Best Practices for Prescribing Opioids and Recognizing Pain, Drug Diversion, and Substance Abuse

About this course

One of the single most difficult challenges for any prescriber is to distinguish between the legitimate prescription of controlled substances and the prescription potentially used for illegitimate purposes. To differentiate between the two, prescribers need to understand the signs, symptoms, and treatment of acute and chronic pain, as well as the signs and symptoms of patients using controlled substances for non-legitimate purposes. This learning topic provides an overview of pain, opioid use disorder, and current practices in prescribing controlled substances.

Learning objectives

• Define controlled substances and drug use disorder.
• Distinguish between drug misuse and drug use disorder.
• Explain the Controlled Substance Act, the various classifications of scheduled drugs, and drugs that are most likely to be misused.
• Describe drug seeking behaviors and possible treatment options.
• Discuss guidelines for safe prescribing of drugs.

Course outline

22 sections · finish in any order across devices

1. 1

   Introduction

   One of the single most difficult challenges for any prescriber is to distinguish between the legitimate prescription of controlled substances and the prescription potentially used for illegitimate purposes. To differentiate between the two, prescribers need to understand the signs, symptoms, and tre

   4 min

2. 2

   Definitions

   Addiction:

   4 min

3. 3

   Pain

   Pain is among the primary reasons that people receive federal and private disability payment support. Pain syndromes affect as much as 50% of the United States population at some point in their lifetime. For those over 21 years of age, approximately 10% have experienced pain for 3-12 months, and alm

   4 min

4. 4

   Pain Pathways

   Opioids bind to receptors in the central and peripheral nervous systems (primarily delta, kappa, and mu receptors), and produce therapeutic effects for pain, cough, and diarrhea. The action on these receptors produces intense euphoria. The euphoria causes some people to continue use drugs with the i

   4 min

5. 5

   Pain Modulation and Transmission of Pain

   Pain fibers enter the spinal canal and the spinal cord at the dorsal root ganglia and then synapse in the dorsal horn. Fibers cross over and go up the lateral columns to the thalamus, followed by the cerebral cortex.

   4 min

6. 6

   Psychologic Factors Causing Pain

   Psychogenic factors can modulate pain intensity. Emotion has a vital role in one’s perception of pain. Patients in chronic pain have a high degree of psychologic distress and often suffer from anxiety and depression. Patients with poorly explained pain may be incorrectly diagnosed with a psychiatric

   4 min

7. 7

   Controlled Substance Act

   All providers should be familiar with the guidelines and laws for each scheduled drug, including the purpose of the drug and the risk of use disorder. In the United States, controlled substances are under strict regulation by both federal and state laws which guide their manufacture and distribution

   4 min

8. 8

   Schedule I

   Schedule I drugs possess the highest potential for use disorder and misuse. They do not have any medical use and are illicit or “street” drugs. Examples of schedule I drugs include heroin, methylenedioxymethamphetamine (MDMA), methaqualone, lysergic acid diethylamide (LSD), marijuana (cannabis), and

   4 min

9. 9

   Schedule II

   Schedule II drugs have a reduced potential for use disorders than schedule I drugs, but the potential still exists for misuse and use disorders. They are also high risk for both physical and psychological dependence. Examples of schedule II drugs include dextroamphetamine, fentanyl, hydromorphone, m

   4 min

10. 10

    Schedule III

    Schedule III drugs have a lower potential for misuse than schedule I and II drugs. Drugs in schedule III category may cause physical dependence, but they are more likely to lead to psychological dependence. Schedule III drugs are often used for pain control, anesthesia, and appetite suppression. Exa

    4 min

11. 11

    Schedule IV

    Schedule IV drugs have an even lower potential for misuse than schedules I, II, or III. Examples of schedule IV drugs include alprazolam, carisoprodol, clonazepam, clorazepate, diazepam, lorazepam, midazolam, and temazepam. Drugs in this class may be used for anxiety and pain control as long as the

    4 min

12. 12

    Schedule V

    Schedule V drugs are the least likely of the controlled substances to be misused. Examples include cough medicines with codeine, antidiarrheal medications that contain atropine/diphenoxylate, pregabalin, and ezogabine. These drugs result in limited physical or psychological dependence. Despite their

    4 min

13. 13

    Drug Use Disorder, Abuse, and Misuse

    Use disorder of prescription drugs has become a common problem. Opioid use disorder and opioid addiction remain at epidemic levels in the US and worldwide. Three million US citizens and 16 million individuals worldwide have had or currently suffer from opioid use disorder.

    4 min

14. 14

    Diversion

    Some individuals use controlled substances in ways for which they were not originally intended. Rather than pain control, they may be used to stay awake, induce sleep, or get "high." Some prescription drugs will sell on the street for as much as $50 a tablet. Diversion is when a patient sells their

    4 min

15. 15

    Signs and Symptoms of Drug Seeking and Diversion

    A common method to evaluate whether a patient is taking, or misusing opioids is a random urine drug screen. Studies show that as high as 25% of patients prescribed opioids will randomly test negative. Patients discontinue opioid use due to remission of pain, side effects, lack of efficacy, and in so

    4 min

16. 16

    Pill Shopping

    A common practice among those that deliberately misuse controlled substances is to seek out multiple sources of drugs. They do this by seeing different health care providers, and often present with a different list of complaints that are fictitious and different for each provider. The patient may be

    4 min

17. 17

    Assessing for Opioid Use Disorder

    The history and physical examination in patients with opioid use disorder varies depending on the duration and intensity of use. Patients who sporadically misuse small doses of opioids may have a completely normal physical exam and no clear assessment findings. Patients with chronic oral opioid use

    4 min

18. 18

    Evaluation of Pain

    The clinicians must have a complete understanding of the patient’s primary disease and any issues in regard to the evaluation of proper use, potential side effects, and effectiveness of opioid use for chronic pain. Providers who suspect opioid use disorder should begin with a detailed history and ph

    4 min

19. 19

    Treatment of Pain

    Due to the risks of dependency with opioid use, the opioid prescription should include a treatment agreement or written informed consent. Treatment agreements should include notification of the following risks:

    4 min

20. 20

    Conclusion

    A common concern of patients is how effectively we treat their pain. The provider must work collaboratively with the patient to assess and treat the pain appropriately and avoid opioid use disorder. The therapy should always be started on the lowest dose possible, and then the dose and frequency can

    4 min

21. 21

    Prescribing Opioids Posttest

    The pain assessment is known as the fifth vital sign.

    4 min

22. 22

    Prescribing Opioids Posttest Answers

    The pain assessment is known as the fifth vital sign.

    5 min

This course satisfies

Requirement summaries come from our state requirement records. Always confirm details with your board before you renew.

References and resources

• Clinton, H. A., Hunter, A. A., Logan, S. B., & Lapidus, G. D. (2019). Evaluating opioid overdose using the national violent death reporting system, 2016. Drug and Alcohol Dependence, 194, 371-376. https://doi.org/10.1016/j.drugalcdep.2018.11.002
• Copenhaver, D. J., Karvelas, N. B., & Fishman, S. M. (2017). Risk management for opioid prescribing in the treatment of patients with pain from cancer or terminal illness. Anesthesia & Analgesia, 125(5), 1610-1615. https://doi.org/10.1213/ane.0000000000002463
• D'Aunno, T., Park, S. (., & Pollack, H. A. (2019). Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011–2017. Journal of Substance Abuse Treatment, 96, 18-22. https://doi.org/10.1016/j.jsat.2018.10.006
• Gomes, T., Khuu, W., Craiovan, D., Martins, D., Hunt, J., Lee, K., Tadrous, M., Mamdani, M. M., Paterson, J. M., & Juurlink, D. N. (2018). Comparing the contribution of prescribed opioids to opioid-related hospitalizations across Canada: A multi-jurisdictional cross-sectional study. Drug and Alcohol Dependence, 191, 86-90. https://doi.org/10.1016/j.drugalcdep.2018.06.028
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• Kaldy, J. (2016). Controlled substances add new layer to E-prescribing. The Consultant Pharmacist, 31(4), 200-206. https://doi.org/10.4140/tcp.n.2016.200
• Manchikanti, L. (2017). Responsible, safe, and effective prescription of Opioids for chronic non-cancer pain: American Society of interventional pain Physicians(ASIPP) guidelines. Pain Physician, 2(20;2), s3-s92. https://doi.org/10.36076/ppj.2017.s92
• Rigg, K. K., March, S. J., & Inciardi, J. A. (2010). Prescription drug abuse & diversion: Role of the pain clinic. Journal of Drug Issues, 40(3), 681-701. https://doi.org/10.1177/002204261004000307
• Rose, A. J., McBain, R., Schuler, M. S., LaRochelle, M. R., Ganz, D. A., Kilambi, V., Stein, B. D., Bernson, D., Chui, K. K., Land, T., Walley, A. Y., & Stopka, T. J. (2018). Effect of age on opioid prescribing, overdose, and mortality in Massachusetts, 2011 to 2015. Journal of the American Geriatrics Society, 67(1), 128-132. https://doi.org/10.1111/jgs.15659
• Tenney, L., McKenzie, L. M., Matus, B., Mueller, K., & Newman, L. S. (2018). Effect of an opioid management program for Colorado workers’ compensation providers on adherence to treatment guidelines for chronic pain. American Journal of Industrial Medicine, 62(1), 21-29. https://doi.org/10.1002/ajim.22920
• Thomas, C. P., Ritter, G. A., Harris, A. H., Garnick, D. W., Freedman, K. I., & Herbert, B. (2018). Applying American society of addiction medicine performance measures in commercial health insurance and services data. Journal of Addiction Medicine, 12(4), 287-294. https://doi.org/10.1097/adm.0000000000000408
• Urch, C. E. (2010). Pathophysiology of neuropathic pain. Neuropathic Pain, 9-16. https://doi.org/10.1093/med/9780199563678.003.0002

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