The consistent and diligent review of best practices and the most recent evidence in the field of pharmacology are necessary components to a safe and effective medical practice (Hudspeth, 2016). Finally, inappropriate prescribing and high-risk situations in which controlled substances are sometimes prescribed will be highlighted in an effort to ensure the APN uses these agents in the safest manner possible. (2017, August 29). An honest dialogue with the patient regarding risks, benefits, treatment goals, treatment alternatives, and expectations of both parties prior to prescribing can help prevent misuse of the potentially dangerous medications. (2018, January 17). The 2015 American Geriatric Society Beers Criteria: Implications for Nurse Practitioners. Psychological dependence occurs when the ingestion of a medication becomes associated with the alleviation of discomfort, such as pain, anxiety, depression, etc. This course complies with the Florida Board of Nursing requirement for 3.0 continuing education hours of controlled substance education in each biennial license renewal. Prescribers should consider this safety option in patients currently taking a high dose of opioids (>90 MME/day), chronic opioids (greater than three months), concurrent opioids and benzodiazepines, current ongoing treatment for drug use disorder, past history of opioid misuse or overdose, or immediate family members with a history of opioid misuse or overdose. Currently, according to the Drug Enforcement Agency (DEA), nurse practitioners, nurse midwives, and physician assistants are legally permitted to prescribe schedule II-V medications within the state of New York (DEA, 2018). (2016). Nevada Nurses. Ultimately, a patientâs risk should be considered amongst all of the other data collected in order to make the best decision regarding appropriate treatment moving forward. Pain Management and Dosing Guide. Prescribers should be aware of the common pitfall of assuming a well-liked or well-known patient is at lower risk for abuse/misuse. The goal of treatment is to correct the imbalance in brain circuits that mediate reward, decision-making, impulse control, learning, and other functions to restore the patient to a normal affective state. The cost of UDT should also be considered, discussed with the patient, and included in the provider agreement. Included in this talk is information on: An understanding of controlled substances is key to safe prescribing for the Advanced Nurse Practitioner. Loss of consciousness should not always be assumed to be directly caused by high doses of opioid painkillers in the dying patient if those doses have been stable or slowly increasing over time, especially in chronic cancer pain. Each video is accompanied by a 5-item quiz. What is the best screening test for depression in chronic spinal pain patients?. The Journal for Nurse Practitioners,12(3), 154-160. doi:10.1016/j.nurpra.2015.10.025, Centers for Disease Control and Prevention. The informed consent puts down on paper what should be communicated directly to the patient during the initial visit, prior to prescribing. (2017, June). Looking for Advanced Practice Nursing CEUs? Effective July 22, 2016, there exists a 7-day supply limit for any opioid prescriptions at an initial consultation or treatment for acute, Chorionic gonadotropin may be prescribed for up to 3 months, and anabolic steroids for up to 6 months, in the treatment of panic disorders, attention deficit disorder (ADD), chronic debilitating neurological conditions characterized as a movement disorder or exhibiting seizure, relief of pain in conditions known to be chronic or incurable, narcolepsy, hormone deficiency states in males, gynecological conditions or metastatic breast cancer, anemia, or angioedema. Manufacturer impurities have also shown hydrocodone amounts to be evident in oxycodone products. This course is now approved by the California Board of Registered Nursing for initial furnishing requirements, as well as continuing education. Other Opioid Prescribing Resources. Regarding the gastrointestinal risks of NSAIDs, celecoxib and nabumetone have been shown to be gastroprotective in the short term, and studies have shown that adding misoprostol, a proton pump inhibitor or H2 blocker is gastroprotective. Adverse reactions of opioid use include respiratory depression, drowsiness, mental confusion, nausea/vomiting, dizziness, headache, fatigue, pruritus, pinpoint pupils, urinary retention and constipation. Barbiturates, such as mephobarbital (Mebaral), phenobarbital (Luminal) and pentobarbital (Nembutal), are less commonly used medications for anxiety and sleep disorders due to their high risk of potential overdose, but are still used in seizure disorders and during surgical procedures. If pharmacological treatment is required, treatment should start with NSAIDs and/or skeletal muscle relaxants such as ibuprofen, naproxen, carisoprodol, and cyclobenzaprine (Qaseem, 2017). These include rapid increases in the amount of medications needed, frequent/unscheduled refill requests, repeated dramatic stories about prescriptions or medication being lost or stolen, multiple visits with multiple providers or pharmacies, resistance to nonopioid and nonpharmacological treatments, or frequent after-hours calls to the on-call prescriber or trips to the emergency department resulting in prescriptions. Tolerance to a medication is defined as a lack of expected and historic response to a given medication dosage, necessitating an increase in dose to achieve the same prior pain relief response. False positives can happen. Stimulants, such as methamphetamine, dextroamphetamine (Adderall and Dexedrine) and methylphenidate (Ritalin and Concerta) work by enhancing the effects of the neurotransmitters norepinephrine and dopamine in the brain. To identify general precautions associated with prescribing controlled substances. Within the state of New York, naloxone can be accessed without a doctorâs prescription, and sometimes with no out-of-pocket cost to the patient, via an authorized opioid overdose program or at a participating pharmacy via the voluntary standing order program (currently includes CVS, Duane Reade, Rite Aid and Walgreens) (NYSDoH, N.D.). In general, this group of medications should be used with great caution for short-term use only due to a very high risk of tolerance, dependence and addiction. Non-pharmacological treatments such as heat, ice, massage, acupuncture, or spinal manipulation have low to moderate-quality evidence but negligible risk. This should be done in a balanced manner that acknowledges the importance of avoiding drug diversion. Neither Barkley & Associates nor any contributing authors assume any responsibility for any injury and/or damage to persons or property arising from this publication. Approved controlled substances education for Nurse Practitioners. RNs and LPNs are required 20 contact hours every two years. Repeated misuse of stimulants has been linked to feelings of hostility, paranoia, and psychosis, and overdose can lead to hyperthermia, arrhythmias, cardiovascular arrest, or seizures. The provision of appropriate pain relief rarely poses a serious risk of respiratory depression. Any concerning or aberrant behavior should be carefully documented with as much detail as possible. It utilizes 12 adjectives describing pain and the patient is asked to rate each adjective from 0 to 10. Addiction is defined as a primary, chronic, neurologic, relapsing disease that is characterized by dependence along with a constant, focused need for something (for the purposes of this article, a medication) despite any cost and possible harmful consequences to the individual or others. It is unknown if methylphenidate is excreted in breastmilk, but amphetamines are (Hudspeth, 2016 and USFDA Center for Drug Evaluation and Research, 2018). Retrieved August 23, 2018, from https://www.health.ny.gov/regulations/medical_marijuana/practitioner/, New York State Department of Health. AANP Provider Number 080518. The treatment of cancer pain is extremely complex, and is usually best managed by oncologists, not advanced practice nurse prescribers. Dose adjustments may need to be made as early as every 2-3 days. Controlled Substance II certification is an essential tool for health care practitioners. In fact, the state of New York specifies this requirement in its prescriptive rules and regulations (section 80.63). To increase awareness of drug diversion and abuse, acknowledging the roles of State reporting systems and Prescription Drug Monitoring Programs. The cost for non-members is $300. For opioid use disorders and addiction, this combination is referred to as medication-assisted treatment (MAT). The uses of these drugs will be discussed, particularly in pediatric and geriatric populations. Drug Safety and Availability - Medication Guides. You can choose the acronym or your choice for a full and consistent pain assessment every time (OLDCART, SOCRATES, OPQRST, etc). However, St Louis County has developed its own PDMP, and other counties in the state are permitted to utilize their system, so currently 79% of the population of Missouri is covered by the St Louis County PDMP. (2018, July). Essentially, there is only one course that meets state requirements. The descriptor differential tool is the most reliable and consistent, but quite lengthy to administer. Learning Objectives—Introduction to Controlled Substances. Concerns within these populations continue to be overdose, respiratory depression, and potential loss of consciousness or hastening of end-of-life. Those goals should be collaborative. The lowest effective dose of immediate-release opioids should be used initially, avoiding ER or LA versions until a stable dose has been established. Medication options for opioid use disorders are listed, with individual details, below: There continues to be a discrepancy in the estimated number of people in the US with opioid use disorder and the capacity of available OTPs and trained prescribers of buprenorphine, so this highly effective treatment remains difficult to access for patients that desperately need help for their addiction. A naloxone prescription should also be considered during periods of transition from one opioid to another in case of accidental overdose. Variations and exceptions need to be made to account for variability in the pharmacologic properties of each medication and patient individuality when changing from one opioid to another, and extreme caution should be used to limit the risk for incidental overdose or under dose. 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