__________________________________________________ Responsible Prescribing of Controlled Substances
POLYPHARMACY AND MEDICATION RECONCILIATION
There are no universal recommendations for the proper disposal of unused opioids, although efforts toward patient education on what to do with unused or expired medica- tions have increased. According to the FDA, the best way to dispose of most types of unused or expired medications (both prescription and over-the-counter) is to immediately use a take-back option, such as a designated “take-back location” or by mailing medications back using a prepaid drug mail- back envelope. As of April 2025, the FDA began requiring OA REMS Program Companies to provide prepaid mail-back envelopes upon request to pharmacies and other dispensers of opioid analgesics to improve proper and equitable disposal of this class of drugs [40]. If these options are not available, it is recommended to consult the list of medications recommended for disposal by flushing down the toilet. For example, the FDA recommends that certain medications, including oxycodone/acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl patches (Duragesic Transdermal System), be flushed down the toilet instead of thrown in the trash. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so. If medication is not on the flush list, it is recommended to mix the medication with an undesirable substance (e.g., cat litter, dirt, used coffee grounds), and put into an impermeable, nondescript container (e.g., disposable container with a lid or a sealed bag) before throwing in trash at home. Any personal information should be obscured or destroyed [40; 41].
The term polypharmacy is often used but not well defined. There are varied definitions in medical literature, but in gen- eral, polypharmacy has been defined as a single patient taking more than 5 drugs every day, with excessive polypharmacy defined as the prescription of 10 or more daily medications. Polypharmacy may be used to describe excessive or unneces- sary medications, inappropriate prescribing, or excessive use, overuse, or duplication of medications. There has been a call to redefine polypharmacy beyond an arbitrary number of medications. In some cases of multimorbidity and chronic conditions (e.g., hypertension), the use of multiple medications may be the best practice according to clinical guidelines; this may be referred to as “appropriate polypharmacy” [24; 43]. However, even when the prescription of multiple medications is warranted, it raises the risks of drug interactions, compliance issues, and adverse effects. Generally, the term polypharmacy has a negative connotation and is associated with the co- prescribing of potentially inappropriate medications. Medication reconciliation is the process of creating and updat- ing a current medication list as compared with any previous lists. This should be conducted [44]: • On admission • During routine and acute visits by providers • After transitions of care • During significant change in condition • When the goals of care change • Before prescribing new medications • When discontinuing any as-needed or routine orders • When considering the risks, benefits, and burden of any prescription Attempts to reduce or discontinue medications should be done selectively, one medication at a time. Medications may have been initially prescribed many years previously for a chronic condition, and newer agents with improved side effect profiles may be available. In some patients, addiction and dependence issues may arise. Regular comprehensive assessments of the patient are crucial, with the appropriate and necessary refer- rals made to psychiatry, psychology, addiction specialists, pain management, and other specialists as necessary. Certain medications should not be abruptly stopped and should instead be slowly reduced with medical supervision. This includes benzodiazepines and opioids (due to risk of symptoms of drug withdrawal). As noted, co-prescribing opioids and CNS depressants (e.g., benzodiazepines) should be avoided, if pos- sible. Co-administration increases the risk of opioid toxicity, CNS depression, and death [44].
TAPERING AND DISCONTINUING OPIOID THERAPY
The decision to continue or end opioid prescribing should be based on a physician-patient discussion of the anticipated benefits and risks. An opioid should be discontinued with resolution of the pain condition, intolerable side effects, inadequate analgesia, lack of improvement in quality of life despite dose titration, deteriorating function, or significant aberrant medication use [1; 2]. Clinicians should provide physically dependent patients with a safely structured tapering protocol. Withdrawal is managed by the prescribing physician or referral to an addiction specialist. Patients should be reassured that opioid discontinuation is not the end of treatment; continuation of pain management will be undertaken with other modalities through direct care or referral [1; 2]. As a side note, cannabis use by chronic pain patients receiving opioid therapy has traditionally been viewed as a treatment agreement violation that is grounds for termination of opioid therapy. However, some now argue against cannabis use as a rationale for termination or substantial treatment and monitor- ing changes, especially considering the increasing legalization of medical use at the state level [42].
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