Diligence and Documentation: Managing the Risks of Prescribing Controlled Substances

Author: Michael C. Barnes

Policymakers, in their sense of urgency to stem the rate of overdose deaths ravaging their communities, may have been shortsighted in their approaches to reducing drug abuse in its entirety. For example, they focused on greater safety precautions only for opioid analgesics prescribed for pain rather than for other commonly abused controlled prescription medications (CPMs), including opioids indicated for treating addiction, benzodiazepines, sleep medications, and stimulants. In some cases, the abuse of these medications continues unabated. Additionally, while policymakers have focused heavily on limiting the supply of opioid pain relievers available for abuse, they may not have adequately accounted for demand for other substances of abuse. Analog fentanyl and heroin--widely available at relatively low prices, with variable and oftentimes dangerously high levels of potency--are increasingly contributing to the nation's overdose epidemic. To protect their patients from developing substance use disorders and inadvertently overdosing, and to shield themselves from criminal, civil, and administrative liability, prescribers of all controlled medications--not just opioid analgesics-- should be exceptionally diligent. This article sets forth principles and recommendations that a prescriber might consider in establishing policies and practices for the prescribing of all controlled medications.

CPMs, by definition, have a higher potential for abuse than noncontrolled prescription medications. Given that these medications carry these greater risks, practitioners who prescribe them have a higher duty of care and should take corresponding steps to prevent harm to their patients. Under federal and state controlled substances acts, the risks and related duties are categorized by controlled substance schedules (eg, Schedule II vs Schedule V), regardless of drug class (eg, opioid analgesic vs anticonvulsant). In other words, under federal and state controlled substances laws, the minimum steps a prescriber should take to prevent harm to the patient and the public parallels the cpm's schedule, irrespective of the prescribed substance's chemical type or intended use. To comply with these laws, for example, a prescriber should employ a minimal level of caution in prescribing a Schedule IV sleep medication equivalent to that used in prescribing a Schedule IV opioid pain reliever.

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