Presentation on theme: "Controlled Substance Prescribing in the Geriatric Population Lisa Byrd PhD, FNP-BC, GNP-BC Gerontologist."— Presentation transcript:
Controlled Substance Prescribing in the Geriatric Population Lisa Byrd PhD, FNP-BC, GNP-BC Gerontologist
Outline Review classes of controlled substances Guidelines for Prescribing Discuss onset of action of short-acting, long- acting, & rapid onset opioids Identify enduring & emerging opioid therapies Describe elements of an overall treatment program that includes opioids Outline the advantages and disadvantages of risk management tools & techniques to identify aberrant behavior, abuse, & addiction
DISCLOSURE Medications to manage pain & other symptoms will be discussed Controlled Substances will be discussed Off-label use may be mentioned but this will be discussed Generic & Trade names will be used Material has been researched & presented by author of this presentation Presenter is on Speakers Bureau for: Novartis Pharmaceuticals Avanir Pharmaceuticals
USE OF CONTROLLED SUBSTANCES are essential to the treatment of a myriad of disorders and represent a wide spectrum of pharmaceutical agents prescribing these substances involves considering a number of important medical, social, and cultural variables along with adherence to applicable federal and state regulations prescribers often stand at the crossroads of these issues and serve as the ultimate gatekeepers of safe and effective treatment
PRESCRIBERS… Must be well-versed in the legal requirements including knowledge of both federal & state law Controlled Substances Act (CSA) is the federal law that regulates such substances The Drug Enforcement Administration (DEA) publishes a guide for prescribers entitled: "Practitioner's Manual, an Informational Outline of the Controlled Substances Act"
TYPES OF PRESCRIBERS Physicians, Doctor of osteopath, Dentists, Podiatrists, & Veterinarians to prescribe controlled substances Other licensed healthcare professionals: Nurse Practitioners Physician Assistants Naturopathic Physicians Optometrists Medscape's US Nurse Practitioner Prescribing Law: A State-by-State Summary DEA's Midlevel Practitioners Authorized by State Website
Evaluation of a Patient Medical history & physical examination FOR PAIN MANAGEMENT: the medical record should document: the nature & intensity of the pain current & past treatments for pain underlying or coexisting diseases or conditions the effect of the pain on physical & psychological function history of substance abuse Medical indications for the use of a controlled substance
TREATMENT PLAN: PAIN MANAGEMENT State objectives that will be used to determine treatment success should indicate if any further diagnostic evaluations or other treatments are planned Adjust drug therapy to the individual medical needs of each patient Other treatment modalities or a rehabilitation program may be necessary
INFORMED CONSENT & AGREEMENT FOR TREATMENT Discuss the risks & benefits of the use of controlled substances One prescriber & One pharmacy If at high risk for medication abuse or has a history of substance abuse consider the use of a written agreement
Pain Management Contract between prescriber and patient outlining patient responsibilities: urine/serum medication levels screening when requested number and frequency of all prescription refills reasons for which drug therapy may be discontinued e.g., violation of agreement
STATE PRESCRIPTION DRUG MONITORING PROGRAMS support access to legitimate medical use of controlled substances drug abuse & diversion intervention with & treatment of persons addicted to prescription drugs inform public health initiatives educate individuals about PDMPs The Alliance of States with Prescription Monitoring Programs
PERIDODIC REVIEW The course of pain treatment & any new information about the etiology of the pain Evaluate progress toward treatment objectives Satisfactory response to treatment Objective evidence of improved or diminished function If the patient's progress is unsatisfactory, the prescriber should assess the appropriateness of continued use
CONSULTATION Refer the patient as necessary Special attention if potential misuse, abuse or diversion History of substance abuse or with a co-morbid psychiatric disorder
MEDICAL RECORDS The prescriber should keep accurate and complete records to include: 1. medical history & physical examination 2.diagnostic, therapeutic and laboratory results 3. evaluations & consultations 4. treatment objectives 5. discussion of risks & benefits 6. informed consent 7. treatments 8. medications including date, type, dosage & quantity prescribed 9. instructions and agreements 10. periodic reviews Records should remain current and be maintained in an accessible manner and readily available for review
COMPLIANCE WITH CONTROLLED SUBSTANCES LAWS AND REGULATIONS Prescriber must be licensed in the state & comply with applicable federal and state regulations Manual of the U.S. Drug Enforcement Administration and (any relevant documents issued by the state medical board) for specific rules governing controlled substances as well as applicable state regulations
DEFINITIONS COMMON TERMS IN USE OF CONTROLLED SUBSTANCES
PAIN an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
ACUTE PAIN is the normal, predicted physiological response to a noxious chemical, thermal or mechanical stimulus & typically is associated with invasive procedures, trauma and disease generally time-limited
CHRONIC PAIN persists beyond the usual course of an acute disease or persists after healing of an injury or may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain
CHRONIC PAIN SYNDROME (CPS) presents a major challenge to healthcare providers because of its complexity ongoing pain lasting longer than 6 months as diagnostic, minimum of 3 months as the minimum criterion constellation of syndromes that usually do not respond to the medical model of care
TOLERANCE is a physiologic state resulting from regular use of a drug in which an increased dosage is needed may or may not be evident during treatment does not equate with addiction
SUBSTANCE ABUSE is the use of any substance(s) for non- therapeutic purposes or use of medication for purposes other than those for which it is prescribed
PHYSICAL DEPENDENCE is a state of adaptation that is manifested by drug class-specific signs & symptoms that can be produced by: abrupt cessation rapid dose reduction decreasing blood level of the drug, and/or administration of an antagonist it is, by itself, does not equate with addiction
PSUEDOADDICTION the iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction resolve upon institution of effective analgesic therapy
ADDICTION is a primary, chronic, neurobiologic disease, with genetic, psychosocial, & environmental factors influencing its development and manifestations it is characterized by behaviors: impaired control over drug use, craving, compulsive use, & continued use despite harm physical dependence & tolerance are normal physiological consequences of extended therapy and are not the same as addiction
A Treatment Improvement Protocol Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders
Pain Control… is every patients right
BASIC PRINCIPLES Pain diagnosis based on inferred pathophysiology identification of contributing factors identification of barriers
Principles of Pain Management Anticipate, prevent, and treat pain Anticipate, prevent, and treat adverse effects of pain management
Pain Assessment Pain history Location Intensity Quality Pattern Aggravating or alleviating factors Medication history
Physical Examination Observe for non-verbal cues withdrawal, fatigue, grimaces, irritability Examine sites of pain skin breakdown, changes in bony structure Palpate areas of tenderness Assess the patient Auscultate lungs, abdomen Percuss for fluid accumulation or gas Conduct neurological exam
NOCICEPTIVE PAIN Nociception implies active mechanical, thermal or chemical process
NEUROPATHIC PAIN Aberrant signaling in the pain transmission or pain modulation pathways Diabetic patient with neuropathy can experience pain due to spontaneous firing of damaged nerves Quality is typically burning & often there is a paroxysmal quality such as shooting, jabbing or shock-like pain
MUSCULAR PAIN is pulling, tight or aching certain movements or positions may accelerate or trigger muscular pain the location or pattern coincides with the affected muscles
PSYCHOGENIC PAIN is pain that originates through cognitive & emotional processing examples are conversion disorder, factitious disorder, & somatization disorder
PAIN SCALES In acute pain: assessment of pain intensity using formal rating scales 0 – 10 visual analog scale where intensity is marked on a 10 cm line from NO PAIN to WORST POSSIBLE PAIN In chronic pain management, intensity is evaluated based on assessing impairment, function, impact of pain & relative improvement in pain
Routes of Administration Oral-offers pain relief equivalent to other routes but due to first pass metabolism-dosing must be increased when compared to IM, IV, or SQ routes i.e.10 morphine IV, IM, or SQ is equivalent to 30 mg orally Immediate release-MS IR Liquid Long acting (sustained release)-MS Contin, Oxycontin, Oramorph, Kadian sprinkles Longer acting allows dosing of 8, 12, 24 hour intervals
Routes of Administration Rectal (also stomal/vaginal) Thrombocytopenia or painful lesions preclude this routes Long acting opioid tablets can be placed rectally when patients are no longer able to swallow Pharmacokinetic studies demonstrate approximately 90% of concentrations in plasma levels achieved when compared to oral delivery Transdermal Only formulary is fentanyl-patch applied every 72 hours (25, 50, 100 mcg/hr) Delayed peak of onset of 17 hours after applying 1 st patch Effects of cachexia and fever are believed to accelerate drug distribution
TRICYCLIC ANTIDEPRESSANTS are effective adjuvant analgesics in a wide range of painful conditions unless contraindicated, consider in most chronic pain patients, especially in cases of neuropathic pain with continuous dysesthesias side effects of these drugs help us choose them for individual patients based on which side effects are minimized or advantageous
ANTICONVULSANTS used in the management of Neuropathic pain Trigeminal neuralgia Carbamazepine is usually the first choice anti- convulsant for pain Phenytoin, clonazepam and valproic acid are also used in the same settings Newer anti-convulsant gabapentin (NeurontinB) for managing neuropathic pain
Pharmacological Therapies for Pain Management Nonopioids Acetaminophen (Tylenol) Action-analgesia, antipyretic DOSAGE: Acetaminophen (Tylenol) 325–500mg every 4 h or 500–1,000mg Maximum dose usually 4 g daily Reduce maximum dose 50% to 75% in patients with hepatic insufficiency or history of alcohol abuse
Pharmacological Therapies for Pain Management Nonsteroidal anti-inflammatory drugs (NSAIDS) Aspirin, Ibuprofen (Motrin), Naproxen (Naprosyn) Action-Analgesia, antiinflammatory, antipyretic, and inhibits prostoglandins by blocking cyclooxygebase. Prostoglandins are rich in the periosteum of bones and in the uterus-thus NSAIDS are very useful in relieving bone pain and dysmenorrhea Do have a ceiling effect-increasing doses above a certain point will not increase analgesia
Tramadol (UltramB) is an analgesic drug that works through two different mechanisms: a weak mu opioid receptor agonist has properties of serotonin and norepinephrine reuptake inhibition Requires a DEA number for prescriptions Analgesic potency is similar to that of other weak opioids. Doses are mg every 4-6 hours up to 400 mg per day. most common side effects are gastrointestinal symptoms, dizziness, dry mouth, drowsiness, constipation, & seizures
CODIENE CIII Used to relieve mild to moderate pain ADULT DOSE:15 mg orally every 6 hours as necessary. May titrate up to 20 mg every 4 hours. Maximum 120 mg/day. GERIATRIC DOSE: 10 mg orally every 6 hours as necessary. Lower doses necessary if renal impairment of liver impairment Acetaminophen with codiene Tylenol #3 (30/300) Tylenol #4 (60/300)
MORPHINECII Used to treat moderate to severe pain Short-acting formulations are taken as needed for acute pain Extended-release formulations are used when chronic pain relief is needed
MORPHINE CII Immediate release2.5–10mg every 4 h Available in tablet form & concentrated oral solution (MSIR, Roxanol) most commonly used for episodic or breakthrough pain and for patients unable to swallow tablets. Sustained release 15mg every 8–24 h (Avinza, Kadian, MSContin, Oramorph SR) see dosing guidelines in the package insert for each specific formulation
MORPHINE DOSING: ADULT Oral, Sublingual, or Buccal: 5 to 30 mg every 3 to 4 hours PRN Extended release: range from 10 mg to 600 mg daily, given in equally divided doses every 8 to 12 hours or given as one dose every 24 hours IM or subcutaneous: 2.5 to 20 mg every 3 to 4 hours PRN IV: 4 to 15 mg every 3 to 4 hours PRN. Give very slowly over 4 to 5 minutes. Starting doses up to 15 mg every 4 hours have been used. Chest pain: 2 to 4 mg repeat PRN Continuous IV: 0.8 to 10 mg/hour. Maintenance dose: 0.8 to 80 mg/hour. Rates up to 440 mg/hour have been used. IV patient controlled analgesia or subcutaneous patient controlled analgesia: 1 to 2 mg injected 30 minutes after a standard IV dose of 5 to 20 mg. The lockout period is 6 to 15 minutes. The 4 hour limit is 30 mg. Continuous subcutaneous: 1 mg/hour after a standard dose of 5 to 20 mg Epidural: 5 mg one time. May give 1 to 2 mg more after one hour to a maximum of 10 mg. Intrathecal: 0.2 to 1 mg one time Intrathecal Continuous: 0.2 mg/24 hours. May be increased up to 20 mg/24 hours. Intracerebroventricular: 0.25 mg via an Ommaya reservoir. Rectal: 10 to 30 mg every 4 hours as needed.
MORPHINE DOSING: Premedication for anesthesia IV: 3 to 4 mg once, may repeat in 5 minutes if necessary. Oral: 0.2 to 0.5 mg/kg/dose every 4 to 6 hours (tablets/solution) or 0.3 to 0.6 mg/kg/dose every 12 hours (extended release) IM,subcutaneous, IV: 0.05 to 0.2 mg/kg/dose (up to 15 mg) every 4 hours as needed IV/subcutaneous Continuous: to mg/kg/hour (sickle cell or cancer pain) or 0.01 to 0.04 mg/kg/hour (postop pain) Epidural (use preservative-free formulation): mg/kg/dose every 6 to 8 hours (postop pain). Maximum per 24 hours: 5 mg. IV patient controlled analgesia: mg/kg/dose (postop pain); lockout period of 10 minutes; 4 hour limit of 0.25 mg/kg.
HYDROMORPHINE CII an opioid (narcotic) analgesic-works by binding to certain receptors in the brain and nervous system to reduce pain DOSAGE: 2 mg to 4 mg, orally, every 4 to 6 hours
FENTANYL CII A potent synthetic narcotic analgesic with a rapid onset & short duration of action It has been used to treat breakthrough pain 100 times more potent than morphine, with 100 micrograms of fentanyl approximately equivalent to 10 mg of morphine and 75 mg of pethidine (meperidine) in analgesic activity Available 12.5; 25; 50; 100 mcg/hr patches applied every 72 hours
FENTANYL PAIN PATCH CONVERSION
HYDROCODONE CIII opiate (narcotic) analgesics - changes the way the brain and nervous system respond to pain Hydrocodone must be used with caution in children. Extended-release products containing hydrocodone should not be given to children younger than 6 years of age and should be used with caution in children 6-12 years of age.
HYDROCODONE DOSE Schedule II Includes pure hydrocodone & formulations containing more than 15 mg hydrocodone per dosage unit. Written prescription required for refills. Schedule III Includes hydrocodone products containing less than 15 mg per dosage unit. May be refilled using phoned prescription. Formulations: (Lortab 2.5/500; 5/500, 7.5/500, 10/500; elixer) (Norco 5/325; 7.5/325; 10/325) (Vicodin regular strength; ES; HP) (Xocol 5/300; 7.5/300; 10/300) (Zydone 5/400; 7.5/400; 10/400)
OXYCODONE CII Oxycodone is used to relieve moderate to severe pain-works by changing the way the brain and nervous system respond to pain. Oxycodone is also available: in combination with acetaminophen (Endocet 10/325) (Percocet 2.5/325; 5/325; 7.5/325; 7.5/500; 10/325; 10/500) (Roxicet 5/325) (Tylox 5/500) in combination with aspirin (Endodan, Percodan, Roxiprin, others) in combination with ibuprofen (Combunox)
OPIOID ANALGESIC EQUIVALENTS WITH APPROXIMATELY EQUIANALGESIC POTENCY Nonproprietary (Trade) Name IM or SC Dose ORAL Dose * Dosages, and ranges of dosages represented, are a compilation of estimated equipotent dosages from published references comparing opioid analgesics in cancer and severe pain. Morphine sulfate10 mg40-60 mg Hydromorphone HCl (DILAUDID)1.3-2 mg mg Oxymorphone HCl (Numorphan)1-1.1 mg6.6 mg Levorphanol tartrate (Levo-Dromoran)2-2.3 mg4 mg Meperidine, pethidine HCl (Demerol) mg mg Methadone HCl (Dolophine)10 mg10-20 mg *
Opioids-Agonists Actions-block the release of neurotransmitters that are involved in the processing of pain Adverse effects- allergic reactions are rare-only absolute contraindication Respiratory depression may occur It is reversible with Narcan Constipation Sedation Urinary retention- Nausea and Vomiting-treat with antiemetics or changing to a different opioid Pruritis-antihistamines can be helpful
Pharmacological Therapies for Pain Management: MEPERIDINE CII Meperidine-used to relieve moderate to severe pain changes the way the body senses pain. Oral bioavailability is poor-50mg orally is equivalent to 650mg aspirin. Injectable Meperidine is painful
Opioid Agonist Treatment refers to the treatment of a narcotics addiction in humans via the administration of similar opioid drugs, agonists, and the resultant cross tolerance and physical dependence. Methadone (CII) is a full opioid agonist Buprenorphine (CIII) is a partial opioid agonist and has substantially less severe withdrawal effects versus methadone
Pharmacological Therapies for Pain Management Mixed agonist-antagonist Butorphanol (Stadol) CII Nalbuphine (Nubain) Rx Pentazocine (Talwin) CIV synthetically derived opioid agonist-antagonist analgesic of the phenanthrene series
Pharmacological Therapies for Pain Management Adjuvant Analgesics Tricyclic antidepressants Amitriptyline (Elavil) Nortriptyline (Pamelor) Desiprmine (Norpramin, Pertofrane) Action-Inhibition of norepinephrine and serotonin.
Pharmacological Therapies for Pain Management Adjuvant Analgesics Anticonvulsants Carbamazepine (Tegretol) Action-blocks pain through sensory neurons. Works well with shooting pains. Adverse effects-liver dysfunction and aplastic anemia Gabapentin (Neurontin) Action-unclear but believed to act on the gamma amino butyric acid system. Non-end of life pain conditions report using mg/day in divided doses Anecdotal reports suggest that pain may be relieved at lower doses
Pharmacological Therapies for Pain Management Adjuvant Analgesics Local Anesthetics Lidocaine- stabilizes the neuronal membrane by inhibiting the ionic fluxes used intravenously, spinally, or topically Bupivacaine (Marcaine) EMLA cream or Lidoderm
Pharmacological Therapies for Pain Management Adjuvant Analgesics Corticosteroids Dexamethasone (Decadron) Prednisolone (Prednisone) Action-inhibits prostaglandin synthesis and reduces edema surrounding tissues. Useful in treating neuropathic pain, bone pain, and visceral pain Standard doses vary-16-24mg/day or higher
ANXIOLYTICS used for the treatment of anxiety, & its related psychological and physical symptoms minor tranquilizers
Anxiolytics/Benzodiazepines Rx:CIII *Generally used on as needed basis* Alprazolam (Xanax) mg every 6 to 8 hours Clonazepam (Klonipin) mg every 12 hours **Long half-life** Clorazepapte (Tranxene) mg every 8 hours Lorazepam (Ativan)0.5-2mg every 6 to 8 hours **SE of class: ataxia, memory impairment, hypotension, falls, tremors, hallucinations Non narcotic alternative: Buspirone (Buspar) 5-15 mg tid
HYPERACTIVITY Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder generally characterized by the following symptoms: Inattention Distractibility Impulsivity Hyperactivity
HYPERSOMNIA excessive daytime sleepiness or prolonged night- time sleep
STIMULANTS Psychoactive drugs which induce temporary improvements in either mental or physical function or both Also known as Stimulants
Methylphenidate CII central nervous system stimulant used to treat attention deficit disorder (ADD) & attention deficit hyperactivity disorder (ADHD) also used in the treatment of a sleep disorder called narcolepsy an uncontrollable desire to sleep Brand Names: Concerta, Metadate, Methylin, Ritalin
Methylphenidate Dosage For children > 6 y/o: Methylphenidate should be started at 5 mg twice daily (before breakfast and lunch) For adults with narcolepsy, the total dosage of Methylphenidate per day is usually 20 mg to 30 mg (divided into two or three doses)
INSOMNIA trouble falling asleep or staying asleep through the night episodes may come and go (episodic), last up to 3 weeks (short-term), or be long-lasting (chronic)
Non Benzodiazepines cyclopyrrolones eszopiclone 1, 2, 3 mg tablets 2-3 mg hs 1 mg hs in elderly or debilitated; max 2 mg 1 mg hs in severe hepatic impairment; max 2 mg imidazopyridines zolpidem zolpidem (controlled release) 5, 10 mg tablets 6.25, 12.5 mg tablets 10 mg hs; max 10 mg 5 mg hs in elderly, debilitated, or hepatic impairment 12.5 mg hs 6.25 mg hs in elderly, debilitated, or hepatic impairment pyrazolopyrimidines zaleplon 5, 10 mg capsules10 mg hs; max 20 mg 5 mg hs in elderly, debilitated, mild to moderate hepatic impairment, or concomitant cimetidine
Benzodiazepines estazolam1, 2 mg tablets 1-2 mg hs 0.5 mg hs in elderly or debilitated temazepam 7.5, 15, 30 mg capsules mg hs 7.5 mg hs in elderly or debilitated triazolam0.125, 0.25 mg tablets 0.25 mg hs; max 0.5 mg mg hs in elderly or debilitated; max 0.25 mg flurazepam15, 30 mg capsules15-30 mg hs 15 mg hs in elderly or debilitated
WEIGHT LOSS All serious diet or weight loss pills When using diet pills, make them part of comprehensive weight-loss program that includes regular exercise and a healthy low-calorie diet.
BODY MASS INDEX (BMI), kg/m2 Height (feet, inches) Weight (pounds)
Diet suppressants may be indicated… For obese individuals who have attempted to lose weight through diet and exercise BMI of 30 and above with no obesity-related conditions BMI of 27 and above with obesity-related conditions, such as diabetes or high blood pressure.
BENEFITS OF DIET PILLS Over the short term, weight loss in obese individuals Some diet pills lower blood pressure, blood cholesterol, triglycerides (fats) and decrease insulin resistance (the body's inability to use blood sugar) over the short term Long-term studies are needed to determine if diet and weight loss pills can improve health
RISKS OF DIET PILLS Abuse of, or dependence on diet pills - Development of tolerance to diet pills
Health risks of diet agents Potential Complications: Hypertension Primary Pulmonary Hypertension (PPH) – a rare, frequently fatal disease of the lungs Valvular Heart Disease Addiction Contraindications: Advanced arteriosclerosis, cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to the sympathomimetic amines, glaucoma. Agitated states. Patients with a history of drug abuse. During or within 14 days following the administration of monoamine oxidase inhibitors (hypertensive crises may result).
WEIGHT MANAGEMENT AGENTS Two approved appetite suppressant diet pills that affect serotonin release and reuptake have been withdrawn from the market (fenfluramine, dexfenfluramine). Medications that affect catecholamine levels (such as phentermine, diethylpropion, and mazindol) may cause symptoms of sleeplessness, nervousness, and euphoria (feeling of well-being) BRAND NAMES (CIV) Adipex-P, Obenix, Oby-Trim
CONTRACTS Informs on rules of obtaining controlled substance prescriptions Prevent misunderstandings
Controlled Substance Contracts KEY ELEMENTS Patient name, Date Patient discloses all medications and past use of controlled substances Patient agrees to take medications as prescribed Patient agrees to drug testing Patient has been truthful in symptoms, past history, & current use of medications Patient signs Prescriber signs
Opiate Contract Pain Management Agreement The purpose of this agreement is to prevent misunderstandings about certain medications you will be taking for pain management. This is to help you and your doctor to comply with the law regarding controlled pharmaceuticals. _____ I understand that this Agreement is essential to the trust and confidence necessary in a prescriber/patient relationship and that my doctor undertakes to treat me based on this Agreement. _____ I understand that if I break this Agreement, my prescriber will stop prescribing these pain control medicines. _____ In this case, my prescriber will taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms. Also, a drug-dependence treatment program may be recommended. ______ I would also be amenable to seek psychiatric treatment, psychotherapy, and/or psychological treatment if my prescriber deems necessary. ______ I will communicate fully with my prescriber about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain.
______ I will not use any illegal controlled substances, including marijuana, cocaine, etc., nor will I misuse or self-prescribe/medicate with legal controlled substances. Use of alcohol will be limited to time when I am not driving, operating machinery and will be infrequent. ______ I will not share my medication with anyone. ______ I will not attempt to obtain any controlled medications, including opiod pain medications, controlled stimulants, or anti-anxiety medications from any other prescriber. ______ I will safeguard my pain medication from loss or theft. Lost or stolen medications will not be replaced. ______ I agree that refills of my prescriptions for pain medications will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends. I agree to use: ________________________________________________ Name of Pharmacy: _______________________Located:_____________ Telephone number: _____________ for filling my prescriptions for all of my pain medicine.
______ I authorize the prescriber and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medication. I authorize my prescriber to provide a copy of this Agreement to my pharmacy, primary care practitioner and local emergency room. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. ______ I agree that I will submit to a blood or urine test if requested by my prescriber to determine my compliance with my program of pain control medications. ______ I agree that I will use my medicine at a rate no greater that the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time. ______ I will bring unused pain medicine to every office visit. ______ I agree to follow these guidelines that have been fully explained to me.
All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me. This Agreement is entered into on this _____ day of ___________, 20__. Patient signature: ________________________________________________ __ Prescriber signature: __________________________________________________ Witnessed by: __________________________________________________
Substance Abuse: Medications Misuse or inappropriate use of prescription or over-the-counter medications Sedatives Hypnotics Narcotics Non-narcotic analgesics Diet aides Decongestants Medical marijuana
Substance Abuse: Street Drugs Younger addicts who have grown old Expanded drug experimentation from the 1960s Marijuana Opiates Cocaine Crack Heroin Other
Substance Abuse-Medications Signs Cognitive changes Falls Kidney or liver disease Increased morbidity and mortality Proactive Approach to Monitoring Evaluate prescription drug use every 1 to 3 months (minimum every 6 months)
Weaning from medications Start with usual dose & wean by 10% of dosing in 24 hour period every three half-lives of the medication Provide support & counseling 12-step program
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