Physician Health Matters

Use Caution When Prescribing Controlled Substances

The inherent dangers of misusing controlled substances require prescribers to exercise care when prescribing them. This article will highlight some guidelines physicians can apply when prescribing controlled medications.

In general, controlled substances work well for diminishing anxiety, improving attention, or treating pain. However, misuse of these medications can lead to dependence and addiction for the patient and legal or disciplinary troubles for prescribing physicians. The problem is compounded by the fact that some controlled substances have significant “street value.”

To help mitigate misuse, physicians should always keep their prescription pads secure. It’s best not to print your DEA number on the prescription itself. Based on the symptoms being treated and how well you know the patient, carefully think through how much of a controlled substance it is prudent to prescribe and whether refills should be included. (Schedule II prescriptions cannot be refilled.)

New Patients
Always obtain a careful history from new patients. That process should include communicating with previous and current providers and family members when appropriate to determine whether the patient has abused prescription medications in the past, and whether there are multiple prescribers. In any case, cautiously consider writing a prescription for a controlled substance on a patient’s first visit. If you do, prescribe only the amount needed until the next visit, and ensure that the follow-up visit is scheduled in a timely manner.

Also, inform the patient about the purpose of the prescription and how and when to take it. If the patient has significant or chronic pain, consult with a pain-management expert or colleague who can assist you in determining appropriate prescribing. Urine screens can also help determine whether the patient is abusing other substances (i.e., positive test) or diverting your prescriptions (i.e., negative test).

Also consider whether adjunctive, non-pharmacological modalities would help the patient. Such modalities might include psychological or physical therapy to lessen the symptoms for which the medication is prescribed. At the follow-up visit, take an interim history and re-contact family members or other providers if appropriate to determine whether the patient has used the prescribed medication correctly. Signs of potential misuse include “doctor shopping” (use of multiple prescribers), taking medications with alcohol or illicit drugs, or using medications inappropriately (e.g., injecting oral formulations).

Established Patients
If the patient in question is one you’ve seen previously and the pain or symptoms continue, a consultation with a colleague, pain specialist, or mental health specialist might be indicated. If the medicine is prescribed in significant doses for an extended period of time, consider instituting a pain-management contract with the patient that outlines in detail how the medication should be used.

Physicians must also stay abreast of the situation “on the street.” A recent article described widespread abuse by suburban adolescents of Klonopin. Opiates, including Percoset and OxyContin, also have significant value on the street. Although physicians with special DEA licenses are prescribing the Schedule III medication buprenorphine for opiate-addicted patients, in general, prescribing controlled substances to substance-dependent patients is neither advised nor allowed, except for carefully considered pain management.

For some physicians the biggest challenge is saying “no” to patients who demand medication when it is ill advised or not indicated. Saying no respectfully and offering other assistance such as consultations with specialists often prove helpful to both patient and physician.

If your patient is a physician and you have identified significant mental, behavioral, or emotional problems and/or substance abuse issues, consider a confidential consultation with Physician Health Services.

For further information, contact Physician Health Services at (781) 434-7404 or www.physicianhealth.org. You can also visit the Massachusetts Board of Registration in Medicine’s website (www.massmedboard.org/regs/) for policies and guidelines on prescribing.

– Luis T. Sanchez, M.D., Director, Physician Health Services

– John R. Knight, M.D., Associate Director, Physician Health Services