2. Follow up visits should document analgesia effectiveness, reports of activities of daily living, medication side effects, compliance with the specified medication schedule, review of a Controlled Substance Monitoring Database and the patient’s affect. 3. Any patients on large doses of opioid medications should be referred to a Pain Management specialist. 4. Patients should be observed for any findings suggesting aberrant medication-taking behaviors. 5. Opioid medications should be discontinued when risks of continued treatment outweigh the benefits. These risks could include aberrant medication taking behavior, lack of efficacy, or side effect severity. Medications may require a taper to prevent withdrawal symptoms. 6. Any patient exhibiting signs of substance use disorder should be referred to an Addiction Specialist. 41 After treatment begins, adjust the dose and other components of therapy to the patient’s individual needs, utilizing non-opioid treatment modalities whenever possible. Items to evaluate and document include analgesia, daily activities, adverse effects, aberrant drug-related behaviors, cognition, function, and quality of life. 41 Throughout treatment, patients must be continually assessed for risks of overdose as respiratory depression leading to fatal or nonfatal overdose is a chief risk. Risk factors for overdose in people taking opioids medically or nonmedically include: 50,54-57 • Middle age • History of SUD • Comorbid mental and medical disorders • High opioid dose (>90 mg morphine equivalents, although risk is present at any dose) • Recent upward titration of opioids (within the first 2 weeks) • Recent opioid rotation • Methadone use • Benzodiazepine use • Antidepressant use • Unemployment • Use of non-prescribed illicit substances • Recent release from jail or prison • Recent release from substance treatment program • Sleep apnea • Heart or pulmonary complications (e.g., respiratory infections, asthma) • Pain intensity A query of the Tennessee Controlled Substances Monitoring Database (CSMD) should also take place before opioids are initiated or continued. 13,33,44 These importance checks of the patient’s past and present opioid prescriptions are done at initial assessment and during the monitoring phase. CSMD data can help to identify patients who have
had multiple practitioner episodes or potentially overlapping prescriptions that place them at risk of a misuse or drug interaction problem. The use of the CSMD is also aimed at stopping the spread of opioid misuse and diversion as a public health problem. If baseline UDT and CSMD checks indicate unauthorized prescriptions or there are other signs suggestive of opioid misuse, the results should be discussed with the patient and, if OUD or another substance-use issue is suspected, treatment should be offered and/or a specialist referral can be given. Using the Tennessee Controlled Substances Monitoring Database The CSMD contains prescription information from all dispensers of controlled substances in Tennessee and those dispensers who ship to a patient residing in Tennessee. This includes mail- order pharmacies and some Veteran’s Affairs pharmacies as well. The CSMD collects and maintains dispensing data regarding all Schedule II, III and IV, and Schedule V controlled substances. All data in the CSMD are reported as submitted to the data collection website by the dispenser. Therefore, if there are any questions about the data a practitioner should contact the dispenser identified within the report. The dispenser can, in turn, correct any errant information by coordinating with the state’s data collection vendor. Neither the data collection vendor nor the Department of Health can edit prescription information found in the CSMD. Registration The state of Tennessee requires all prescribers and dispensers of CS to register for access with the CSMD. Registration may be completed through the website: www.TNCSMD.com. By choosing the “register” link, the healthcare provider may enter information to validate their status to access the CSMD data. Registrants will be assigned a username and password once approved by the CSMD administration. 41 Additionally, two unlicensed physician extenders associated with the practice location may register with CSMD to retrieve information specifically on behalf of the registrants. Extenders may use the same website mentioned above to register for their account. The extenders are required to provide information about the registrant for whom they will access information, as well as their own self- identifying information. The supervisor will then be required to approve the extender once CSMD administrative staff have processed the request. And the supervisor does possess the ability to revoke the extender’s access. All use of the CSMD information is tracked and can be monitored by CSMD administration if indicated. 41 Patient Report The information contained in the CSMD patient report includes prescriber, dispenser as well as controlled substance information. Prescriptions filled by the individual will be listed in reverse chronologic order.
Additionally, information regarding estimated morphine equivalent doses will be generated. The individual accessing the CSMD must be cautioned to verify that they are choosing the correct patient, as many patients have similar names or date of birth. Choosing an incorrect patient could lead to incorporation of erroneous information into the patient report. 41. Prescriber Self-Lookup Prescribers may also perform self-lookup reports. These reports may indicate potential cases of prescription fraud such as stolen prescription pads or phoned-in prescriptions not authorized by the prescriber. It also provides a “snapshot” regarding the prescribers typical CS prescribing habits, and their patient population. 41 BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1 ON THE NEXT PAGE.
Depressants and Sedative-Hypnotics: Benzodiazepines and Barbiturates
The class of depressants includes many widely misused medications. Furthermore, from 2004 to 2019, benzodiazepines and sleep medications zolpidem, zaleplon, and zopiclone were (together with opioids) the most dispensed categories of CS in the United States (Figure 2). 4 Benzodiazepines (Schedule IV) are prescribed for short-term use as anxiolytics and for insomnia. Benzodiazepines include: 58 • alprazolam • chlordiazepoxide
• clonazepam • clorazepate • diazepam • estazolam • flurazepam • lorazepam • midazolam • oxazepam • temazepam • triazolam • quazepam
Benzodiazepines affect neurotransmitters in the brain, in particular, enhancing gamma-aminobutyric acid GABA with the effect of reducing anxiety. 58 Onset and duration of action vary among benzodiazpines. 58 appear to Prescriptions for benzodiazepines have increased along with involvement in overdose deaths. 50 An FDA boxed warning details the risks of prescribing opioids and benzodiazepines together, a combination of medications that has increased in recent years but which is associated with extreme sleepiness, respiratory depression, coma, and death. 20,33 The CDC recommends against combining these 2 medications whenever possible but allows for rare instances when the combination may be indicated (e.g., severe acute pain in the presence of long-term, stable, low-dose benzodiazepine therapy). 13
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