opioids has resulted in an increased quality of life for some patients, the increase in opioid abuse and opioid-related deaths is unacceptable. This quandary calls for responsible prescribing by practitioners to help decrease abuse. It is reported that the United States consumes 83% of the global supply of oxycodone and 99% of the hydrocodone supply despite a population of only 4.6% of the world’s population. The increase in opioid prescriptions correlates to the increase in unintentional drug overdose deaths. While the increase in death rate is alarming, there is also an increase in substance abuse treatment admissions, emergency department visits, and hospital stays [11].

The supply source of illicit drugs may be surprising. In 2013, over half of those using opioids illicitly obtain them for free from a friend or family member. Patients misusing controlled substances obtained the prescription from a prescriber 20% of the time. Instead drug dealers, it appears that the largest supplier of illegal drugs may be family and friends [12].

EBP alert! Research shows that family or friends were a major source of supplying opioids to those who misuse them. Healthcare professionals must educate all patients, family members, and loved ones about the dangers of sharing medications, particularly those that belong to a controlled substance category [12].

Definitions [13]There is a lack of consensus on the terminology surrounding pain therapy, abuse, and misuse. While there is no standardization, these are the most commonly used definitions.

Abuse: Self-administering medications to change one’s state of consciousness (i.e., getting high). This is an intentional, maladaptive pattern of use of a medication (whether legitimately prescribed or not) leading to significant impairment or distress – such as repeated failure to fulfill obligations, recurrent use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems – occurring over a 12-month period.

Addiction: A primary, chronic, neurobiological disease, with genetic, psychological, and environmental factors influencing its development and manifestations. Addiction is characterized by the 4 C’s – (behaviors that include one or more of the following): impaired control over drug use, compulsive use, continued use despite harm, and craving.

Dependence: The manifestation of a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

Diversion: Redirection of a prescription drug from its lawful purpose to an illicit use.

Misuse (noncompliant use): The intentional or unintentional use of a prescribed medication in a manner that is contrary to directions, regardless of whether a harmful outcome occurs.

Overdose: When a drug in swallowed, inhaled, injected, or absorbed through the skin in excessive amounts and injures the body. Overdoses are either intentional or unintentional.

Physical dependence: A state of adaptation manifested by a drug class-specific withdrawal syndrome that occurs by abrupt cessation of a drug, rapid dose reduction, decreasing levels of the drug in the blood, and/or administration of an antagonist resulting in dysphoric signs and symptoms generally the opposite of the desired drug effect, and tolerance defined by adaptation so that that increasing doses of a drug is needed to achieve the same desired effect.

Tolerance: A state of adaptation in which exposure to a given dose of a drug induces changes that result in diminution of one or more of the drug’s effects over time.

Withdrawal: A variety of unpleasant symptoms (e.g., difficulty concentrating, irritability, anxiety, anger, depressed mood, sleep disturbance, and craving) that occur after use of an addictive drug is reduced or stopped. Withdrawal symptoms are thought to increase the risk for relapse.

beFore PreSCrIbING LoNG-term oPIoID treAtmeNt

Consider alternate therapyOpioid therapy is not appropriate first-line medication for most patients with chronic pain. Other medications and non-pharmacological therapy should first be tried. Practitioners should document the effectiveness or failure of these medications prior to initiation with opioid therapy. The World Health Organization (WHO) developed a three-step analgesic ladder in 1996 that is still valid today. [Figure 1] It involves a step-wise progression for the treatment of pain. Chronic opioid therapy should only be used after failure of non-opioids or increasing pain [14].

Figure 1

Step 1

Non-opioid Medication+/- Adjunctive Medication

Step 2

Opioid Medication for mildto moderate pain


Step 3

Opioid Medication for moderate to severe pain


Non-opioid medication: acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) (i.e., ibuprofen).

Opioid medication: Hydrocodone, Morphine, Oxycodone, etc.

Adjunctive medication: Steroids, antidepressants, anticonvulsants, muscle relaxants, etc.

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Comprehensive initial evaluation/assessment of patientWhen conducting a comprehensive initial evaluation, data should be gathered from patient history, physician exam, family member interview, and prescription drug-monitoring review. The goal of the evaluation is to determine the nature of the pain, how the pain is affecting the function and quality of life, assess prior treatment approaches, and detect other conditions that could affect the treatment choice [15,16].

Practitioners should before a detailed patient assessment that includes: ● Indications for opioid therapy. ● Nature and intensity of pain. ● Past and current treatment regimens and response. ● Pain impact on physical and psychological function.

● Pain influence on sleep, mood, work, relationships, leisure, and substance use.

● Comorbid conditions. ● Concomitant medications. Identify interacting medications and

other sedatives. ● Social support, housing, employment. ● Patient history of physical, emotional, or sexual abuse. ● Patient history of substance use, addition, or dependence. ● Home environment.

Nursing consideration: Nurses must be prepared to obtain a detailed patient/family history. They must also know the specific components of the history, particularly as it relates to medication use [15,16].

eVALuAte For rISk oF ADDICtIoN or AbuSe

risk assessmentScreening and assessment tools can help stratify patients according to risk level. Placing patients in a risk level helps guide the degree of structure and monitoring needed in the treatment plan. While there

are multiple tools available, most tools are not extensively evaluated, validated, or compared to each other [17].

opioid risk tool (ort)The ORT is a five-item assessment to help predict aberrant drug-related behavior. The ORT is used to help establish a patient risk level of low, medium, or high, based on responses to questions about

previous alcohol or drug use, family history of alcohol or drug use, physiological disorders, gender, and age [18].

Screener and opioid assessment for patients with pain revised (SoAPP-r)The SOAPP-R is a patient-administered, 24-item questionnaire that helps screen for risk of aberrant behavior. The questions ask about alcohol or substance abuse, psychological status, cravings, mood, and

stress. The score then helps determine if a patient is at high risk for aberrant behavior [19].

CAGe and CAGe-AIDThe CAGE substance abuse screening tool is a simple line of questions to help identify if substance abuse exists. CAGE is derived from the four questions of the tool: Cut down, Annoyed, Guilty, Eye-opener. The CAGE-AID uses the same questions, but adds “drug use” to each

question. The normal cutoff for the CAGE is two positive answers. However, some clinicians recommend lowering the threshold to one positive answer to cast a wider net and identify more patients who may have substance abuse disorders [20].

Diagnosis, intractability, risk, and efficacy (DIRE) toolThe DIRE tool is a risk assessment tool used to predict patient compliance with long-term opioid therapy. The practitioner answers questions regarding the diagnosis, patient involvement in care,

psychological background, chemical health, reliability, social support, and prior drug therapy efficacy. This score identifies patients that may not be a suitable candidate for long-term opioid analgesia [21].

mental health screening toolThis tool is a five-item screen that asks about a patient’s feelings of happiness, calmness, peacefulness, nervousness, and depression in the

last month. A lower score on this tool is an indicator that the patient may need to be referred to a specialist for pain management [16].

Risk stratification for patients prescribed opiatesBased on the present evidence, regardless of use of the screening tools, patients may be classified into three categories: low, medium, or high risk. The patients may be stratified into these categories with proper

history, prescription drug monitoring programs, and psychological evaluation [11].

Low risk ● Definable physical pathology with objective signs and reliable symptoms. ● Clinical correlation with diagnostic testing including magnetic resonance imaging (MRI), physical examination, and interventional diagnostic

techniques. ● With or without mild psychological comorbidity. ● No or well-defined and controlled personal or family history of alcoholism or substance abuse. ● Aged > 45 years. ● High levels of pain acceptance and active coping strategies. ● High motivation and willingness to participate in multimodal therapy and attempting to function at normal levels.


Medium risk ● Significant pain problems with objective signs and symptoms confirmed by radiological evaluation, physical examination, or diagnostic

interventions. ● Moderate psychological problems, well controlled by therapy. ● Moderate coexisting medical disorders that are well controlled by medical therapy and are not affected by chronic opioid therapy (e.g., central

sleep apnea). ● Develops mild tolerance, but not hyeralgesia, without physical dependence or addiction. ● Personal or family history of alcoholism or substance abuse. ● Pain involving more than three regions of the body. ● Defined pathology with moderate levels of pain acceptance and coping strategies. ● Willing to participate in multimodal therapy, attempting to function in normal daily life.

High risk ● Widespread pain without objective signs and symptoms. ● Pain involving more than three regions of the body. ● Aberrant drug-related behavior. ● History of alcoholism or drug misuse, abuse, addiction, diversion, dependency, tolerance, or hyperalgesia. ● Major psychological disorders. ● Aged < 45 years. ● HIV-related pain. ● High levels of pain exacerbation and low levels of coping strategies. ● Unwilling to participate in multimodal therapy, not functioning close to a normal lifestyle.

Nursing consideration: There are a number of screening tools available that can help stratify patients according to risk level. Nurses

should be familiar with the tools used in their facilities and how to properly implement them [11,16,18,19,21].

moNItorING oPIoID ComPLIANCe

Opioid agreements [13,16,22]A patient-practitioner agreement is a document between patient and prescriber that is usually associated with the prescription of a controlled substance. The agreement is not mandated or standardized and can vary in content. In general, they help open a dialog between the prescriber and patient on the goals of therapy. Commonly, opioid agreements include:

● Individual patient and treatment provider responsibilities. ● Treatment goals.

● Risks and potential adverse effects. ● Details of filling and refilling prescriptions. ● A schedule for follow-up visits. ● Monitoring approaches. ● Policies for early refill, emergency appointments, and missed

appointments. ● Criteria for dismissal from practices.

Measure baseline levels [23]Before starting chronic opioid therapy, it is important to measure baseline levels of pain and function. It is also important to identify the diagnosis, and evaluate and assess the underlying pathology and comorbid conditions. One method that can be used to review the efficacy of treatment is the Four A’s:1. Analgesic efficacy

○ What was your pain level on average last week? (0 – 10) ○ What was your pain level at its worse during the past week?

(0 – 10) ○ What percentage of your pain has been relieved during the past

week? (0 – 100%) ○ Is the amount of pain relief you are now obtaining from your

current pain relievers enough to make a difference in your life? (yes/no)

2. Activities of daily living – have patient rate – better/same/worse ○ Physical functioning. ○ Family relationships.

○ Social relationships. ○ Mood. ○ Sleep patterns. ○ Overall functioning.

3. Adverse effects – have patient rate – none/mild/moderate/severe ○ Nausea. ○ Vomiting. ○ Constipation. ○ Itching. ○ Mental cloudiness. ○ Sweating. ○ Fatigue. ○ Drowsiness. ○ Note any other side effects.

4. Aberrant Drug-related Behavior ○ Evaluate patient for signs of addiction, diversion, abuse,

misuse.

Create a treatment planNursing consideration: Nurses are essential to the success of any treatment plan. They should be involved in all steps of the plan and

intervene to help patients and families achieve desired outcomes [14-17, 24].

treatment goalsA practitioner and patient should set goals for therapy. Actively including the patient in this discussion can help improve patient

adherence. These goals should be realistic and tracked throughout therapy. The goals should be measurable and address both pain relief


and function. When evaluating a patient’s pain relief, the baseline level of pain and function should be taken into account. The treatment

goals should be designed to minimize adverse effects. The practitioner should document the discussion and outcomes for future visits [14-17].

Multimodal approach [16]When reviewing a patient’s treatment goals, it is important to discuss other treatment therapies that can assist with positive outcomes. There are several options for adjuncts to chronic opioid therapy, including:

● Adjunctive pharmacological non-opioid medications. ● Breakthrough pain treatment with immediate release opioid

analgesics.

● Psychological approaches (e.g., relaxation training, biofeedback). ● Physical or occupational therapy. ● Alternate treatments (e.g., chiropractors, acupuncture, massage

therapy).

Adverse drug reaction preventionThe most common adverse drug reaction with the use of chronic opioid therapy is constipation. Patients should be educated to monitor the frequency of their bowel movements to prevent impaction. Initial prevention should include adequate hydration, dietary fiber intake, and increased physical activity. A bowel regimen including a stool softener (e.g., docusate) and peristalsis increasing laxative (e.g., senna, bisacodyl) should be started on all patients. Patients should be advised to discontinue the bowel regimen if diarrhea develops [24].

The most serious adverse effect of chronic opioid therapy is respiratory depression. While it is thought that respiratory depression decreases after the first few days of opioid treatment, some patients can experience respiratory depression throughout the course of

treatment. Patients with sleep disordered breathing, increased doses of opioid, or change in opioid medication are at a high risk for respiratory depression [25]. The opioid antagonist, naloxone (Narcan), is the treatment of respiratory depression caused by opioids. While it is not the standard of care yet, many groups are calling for and studying the use of naloxone “take-home” kits for patients prescribed opioid therapy [26].

EBP Alert! Research shows that constipation and respiratory depression are adverse reactions related to chronic opioid therapy. Nurses and other health care professionals must teach patients/families about these adverse effects and how to intervene if and when they occur [24,26].

Compliance evaluationNursing Consideration: Nurses are essential to the process of evaluating compliance. They must be aware not only of the necessary procedural and counseling interventions but how to recognize actions patients take to avoid being “caught” when non-compliant [11,13,16,17].

Compliance evaluation is very important during chronic opioid therapy to ensure the safety of the patient. There are several different methods that may be employed to ensure patients are taking their medications properly. The approaches to monitoring will vary between practices and patients [11,13,17].

Screening recommendations based on opioid riskLow risk:

● Urine drug screen: Every 1-2 years. ● Prescription drug monitoring: 2 times per year. ● May use > 50 mg morphine-equivalent dose if needed. ● If aberrant behaviors are seen, counseling should be advised and if

the behavior continues, opioid use should be reconsidered.Medium risk:

● Urine drug screen: Every 6-12 months. ● Prescription drug monitoring: 3 times per year. ● May use > 50 mg morphine-equivalent dose occasionally.

● If aberrant behaviors are seen, counseling should be advised and if the behavior continues, opioids use should be reconsidered.

High risk: ● Urine drug screen: Every 3-6 months. ● Prescription drug monitoring: 4 times per year. ● Avoid opioids; or use very low dose (e.g., 10 mg of morphine-

equivalent dose). ● Avoid dose escalations. ● Use > 50 mg morphine-equivalent dose rarely. ● Patients displaying aberrant behavior should be weaned off

opioids.

urine drug screenWhen treating a patient with a controlled substance, a urine drug screen can be used to detect unauthorized drug use, non-compliance, and diversion. Several trials have shown that using urine drug screens on a regular basis can help reduce substance use in patients. Prescribes often find it easier to have a policy to test all patients receiving a controlled substance to prevent any risk of patient profiling.

Prior to ordering a urine drug test, the prescriber should obtain a detailed medication history, including prescription and non-prescription medications. Routine urine drug screens

test for amphetamines, benzodiazepines, cocaine, marijuana, methamphetamines, and opioids. A more specialized urine drug screen may need to be ordered depending on the type of medication prescribed for the patient (e.g., fentanyl). While a urine drug test can be helpful, it should not be considered to be the ultimate answer. For example, a patient who is diverting controlled substances may take a dose so that the urine drug test may be positive. Also, since cocaine has a short window of detection on a urine screen, it may not be positive [13,16].

Prescription drug monitoring programsPrescription drug monitoring programs are statewide electronic databases that collect data regarding medications dispensed in each state. Currently, 49 states have legislation supporting the use of these programs and one state, Missouri, has pending legislation [27]. Each state’s prescription drug monitoring program is different. The state determines what schedule of medication is collected. Most states

collect Schedules II through V. Each state also determines when the data are reported to the database (e.g., real-time, daily, weekly, or monthly). Also, the state determines what information is collected and who is authorized to view the information. Even though states have individual programs, some states share data to support safer medication use.


Example of information collected: ● Patient’s name, gender, date of birth, address, phone number. ● Medication’s name, dose, frequency, refill, date written, date filled. ● Payor (e.g., private insurance, Medicare, Medicaid, Worker’s

Compensation, cash). ● Pharmacy’s name, address, phone number, DEA number. ● Prescriber’s name, address, phone number, DEA number.

Prescription drug monitoring programs allow prescribers and dispensers of controlled substances to ensure that the prescription is being used for a legitimate medical purpose. The prescriber and pharmacy both have a corresponding responsibility to ensure legal use of controlled substances. Each state has individual regulations regarding the use of these programs prior to prescribing controlled substances. Some states require evaluation of each patient prior to

writing a prescription, and others only require a report to be evaluated if there is suspicion of abuse. It is good practice to evaluate a patient’s controlled substance record each time prior to writing a controlled substance prescription [15-17,28].

Red flags that may be identified through these programs include: ● Multiple prescribers. ● Multiple pharmacies. ● Inconsistent medication use. ● Multiple prescriptions from emergency rooms, dentists. ● Various payor types used (e.g., insurance vs. cash). ● Geographic anomalies (e.g., living in one part of the state, but

seeing prescribers in other parts of the state; moving from one part of the state to the other to fill prescriptions).

Pill countingAnother strategy to decrease diversion and increase compliance is to use pill counts. Pill counts can be conducted in various ways. Patients can be asked to bring prescription bottles to the appointment, called to come into the office for a random visit between scheduled visits, or they could be called on the phone for a pill count. While pill counts can be

effective, they do have some disadvantages. Pill counts can be time-consuming for the prescriber and patient. Pill counts can be manipulated by the patient if they know that they are scheduled. Nevertheless, pill counts are a strong part of decreasing diversion [13, 15-17].

Aberrant behaviorsAberrant drug-related behaviors include any activity that suggests nonmedical use of a medication and or addiction. Altering routes of delivery such as crushing tablets to facilitate rapid release, extraction in fluid for injection, or alteration of drug for intranasal use would be an aberrant drug-related activity. Another suggestive activity would be to obtain opioids from other sources by diverting medications, doctor shopping, stealing from another patient’s prescription, or obtaining medications illegally. Additionally, a patient may display

drug-seeking behaviors such as requesting higher doses, have recurrent prescription losses, request specific or brand name medications, or forge prescriptions. Other behaviors that may be displayed include: acknowledgement of addiction, mood elevating effect of opioids, or withdrawal symptoms. Finally, patients that display a deterioration of overall functioning should be reevaluated for controlled substance use [13, 15-17].

Develop a reassessment planRevaluation of chronic opioid therapy is necessary to ensure effectiveness of therapy, monitor for adverse drug reactions, and evaluate for aberrant drug-related activity. During reassessment, the practitioner should conduct a physical exam, evaluate the 4 A’s, review the prescription drug monitoring program, perform pill counts, and

conduct urine drug screens as appropriate. The practitioner should also review other pertinent information, such as other aspects of medical history, family information, current medications, and any social aspects of care [15-17].

risk evaluation and mitigation Strategy (remS)In 2012, the U.S. Food and Drug Administration (FDA) approved a Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-acting opioid medications. The REMS is a part of a multi-agency federal effort to address the drug abuse and misuse

epidemic. The main focus of the REMS is educating prescribers about appropriate opioid prescribing. It also concentrates on patient education [29].

Patient counseling for opioid analgesics [30]When prescribing extended-release/long-acting (ER/LA) opioid analgesics, the prescriber should use a patient counseling document to help guide the discussion. This tool provides important safety points and includes blank space to fill in specific drug information. The patient counseling document is available at www.er-la-opioidrems.com.

Prescribers should review the following points with patients when prescribing ER/LA opioid analgesics:

● Review product-specific information about the prescribed product (See Table 1).

● Explain how to take the medication, the importance of adherence, what to do if doses are missed.

● Discuss the importance of calling the practitioner if pain is not controlled.

● Inform the patient that the pills should not be crushed, chewed, or broken and patches should not be cut or torn as this leads to a rapid release of the drug, which may cause an overdose.

● Warn patients against mixing other depressant medications (e.g., benzodiazepines, alcohol, illegal drugs) with ER/LA opioids, as this may lead to overdose and death.

● Advise against abrupt discontinuation of the ER/LA opioid, as it may lead to withdrawal. They should contact the practitioner for a tapering regimen.

● Educate about the signs and symptoms of ER/LA opioid toxicity (e.g., respiratory depression, gastrointestinal obstruction, allergic reactions).

● Inform about the risk of falls, working with heavy machinery, and driving while taking ER/LA opioids.

● Warn that sharing ER/LA opioids with other people is illegal, dangerous, and may lead to death.

● Review the importance of storing ER/LA opioids in a safe place away from children, pets, and visitors.

● Counsel patients to contact their prescriber or FDA with any adverse drug events.


Table 1. Drug Information Common to the Class of ER/LA Opioid Analgesics [30]Avinza (morphine sulfate ER capsule)Butrans (buprenorphine transdermal system)Dolophine (methadone HCL tablet)Duragesic (fentanyl transdermal system)Embeda (morphine sulfate ER – naltrexone capsules)Exalgo (hydromorphone HCl ER capsule)Hysingla ER (hydrocodone bitartrate ER tablets) Kadian (morphine sulfate ER capsules)MS Contin (morphine sulfate ER tablets)Nucynta ER (tapentadol HCl ER tablets)Opana ER (oxymorphone HCl ER tablets)OxyContin (oxycodone HCl ER tablets)Targiniq ER (oxycodone HCl-naloxone HCl ER tablets)Zohydro ER (hydrocodone bitartrate ER capsules)

Key points: ● Reserve for patients that have failed alternative treatment regimens

(e.g., non-opioid analgesics, immediate-release opioids). ● Only to be used as a scheduled regimen, not on an as-needed basis. ● Not for pain that will be short-term, nor for mild pain. ● To be used only for chronic pain, not for acute pain.

Dosing guidelines: ● Titrate doses to provide adequate pain relief and minimal side

effects. ● Review specific product information for titration. Prior to titration,

make sure the time to reach steady-state has been achieved. ● Continually reevaluate the need for chronic pain medication. If

pain increases, attempt to identify the source. ● If an ER/LA opioid is no longer needed, slowly titrate down the

medication to prevent withdrawal. Do not abruptly stop these medications.

Solid oral dosage forms: ● Swallow tablets or capsules whole. ● Do not crush, chew, break, cut, or dissolve the medication, as

it could result in a rapid release of the drug, leading to a fatal overdose.

Transdermal systems: ● Do not place patch on skin that is oily, burned, cut, irritated,

damaged, or sensitive. ● If there is hair, do not shave, instead clip hair as closely as

possible. ● Clean area with water only and pat dry. Do not use soap, lotion, or

alcohol on the skin prior to applying patch. ● Avoid exposure to external heat. Avoid hot baths, sunbathing,

hot tubs, saunas, heating pads, electric blankets, tanning beds, or activities (e.g., strenuous exercise) that increase body temperature.

Drug interactions: ● Increased sedation, respiratory depression, hypotension, or coma

with the following medications: ○ Sedatives, hypnotics, general anesthetics, antiemetics,

phenothiazines, and alcohol. ● Risk of withdrawal symptoms with concurrent use of mixed opioid

agonist/antagonists. ● Increased urinary retention and severe constipation with

concurrent anticholinergic medication.

Avinza Morphine Sulfate ER CapsulesDosage forms 30 mg, 45 mg, 60 mg, 75 mg, 90 mg, 120 mg.Dosing interval Once daily.Dosing guidelines Initial dose in opioid non-toleratant patients:

30 mg.Titrate dose by < 30 mg using a minimum of 3-4 day intervals.Capsules may be opened and sprinkled on applesauce.Maximum daily dose 1600 mg/day.Opioid-tolerant patients only: 90 mg, 120 mg capsules.

Butrans Buprenorphine Transdermal SystemDosage forms 5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr, 15 mcg/hr,

20 mcg/hr.Dosing interval Every 7 days.Dosing guidelines Initial dose in opioid non-tolerant patients

when converting from < 30 mg morphine equivalents, and in mild to moderate hepatic impairment: 5 mcg/hr.When converting from 30-80 mg morphine equivalents, first taper to 30 mg morphine equivalent: 10 mcg/hr.Prior total dose > 80 mg of oral morphine equivalent, buprenorphine may not be effective. Titrate dose by 5-10 mcg/hr patches with a minimum of 72-hour intervals.Maximum daily dose: 20 mcg/hr (due to QTc prolongation). Opioid-tolerant patients only: 7.5 mcg/hr, 10 mcg/hr, 15 mcg/hr, 20 mcg/hr.

Drug interactions Cyp3A4 inhibitors increase levels (e.g., clarithromycin, itraconazole).Cyp3A4 inducers decrease levels (e.g., rifampin, carbamazepine).Antiarrhythmics may increase risk of QTc prolongation.

Adverse drugs QTc prolongation and torsade des pointes.Hepatotoxicity.Skin-site reactions.


Dolophine Methadone Hydrochloride TabletsDosage forms 5 mg, 10 mg.Dosing interval Every 8-12 hours.Dosing guidelines Initial dose in opioid non-tolerant patients:

2.5-10 mg.Conversion of opioid tolerant patients using equianalgesic tablets can lead to overdose. Start with lower dosing.Titrate dose with a minimum of 1- to 2-day intervals.Large interpatient variability in absorption, metabolism, equal dosing potency.Opioid detoxification is only to be provided by a federally certified addiction treatment program.

Drug interactions Cyp3A4 inhibitors increase levels (e.g., clarithromycin, itraconazole).Cyp3A4 inducers decrease levels (e.g., rifampin, carbamazepine).Antiarrhythmics may increase risk of QTc prolongation.

Adverse drug reactions

QTc prolongation and torsade de pointes.Respiratory depression may be delayed and persist longer.

Duragesic Fentanyl Transdermal SystemDosage forms 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/

hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr, 100 mcg/hr.

Dosing interval Every 72 hours.Dosing guidelines See package insert for dosing

recommendations.Use 50% of the dose in mild-moderate hepatic or renal failure.Avoid use in severe hepatic or renal failure.Opioid-tolerant patients only: all strengths.

Drug interactions Cyp3A4 inhibitors increase levels (e.g., clarithromycin, itraconazole).Cyp3A4 inducers decrease levels (e.g., rifampin, carbamazepine).

Embeda Morphine Sulfate ER – Naltrexone CapsulesDosage forms 20 mg/0.8 mg, 30 mg/1.2 mg, 50 mg/2 mg, 60

mg/2.4 mg, 80 mg/3.2 mg, 100 mg/4 mg.Dosing interval Every 12-24 hours.Dosing guidelines Initial dose in non-tolerant opioid patients: 20

mg/0.8 mg.Titrate dose using a minimum of 1 to 2 days.Capsules may be opened and sprinkled on applesauce.Opioid-tolerant patients only: 100 mg/4 mg.

Drug interactions Alcoholic beverages or medications containing alcohol may increase morphine levels leading to fatal overdoses.

Exalgo Hydromorphone HCl ER TabletsDosage forms 8 mg, 12 mg, 16 mg, 32 mg.Dosing interval Once a day.Dosing guidelines See package insert for dosing recommendations.

Moderate hepatic impairment: 25% of normal starting dose.Moderate renal impairment: 50% of normal starting dose.Severe renal impairment: 25% of normal starting dose.Titrate by 4-8 mg dosing increments using a minimum of 3- to 4-day intervals.Opioid-tolerant patients only: all strengths.


Allergic reactions in patients allergic to sulfite – avoid use.

Hysingla ER Hydrocodone Bitartrate ER TabletsDosage forms 20 mg, 30 mg, 40 mg, 60 mg, 80 mg, 100 mg,

120 mg.Dosing interval Once a day.Dosing guidelines Initial dose in non-tolerant opioid patients:

20 mg.Titrate by 10 – 20mg increments using a minimum of 3-5 days.Severe hepatic impairment or moderate to severe renal impairment: 50% of normal starting dose.Opioid-tolerant patients only: 80 mg, 100 mg, 120 mg.

Drug interactions Cyp3A4 inhibitors increase levels (e.g., clarithromycin, itraconazole).Cyp3A4 inducers decrease levels (e.g., rifampin, carbamazepine).Medications that increase gastric motility (e.g., lactulose) may decrease levels.MAO inhibitors or TCA may increase the effect of the antidepressant or Hysingla ER.


Esophageal obstruction, dysphagia, and choking – use caution in patients with difficulty swallowing. Patients should take with enough water to ensure complete swallowing.QTc prolongation – more likely with doses > 160 mg, heart failure, arrhythmias, electrolyte abnormalities, or concomitant QTc prolonging medications.


Kadian Morphine Sulfate ER CapsulesDosage forms 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg,

70 mg, 80 mg, 100 mg, 130 mg, 150 mg, 200 mg.

Dosing interval Every 12-24 hours.Dosing guidelines Package insert recommends not to use as

initial opioid.Titrate using a minimum of 2 days.Capsules may be opened and sprinkled on applesauce.Opioid-tolerant patients only: 100 mg, 130 mg, 150 mg, 200 mg.

Drug interactions Alcoholic beverages or medications containing alcohol may increase morphine levels leading to fatal overdoses.P-glycoprotein inhibitors (e.g., amiodarone, atorvastatin, quinidine) may double absorption/exposure to morphine.

MS Contin Morphine Sulfate ER TabletsDosage forms 15 mg, 30 mg, 60 mg, 100 mg, 200 mg.Dosing interval Every 8-12 hours.Dosing guidelines Package insert recommends not to use as

initial opioid.Titrate using a minimum of 1-2 days.Opioid-tolerant patients only: 100 mg, 200 mg.

Drug interactions P-glycoprotein inhibitors (e.g., amiodarone, atorvastatin, quinidine) may double absorption/exposure to morphine.

Nucynta ER Tapentadol ER TabletsDosage forms 50 mg, 100 mg, 150 mg, 200 mg, 250 mg.Dosing interval Every 12 hours.Dosing guidelines Initial dose in opioid non-tolerant patients: 50

mg every 12 hours.Titrate by 50 mg using a minimum of 3 days.Maximum total daily dose: 500 mg.Moderate hepatic impairment: 100 mg once daily – maximum.Avoid use in severe hepatic or renal impairment.

Drug interactions Alcoholic beverages or medications containing alcohol may increase tapentadol levels leading to fatal overdoses.Contraindicated with MAOIs.


Serotonin syndrome.Angioedema.

Opana ER Oxymorphone HCL ER tabletsDosage forms 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, 30 mg,

40 mg.Dosing interval Every 12 hoursDosing guidelines Initial dose in opioid non-tolerant patients: 5

mg every 12 hours.Initial dose in patients with mild hepatic impairment, mild renal impairment (CrCl < 50 mL/min) and patients > 65 years of age: 5 mg every 12 hours.Avoid use in moderate to severe hepatic impairment.Titrate by 5-10mg using a minimum of 3-7 days.Patients may benefit from a different dose given in the a.m. than in the p.m.

Drug interactions Alcoholic beverages or medications containing alcohol may increase oxymorphone levels leading to fatal overdoses.


Esophageal obstruction – use caution in patients with difficulty swallowing. Patients should take with enough water to ensure complete swallowing.

OxyContin Oxycodone HCl ER tabletsDosage forms 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg,

80 mg.Dosing interval Every 12 hours.Dosing guidelines Initial dose in opioid non-tolerant patients: 10

mg every 12 hours.Initial dose in patients with hepatic impairment: One-third to one-half the usual dose.Initial dose in patients with renal impairment (CrCl < 60 mL/min): One-half the usual dose.Titrate using a minimum of 1-2 days.Opioid-tolerant patients only: 40 mg, 60 mg, 80 mg.





Targiniq ER Oxycodone HCl/Naloxone HCl ER tabletsDosage forms 10 mg/5 mg, 20 mg/10 mg, 40 mg/20 mg.Dosing interval Every 12 hours.Dosing guidelines Initial dose in opioid non-tolerant patients: 10

mg/5 mg every 12 hours.Initial dose in patients with hepatic impairment: One-third to one-half the usual dose.Initial dose in patients with renal impairment (CrCl < 60 mL/min): One-half the usual dose.Contraindicated in severe hepatic impairment.Titrate using a minimum of 1-2 days.Maximum total daily dose 80 mg/40 mg.Opioid-tolerant patients only: 40 mg/20 mg.




Zohydro ER Hydrocodone Bitartrate ER capsulesDosage forms 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg.Dosing interval Every 12 hours.Dosing guidelines Initial dose in opioid non-tolerant patients: 10

mg every 12 hours.Titrate by 10 mg using a minimum of 3-7 days.Opioid-tolerant patients only: 40 mg, 50 mg.

Drug interactions Alcoholic beverages or medications containing alcohol may increase hydrocodone levels leading to fatal overdoses.Cyp3A4 inhibitors increase levels (e.g., clarithromycin, itraconazole).Cyp3A4 inducers decrease levels (e.g., rifampin, carbamazepine).

opioid equianalgesic doses

Drug Oral DoseMorphine 30 mgHydromorphone 7.5 mgOxycodone 20 mgOxymorphone 10 mgHydrocodone 20 mg

Step 1: Add the total daily dose of the opioid.

Step 2: Determine the equianalgesic dose.

Step 3: Reduce new opioid dose by 50% to account for cross-tolerance, dosing ratio variation, and patient variability.

Patient example 1AB is a 45-year-old male with a past medical history of back pain after a traumatic injury. He is currently taking MS Contin 60 mg every 12 hours. However, he is not having adequate pain control, so you are going to transition him to OxyContin. What dose of OxyContin would you start him on?

Step 1: 60 mg MS Contin (morphine) twice daily = 120 mg total daily dose of morphine.

Step 2: 120 mg morphine = Equianalgesic dose of OxyContin30 mg 20 mgEquianalgesic dose of OxyContin = 80 mg

Step 3: Reduce dose by 50% to account for cross-tolerance = OxyContin 40 mg total daily dose.

Start OxyContin 20 mg every 12 hours.

Patient example 2CD is a 32-year-old female with chronic pain. She is taking Exalgo (Hydrocodone ER) 16 mg once daily and hydromorphone immediate-release 4 mg three times daily for breakthrough pain. The patient needs to be transitioned to MS Contin due to insurance issues. What dose of MS Contin would you start her on?

Step 1: Exalgo 16 mg once daily + Hydrocodone immediate-release 4 mg three times daily = 28 mg total daily dose of Hydromorphone.

Step 2: 28 mg Hydromorphone = Equianalgesic dose of MS Contin7.5 mg 30 mgEquianalgesic dose of MS Contin = 112 mg

Step 3: Reduce dose by 50% to account for cross-tolerance = MS Contin 56 mg total daily dose.

Start MS Contin 30 mg twice daily.

Drug information common to the class of short acting opioid analgesics [16]

Codeine/acetaminophen (Tylenol with Codeine)Hydrocodone/acetaminophen (Hycet, Lortab, Norco, Vicodin, Xodol)Hydromorphone (Dilaudid)Morphine (MS IR)Oxycodone (Oxy IR, Roxicodone)Oxycodone/acetaminophen (Endocet, Percocet, Roxicet)Oxymorphone (Opana)Tapentadol (Nucynta)

Key points: ● Utilize for short-term acute pain that is refractory to step-wise

therapy. ● May be utilized for breakthrough therapy with ER/LA opioid

treatment plans.Dosing guidelines:

● Titrate doses to provide adequate pain relief and minimal side effects.

● Review specific product information for titration. Prior to titration, make sure the time to reach steady-state has been achieved.


Drug interactions: ● Increased sedation, respiratory depression, hypotension, or coma

with the following medications: ○ Sedatives, hypnotics, general anesthetics, antiemetics,

phenothiazines, and alcohol. ● Risk of withdrawal symptoms with concurrent use of mixed opioid

agonist/antagonists. ● Increased urinary retention and severe constipation with

concurrent anticholinergic medication.

Codeine/Acetaminophen

Tylenol with Codeine tablets

Dosage forms 30 mg/300 mg (#3), 60 mg/300 mg (#4).Dosing guidelines Codeine 15-60 mg every 4 hours as needed.

Codeine maximum: 360 mg/day.Acetaminophen maximum: 4000 mg/day.

Caution Risk of hepatotoxicity with acetaminophen.

Hydrocodone/ Acetaminophen

Hycet, Lortab, Norco, Vicodin, Xodol Tablets

Dosage forms 2.5 mg/325 mg, 5 mg/300 mg, 5 mg/325 mg, 7.5 mg/300 mg, 7.5 mg/325 mg, 10 mg/300 mg, 10 mg/325 mg.

Dosing guidelines Hydrocodone 2.5-10 mg every 4-6 hours as needed.Hydrocodone maximum: limited by acetaminophen content.Acetaminophen maximum: 4000 mg/day.

Caution Risk of hepatotoxicity with acetaminophen.

Hydromorphone Dilaudid TabletsDosage forms 2 mg, 4 mg, 8 mg.Dosing guidelines Opioid-naïve: 2-4 mg every 4-6 hours as

needed.Elderly/debilitated patients may require lower doses.Opioid-tolerant patients may require higher starting doses.

Morphine MS IR tabletsDosage forms 15 mg, 30 mg.Dosing guidelines Initial: 10-30 mg every 4 hours as needed.

Elderly/debilitated patients may require lower doses.Opioid-tolerant patients may require higher starting doses.

Oxycodone Oxy IR, Roxicodone tabletsDosage forms 5 mg, 10 mg, 15 mg, 20 mg.Dosing guidelines Initial: 5-15 mg every 4-6 hours as needed.


Oxycodone/Acetaminophen

Endocet, Percocet, Roxicet Tablets

Dosage forms. 2.5 mg/325 mg, 5 mg/325 g, 7.5 mg/325 mg, 10 mg/325 mg.

Dosing guidelines Initial: 5-15mg every 4-6 hours as needed.Elderly/debilitated patients may require lower doses.Opioid-tolerant patients may require higher starting doses.Oxycodone maximum: limited by acetaminophen content.Acetaminophen maximum: 4000 mg/day.

Oxymorphone OpanaDosage forms 5 mg, 10 mg.Dosing guidelines Initial: 5-10mg every 4-6 hours as needed.


Tapentadol NucyntaDosage forms 50 mg, 75 mg, 100 mg.Dosing guidelines Initial Day #1: 50-100 mg every 4-6 hours as

needed.May administer second dose > 1 hour after initial dose.Maximum dose on Day #1: 700 mg.Dosing on > Day #2: 50-100 mg every 4-6 hours as needed.Maximum dose on > Day #2: 600 mg.

Caution Contraindicated with concomitant MAOI therapy.

Attention deficit hyperactivity disorder (ADHD) OverviewAttention deficit hyperactivity disorders (ADHD) is one of the most commonly diagnosed childhood disorders. It is estimated that approximately 11% of children 4 to 7 years of age in the United States have been diagnosed with ADHD as of 2011 – that is approximately 6.4 million children. The prevalence is more common in boys than girls. The average age of diagnosis is 7 years of age; however, diagnosed age can range from as young as 3 through adulthood [31].

EBP alert! Research shows that ADHD affects about 11% of children 4 to 7 years of age in the United States. It is essential that all healthcare professionals be aware of the management of ADHD, particularly the pharmacological implications of such management [31].

ADHD is a syndrome with two categories of symptoms: hyperactivity/impulsivity and inattention. The diagnosis of ADHD in children requires comprehensive medical, developmental, educational, and

psychological evaluations. The evaluations should include the family and teachers to provide all-inclusive evaluation of the patient. There is a broad array of disease states that can be confused with ADHD. Multiple rating scales have been used for the assessment and monitoring of ADHD [32].

The American Psychiatric Association (APA) has defined consensus criteria for the diagnosis of ADHD. For children < 17 years, the diagnosis of ADHD requires ≥ 6 symptoms of hyperactivity and impulsivity or ≥ 6 symptoms of inattention. For adolescents ≥ 17 years and adults, ≥ 5 symptoms of hyperactivity and impulsivity or ≥ 5 symptoms of inattention are required. The symptoms must occur often, be present in more than one setting (e.g., school and home), persist for more than 6 months, be present before the age of 12, impair function


in academic, social, or occupational activities, and be excessive for the developmental level of the child [32].

Symptoms of hyperactivity and impulsivity ● Excessive fidgetiness (e.g., tapping the hands or feet, squirming

in seat). ● Difficulty remaining seated when sitting is required (e.g., at

school, work). ● Feelings of restlessness (in adolescents) or inappropriate

running around or climbing in younger children. ● Difficulty playing quietly. ● Difficult to keep up with, seeming to always be “on the go.” ● Excessive talking. ● Difficulty waiting turns. ● Blurting out answers too quickly. ● Interruption or intrusion of others.

Symptoms of inattention ● Failure to provide close attention to detail, careless mistakes. ● Difficulty maintaining attention in play, school, or home

activities. ● Seems not to listen, even when directly addressed. ● Fails to follow through (e.g., homework, chores). ● Difficulty organizing tasks, activities, and belongings. ● Avoids tasks that require consistent mental effort. ● Loses objects required for tasks or activities (e.g., school books,

sports equipment). ● Easily distracted by irrelevant stimuli. ● Forgetfulness in routine activities (e.g., homework, chores).

While ADHD is typically diagnosed in childhood, it can be diagnosed later in adulthood as well. Symptoms typically seen in adults are inattention, impulsiveness, restlessness, executive dysfunction, and emotional dysregulation. The diagnosis of ADHD in adults is similar to children; however, they need to have some symptoms prior to the age of 12. Adult patients are more likely to have symptoms of inattention [33].

ADHD treatment recommendations [32, 34-35]The treatment recommendations for ADHD vary based on age. Regardless of age, all patients should receive behavioral interventions and other non pharmacotherapy interventions as needed (e.g., social skills training). Treatment with stimulants are first-line therapy for all patients requiring pharmacotherapy. There are multiple medication choices available. The prescriber must weigh the advantages and disadvantages of the medication for each individual patient. Prescribers should consider the following points prior to choosing a stimulant:

● Age of patient (child, adolescent, adult) and efficacy of agent. ● Preferred length of coverage time (e.g., long enough to complete

homework). ● Ability to swallow capsule or tablet whole. ● Long-acting to avoid dosing during school hours. ● Potential adverse effects. ● History of substance abuse. ● Preference of patient/family member. ● Expense.

Long-acting stimulant medications

Methylphenidate SR Ritalin SR tabletsDosage forms 20 mg.Dosing guidelines Initial dose: 20 mg.

Increase dose by 20mg at a minimum of 3-7 days.Max dose < 50 kg: 60 mg.Max dose > 50 kg: 100 mg.Delayed onset with continuous release over 3-8 hours. May require twice daily dosing or use with immediate-release methylphenidate.

Methylphenidate ER Metadate ER tabletsDosage forms 10 mg, 20 mg.Dosing Initial dose: 10 mg.

Increase dose by 10 mg at a minimum of 3-7 days.Max dose < 50 kg: 60 mg.Max dose > 50 kg: 100 mg.Delayed onset with continuous release over 3-8 hours. May require twice daily dosing or use with immediate-release methylphenidate.

Methylphenidate LA Ritalin LA capsulesDosage forms 10 mg, 20 mg, 30 mg, 40 mg.Dosing Initial dose: 10-20 mg.

Increase dose by 10-20 mg at a minimum of 3-7 days.Max dose < 50 kg: 60 mg.Max dose > 50 kg: 100 mg.50% immediate release and 50% delayed release over 8-12 hours. Capsule may be opened and contents sprinkled on food.

Methylphenidate CD Metadate CD capsulesDosage forms 10 mg, 20 mg, 30 mg, 40 mg, 50 mg,

60 mg.Dosing Initial dose: 20 mg.

Increase dose by 10 mg at a minimum of 3-7 days.Max dose < 50 kg: 60 mg.Max dose > 50 kg: 100 mg.30% immediate release and 70% delayed release over 8-12 hours. Capsule may be opened and contents sprinkled on food.


Methylphenidate ER Concerta tabletsDosage forms 18 mg, 27 mg, 36 mg, 54 mg.Dosing Initial dose: 18 mg.

Increase dose by 9-18 mg at a minimum of 3-7 days.Max dose < 13 years : 54 mg.Max dose > 13 years: 72 mg.20% immediate release and 80% delayed release over 10-12 hours.

Methylphenidate XR Quilivant XR oral suspensionDosage forms 5 mg/mL.Dosing Initial dose: 20 mg.

Increase dose by 10 mg at a minimum of 7 days.Max dose: 60 mg.20% immediate release and 80% delayed release over 10-12 hours.

Methylphenidate patch Daytrana patchDosage forms 10 mg, 15 mg, 20 mg, 30 mg.Dosing Initial dose: 10 mg.

Increase dose by 5 mg at a minimum of 3-7 days.Max dose: 30 mg.The patch is applied 2 hours prior to needed onset and worn for 9 hours.Onset 2 hours after patch application and continuous release over 10-12 hours.

Dexmethylphenidate XR

Focalin XR capsules

Dosage forms 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg.

Dosing Initial dose: 5 mg.Increase dose by 5 mg at a minimum of 3-7 days.Max dose: 40 mg.50% immediate release and 50% delayed release over 10-12 hours. Capsule may be opened and contents sprinkled on food.

Dextroamphetamine SR

Dexedrine spansule

Dosage forms 5 mg, 10 mg, 15 mg.Dosing Initial dose: 5 mg.

Increase dose by 5 mg at a minimum of 3-7 days.Max dose < 50 kg: 40 mg.Max dose > 50 kg: 60 mg.Combination of immediate and continuous release over 6-8 hours.May require divided dose twice daily.

Amphetamine-Dextroamphetamine ER

Adderall XR capsule

Dosage forms 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg.

Dosing Initial dose: 5 mg.Increase dose by 5 mg at a minimum of 3-7 days.Max dose: 40 mg.Combination of immediate and continuous release over 8-10 hours.

Lisdexamfetamine Vyvanse capsuleDosage forms 20 mg, 30 mg, 40 mg, 50 mg, 60 mg,

70 mg.Dosing Initial dose: 20 mg.

Increase dose by 10-20 mg at a minimum of 3-7 days.Max dose: 20 mg.Prodrug converted to dextroamphetamine in bloodstream with an effect over 10 hours. Capsule may be opened and dissolved in water for immediate use.

Short-acting stimulant medications

Methylphenidate Ritalin tabletsMethylin chewableMethylin oral suspension

Dosage forms 5 mg, 10 mg, 20 mg tablets.2.5 mg, 5 mg, 10 mg chewable tablets.5 mg/5 mL, 10 mg/5 mL oral solution.

Dosing Initial dose: 5 mg once a day, then 5 mg twice a day.Initial dose < 25 kg: 2.5 mg once a day.Increase dose by 5 mg at a minimum of 3-7 days.Increase dose by 2.5 mg if < 25 kg at a minimum of 3-7 days.Max dose < 25 kg: 35 mg.Max dose > 25 kg: 60 mg.Duration of action 3-5 hours.

Dexmethylphenidate FocalinDosage Forms 2.5 mg, 5 mg, 10 mg tablets.Dosing Initial dose patients not taking

methylphenidate: 2.5 mg twice daily.Initial dose patients taking methylphenidate: half current daily dose up to 10 mg twice daily.Increase dose by 2.5-5 mg at a minimum of 3-7 days.Max dose: 20 mg.Duration of action 5-6 hours.May not be appropriate for children < 6 years of age due to higher potency and lack of chewable tablets or oral solution.


Dextroamphetamine Dexedrine, DextrostatProCentra oral solution

Dosage forms 5 mg, 10 mg tablets.5 mg/5 mL oral solution.

Dosing Initial dose 3-5 years of age: 2.5 mg once a day, then 2.5 mg twice daily.Initial dose > 6 years of age: 5 mg once a day, then 5 mg twice a daily.Dose titration if 3-5 years of age: 2.5 mg per day at minimum 3-7 days.Dose titration if > 6 years of age: 5 mg per day at minimum 3-7 days.Max dose if 3-5 years of age: 20 mg.Max dose if > 6years of age and < 50 kg: 40 mg.Max dose if > 6years of age and > 50 kg: 60 mg.Duration of action 4-6 hours.

Amphetamine-Dextroamphetamine

Adderall

Dosage forms 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg tablets.

Dosing Initial dose 3-5 years of age: 2.5 mg once a day, then 2.5 mg twice daily.Initial dose > 6 years of age: 5 mg once a day, then 5 mg twice a daily.Dose titration if 3-5 years of age: 2.5 mg per day at minimum 3-7 days.Dose titration if > 6 years of age: 5 mg per day at minimum 3-7 days.Max dose if < 50 kg: 40 mg.Max dose if > 50 kg: 60 mg.Duration of action 4-6 hours.

Nursing consideration: Nurses must take an active role in teaching patients and failies about treatment goals and compliance [25,32].

monitoring therapy and goals of treatment Patients and prescribers should set goals to help monitor the efficacy of treatment. Goals should be individualized, observable, and measurable. Specific goals may change throughout the course of treatment. Examples of goals include:

● Plays at recess without fighting. ● Completes chores in timely manner. ● Does not interrupt teacher during class. ● Remembers to bring assigned books to class.

Prescribers should also monitor patients for side effects from stimulants. While side effects are generally mild and reversible with dose reduction, patients and caregivers should be aware of potential risks of stimulant use. The most comment side effects are anorexia leading to poor growth or weight loss, sleep disturbance, and jitteriness. Patients can also have emotional liability or the development of tics. Rare side effects include tachycardia, hypertension, priapism, and psychotic symptoms (e.g., hallucinations, mania). Patients and caregivers should be advised to contact the prescriber with any adverse events [32,25].

Diversion of stimulant medicationsThere has been an increase in the number of children and adults diagnosed with ADHD within the past 20 years. Multiple studies have shown that prescription stimulants are the most efficacious medication for treatment. Approximately 70% of patients respond to treatment [32].

With the rise in treatment, there has also been a rise in illicit drug use of prescription stimulants. The nonmedical use of prescription stimulants represents the second most common form of illicit drug use in college, second only to marijuana. [36] Prescription stimulants are often misused to achieve euphoria and to assist in the educational environment. Prescription stimulants lead to abuse by increasing the levels of dopamine causing euphoria. While stimulants may be safe in

patients with ADHD, they do have cardiac adverse effects which could contribute to sudden death [37].

Education of patients and family members is key to decrease diversion. Most diversion takes place between students. Patients should be informed of the legal liabilities of diversion and risk of adverse effects and death. Clinicians should carefully prescribe stimulants and use similar techniques as when prescribing opioids. Patients should be observed for signs of diversion (e.g., increased dosage request, lost prescriptions) Prescribers should be aware of signs and symptoms of stimulant abuse. Patients with a history of substance abuse should be prescribed nonstimulant medications (e.g., atomoxetine, guanfacine, clonidine) and use nonmedication strategies [32,35,37].

Signs and symptoms of stimulant abuse ● Aggressive Behavior ● Agitation ● Anxiety ● Anorexia ● Confusion ● Depression ● Hypertension

● Irritability ● Infection from intravenous use ● Memory loss ● Paranoia ● Psychosis ● Seizures ● Tremor

ConclusionControlled substance prescribing for nurse practitioners comes with great responsibility. Prescribers should ensure they are familiar with DEA regulations and state requirements for controlled substance

prescribing. Appropriate prescribing of controlled substances will help increase efficacy, minimize adverse events, and deter substance abuse.

references1. Pearson LJ. (2014). The 2014 Pearson report: The annual state-by-state national overview of

nurse practitioner legislation and healthcare issues. Retrieved from http://nursing.jbpub.com/pearsonreport/

2. Brown ME, Swiggart WH, Dewey CM, Ghulyan MV. (2012). Searching for answers: proper prescribing of controlled prescription drugs. J Psychoactive Drugs, 44(1), 79-85.


3. Courtwright DT. (2004). The controlled substances act: how a “big tent” reform became a punitive drug law. Drug Alc Depend, 76(1), 9-15.

4. U. S. Drug Enforcement Agency. (2015). Title 21 United States Code (USC) Controlled Substance Act. Retrieved from http://www.deadiversion.usdoj.gov/21cfr/21usc/

5. U.S. Drug Enforcement Agency. (2015). Controlled Substance Schedules. Retrieved from http://www.deadiversion.usdoj.gov/schedules/

6. U.S. Drug Enforcement Agency. (2015). Practitioner’s Manual – SECTION V. Retrieved from http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section5.htm

7. Substance Abuse and Mental Health Services Administration. (2015). Federal guidelines for opioid treatment programs. Retrieved from http://store.samhsa.go

8. Dzau Vj, Pizzo PA. (2014) Relieving pain in America: Insights from an Institute of Medicine committee. JAMA, 312(15, )1507-1508.

9. Taylor S, Voytovich AE, Kozol RA. (2003). Has the pendulum swung too far in postoperative pain control? Am J Surg, 186(5), 472-475.

10. Centers for Disease Control and Prevention. (2015).National Vital Statistics System mortality data. Retrieved from http://www.cdc.gov/nchs/deaths.htm

11. Atluri S, Akbik H, Sudarshan G. (2012). Prevention of opioid abuse in chronic non-cancer pain: an algorithmic, evidence based approach. Pain Physician, 15, ES177-ES189.

12. Jones C, Paulozzie L, Mack K. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008 – 2011. JAMA Int Med, 175(5), 802-803.

13. American College of Preventative Medicine. (2011). Use, abuse, misuse, and disposal of prescription pain medication time tool: A resource from the American College of Preventative Medicine. Retrieved from www.acpm.org/resource/resmgr/timetools-files/painmedsclinicalreference.pdf

14. Reid C, Davies A. (2004). The World Health Organization three-step analgesic ladder comes of age. Palliat Med, 18(3), 175-176.

15. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O’Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C, American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. (2009). J Pain, 10(2), 113-130.

16. Benzon, HT. (2011). Essentials of Pain Medicine, Third Edition. Philadelphia, PA: Elsevier Saunders.

17. Manchikanti L, Abdi S, Atluri S, Balog CC, Benyamin RM, Boswell MV, & Wargo BW. (2012). American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: part 2 - guidance. Pain Physician, 15(3 Suppl), S67-S116.

18. Webster LR, Webster RM. (2005). Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med, 6(6), 432-442.

19. Butler SF, Fernandez K, Benoit C, Budman S, Jaimson RN. (2008). Validation of the revised screener and opioid assessment for patients with pain (SOAPP-R). J Pain, 9(4), 360-372.

20. Leonardson GR, Kemper E, Ness FK, Koplin BA, Daniels MC, Leonardson GA. (2005). Validity and reliability of the AUDIT and CAGE-AID in Northern Plains American Indians. Psychol Rep, 97(1), 161-166.

21. Belgrade MJ, Schamber CD, Lindren BR. (2006). The DIRE score: predicting outcomes of opioid prescribing for chronic pain. J Pain, 7(9), 671-681.

22. Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med, 152(11), 712-720.

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25. Jarzyna D, Jungguist CR, Pasero C, Willens JS, Nisbet A, Oakes L, Dempsey SJ, Santangelo D, Polmano RC. (2011). American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs, 12(3), 118-145.

26. Enteen L, Bauer J, McLean R, Wheeler E, Huriaux E, Kral AH, Bamberger JD. Overdose prevention and naloxone prescription for opioid users in San Francisco. J Urban Health, 87(6), 931-941.

27. National Association of State Controlled Substance Authorities.(2014) Prescription Drug Monitoring Programs, updated 1/26/2014. Retrieved from http://www.nascsa.org/nascsaPMP/NationalPDMPmap1.26.14.pdf

28. Haffajee RL, Jena AB, Weiner SG. (2015). Mandatory use of prescription drug monitoring programs. JAMA, 313(9), 891-892.

29. Stanos S. (2012). Evolution of opioid risk management and review of the classwide REMS for extended-release/long-acting opioids. Phys Sportsmed, 40(4), 12-20.

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32. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. (2011). ADHD: Clinical practice guidelines for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 128(5), 1007-1022.

33. Kooij, J. S., Huss, M., Asherson, P., Akehurst, R., Beusterien, K., French, A., & Hodgkins, P. (2012). Distinguishing comorbidity and successful management of adult ADHD. Journal of attention disorders, 16(5suppl), 3s-19s.

34. Daughton JM, Kratochvil CJ. (2009). Review of pharmacotherapies: advantages, disadvantages, and clinical pearls. J Am Acad Child Adolesc Psychiatry, 48(3), 240 – 248.

35. Sharma A, Couture J. (2014). A review of the pathophysiology, etiology, and treatment of attention-deficit hyperactivity disorder (ADHD). Ann Pharmaocther, 48(2), 209-225.

36. Setlik J, Bond GR, Ho M. (2009). Adolescent prescription ADHD medication abuse is rising along with prescriptions for these medications. Pediatrics. 2009 124(3),875-880.

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Answers: 1.C 2.A 3.B 4.C 5.B 6.C 7.A 8.B 9.B 10.C 11.A 12.B 13.C 14.C 15.BCoNtroLLeD SubStANCeS: A NurSe PrACtItIoNer’S GuIDe

Self evaluation exercisesSelect the best answer for each question and check your answers at the bottom of the page.

You do not need to submit this self-evaluation exercise with your participant sheet..

1. How many states permit Nurse Practitioners to write controlled substance prescriptions?a. 45.b. 47.c. 49.d. 50.

2. If a substance has no acceptable medical use, in which schedule is it classified?a. Schedule I.b. Schedule II.c. Schedule IIN.d. Schedule V.

3. Which of the following is not required on a controlled substance prescription?a. Patient’s full name.b. Pharmacy name.c. Practitioner’s DEA registration number.d. Date when issued.

4. When can a Schedule II Controlled Substance be faxed to the pharmacy?a. For refills only.b. If it is for 48 hour day supply.c. For hospice patients.d. Only for patients less than 18 years of age.

5. How many times can Lorazepam be refilled before a new prescription is needed?a. Up to 12 times in 1 year.b. Up to 5 times in 6 months.c. Unlimited number of times in 6 months.d. Never, a new prescription is needed each time.

6. Which of the following screening tools help predict compliance with long-term opioid therapy?a. SOAPP-R.b. CAGE.c. DIRE.d. Mental Health Screening Tool.

7. Which of the patients is at high risk for opioid abuse?a. 27-year-old female with history of alcoholism.b. 56-year-old male with leg fracture diagnosed on x-ray.c. 45-year-old male who failed prior medication therapy.d. 78-year-old female with depression, controlled with

medication.

8. What is the reversal agent for Opioid induced respiratory depression?a. Docusate.b. Naloxone.c. Flumazenil.d. None of the above.

9. Which of the following stimulants may be a good choice for a child that cannot swallow a long acting pill?a. Concerta.b. Daytrana Patch.c. Adderall XR.d. Metadate ER.

10. What would be an achievable goal for ADHD treatment?a. Be good at school.b. Be nice to friends.c. Remember to bring ball to soccer practice.d. All of the above.

11. What are the most common side effects of stimulant medications?a. Anorexia.b. Weight gain.c. Bradycardia.d. Sedation.

12. Which of the following is a schedule IV medication?a. Androderm.b. Klonopin.c. Fiorinal.d. Suboxone.

13. A telephone prescription may be called in for which of the following medications?a. Concerta.b. Methadone.c. Suboxone.d. Vyvanse.

14. Which of the following is true about Opioid agreements?a. They are mandated by the federal government.b. There is a standardized agreement for every chronic opioid

patient.c. They help open dialogue between prescriber and patient.d. They are utilized for every patient receiving Schedule II

medications.

15. Which of the following government departments initiated the ER/LA opioid REMS program?a. DEA.b. FDA.c. CDC.d. Board of Pharmacy.


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