The counseling most often used are behavioral treatments such as cognitive-behavioral therapy or contingency management which help change previous thinking patterns and behavior and teach coping strategies and avoidance of triggers to limit the future risk of relapse. There are no refills allowed on Schedule II medications or benzodiazepines, and no more than 5 refills allowed on Schedule III-V. The most substantial risks are that of potentially fatal neonatal withdrawal syndrome, lower birth weight, and premature birth, but animal studies have shown no evidence of teratogenicity. In 2007, Health Canada proposed a new framework to regulate prescriptive authority for controlled substances, titled New Classes of Practitioners Regulations (NCPR). What States Need to Know about PDMPs. Retrieved August 23, 2018, from, New York State Department of Health. If a substance abuse disorder is suspected, a referral to an addiction specialist is recommended. AANP Provider Number 080518. Loss of consciousness in this population is more commonly related to metabolic encephalopathy, infection, or brain metastases (Berger, 2013). Retrieved August 16, 2018, from https://www. Moderate pain can often be managed with weaker opioids such as codeine or tramadol, a synthetic analog of codeine with a low affinity for opioid receptors. 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. Topics range from acute pain management to thyroid emergencies and everything in between — all free for AANP members! (2018). Nevada Nurses. Physical dependence is defined as the body’s physical adaptation to the presence of the drug, whereby the drug is necessary for normal body functioning to occur, and withdrawal symptoms are seen when the drug is no longer present in the patient’s system. It is still unknown if it is excreted in breastmilk (Calás, 2016 and CoNYDoH, N.D.). 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. The informed consent puts down on paper what should be communicated directly to the patient during the initial visit, prior to prescribing. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration and contraindications. 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. Contrary to a widely shared misunderstanding, psychological dependence on pain medication rarely occurs in terminally ill patients. In this presentation, controlled substances and their schedules will be described. (2017, March). Journal of Pain Research, 11, 1–4. Concurrent use of benzodiazepines and opioid pain medications should be avoided due to the additive risks of these two groups of medications (NIDA, 2017). These risks can be minimized by using the lowest effective dose to achieve pain control, but the patient should be very well informed of all of these risks prior to issuing any opioid or controlled substance prescriptions. (2017, June). Retrieved August 17, 2018, from, Choi, Y., Mayer, T. G., Williams, M. J., & Gatchel, R. J. Each video is accompanied by a 5-item quiz. The SAMHSA website also provides a search engine for OTPs by state, or providers can reference the Office of Alcoholism and Substance Abuse Services website ( and utilize their provider and program search tool. But, the online continuing education market still seems to be lagging when it comes to offering such courses. It utilizes 12 adjectives describing pain and the patient is asked to rate each adjective from 0 to 10. Treatment with the same aforementioned behavioral therapies has been shown to be effective in patients recovering from CNS depressant or stimulant addiction., Berger, J. M., & Vadivelu, N. (2013). Special consideration should be when prescribing for older (>65) or pregnant patients. Acetaminophen can be used in pregnancy and while breastfeeding relatively safely. New York Codes, Rules and Regulations. Opioid Replacement Now Qualifying Condition for Medical Marijuana. Nurse Practitioners (NPs) in Ontario can prescribe controlled substances, if they have completed approved controlled substances education. It is the responsibility of the licensed prescriber, relying on expertise and knowledge of the patient, to determine dosages and the best treatment for each individual patient. The 2015 American Geriatric Society Beers Criteria (BC) of potentially inappropriate medication use in older adults publishes medications that should be avoided (Terrery & Nicoteri , 2016). Risk factors for controlled substance misuse include a personal or family history of alcohol or drug abuse, younger age, and a current psychiatric condition (SAMHSA, 2017). Medication-Assisted Treatment (MAT). Systemic corticosteroids do not have great evidence to support their effectiveness or use, and certainly have substantial adverse effects, especially in the diabetic patient (Qaseem, 2017). Nurse Practitioners (NPs) in Ontario can prescribe controlled substances, if they have completed approved controlled substances education. Tapering controlled substance to reduce the risk of withdrawal is appropriate in more severe or persistent cases of misuse. 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. Poppy seeds or the herb Papaveris fructus may cause positive morphine results. No prescriptions exceeding a 30-day supply of schedule II drugs is permitted, and additional prescriptions may not be issued for at least 23 days. Patients that repeatedly delay needed or planned surgeries and opt instead to treat with an otherwise correctable condition with medications should be monitored closely. How the results of a UDT will be interpreted, confirmed, and used, including its effects on continuation of treatment, should be explained to the patient prior to testing. Because they can induce euphoria, especially when taken in higher doses than prescribed or ingested via snorting or injection, these drugs are a high risk for abuse and addiction. Within the state of New York, naloxone can be accessed without a doctor’s 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.). The new regulatory framework was passed in November 2012; it gives nurse practitioners (NPs), midwives and podiatrists the authority t … When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. View Courses … (2018, January 17). In particular, ethical and fiscal considerations of prescribing will be considered.1. Non-pharmacological treatments such as heat, ice, massage, acupuncture, or spinal manipulation have low to moderate-quality evidence but negligible risk. New York State statutes and regulations should be modified to increase the availability of medically necessary analgesic medications, including opioids. (2017, October 03). Opioids are excreted in breastmilk and increase the risk for CNS and respiratory depression if taken while breastfeeding. All Rights Reserved. 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. Manufacturers of medication are studying and trialing various methods to make medications less vulnerable to abuse or misuse, called abuse-deterrent formulations (ADF). Retrieved August 23, 2018, from, Wang, Y., & Gorenstein, C. (2013). Tramadol is a schedule IV synthetic opioid commonly used to treat mild to moderate pain. In this presentation, the Advanced Nurse Practitioner will learn about State and Federal laws that apply to the authority relating to prescribing controlled substances. As of the writing of this article, there are currently over 3,000 authorized buprenorphine prescribers in the state of New York. The Centers for Disease Control and Prevention (CDC) estimates that opioids, both prescription and heroin, killed more than 42,000 people in the United States in 2016, a new record high (CDC, 2017). The education covers competencies related to safe, effective and ethical prescribing, and managing clients who are treated with controlled substances. Drug Safety and Availability - Medication Guides. (2017, October 23). Patients must meet certification qualifications with a listed qualifying diagnosis, such as severe chronic pain, opioid use disorder or as a replacement for opioids. To acknowledge safe methods for prescribing these agents and be able to apply them in the practice setting for CS across the schedules. The CS II course qualifies for three contact hours. Misuse of Prescription Drugs. Implications of Controlled Substance Prescribing4. Drug testing and detection methods are examined, along with common methods for adulterating drugs tests. 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. Patient visit notes should be clear, concise, and include all details of any dose adjustments or medication changes with associated justifications and equivalency calculations, effectiveness of treatments based on consistent pain assessments repeated at each visit, and any adverse effects and associated treatments required. The Journal for Nurse Practitioners,12(3), 154-160. doi:10.1016/j.nurpra.2015.10.025, Centers for Disease Control and Prevention. CDC has come under some scrutiny recently for its published opioid guidelines, being called too strongly anti-opioid. CNS depressants is a drug class that includes tranquilizers, sedatives, and hypnotics used to treat anxiety and sleep disorders by increasing the inhibitory activity of the neurotransmitter gamma-aminobutyric acid (GABA), inhibiting overall brain activity and producing a drowsy or calming effect. (2018, August 8). Retrieved August 14, 2018, from, National Institute on Drug Abuse. This course provides an overview of the safe and effective prescribing of controlled substances for advanced practice nurses and all nurses who are responsible for the safe and effective prescribing practices for controlled substances. Retrieved August 23, 2018, from, New York State Department of Health. Interventions, treatment and management of the patient who abuses drugs are discussed per agent. However, the low cost and ease or availability often make methadone an attractive option if used carefully by a skilled and experienced prescriber (Hudspeth, 2016). 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. Overdose Prevention Resources for Providers. (2018, July). AANP Resources by Therapeutic Area CE Courses Pharmacology Courses More than 90 CE courses are available with pharmacology credit. Controlled Substance II certification is an essential tool for health care practitioners. Pain can be broken down into two basic categories, acute (<3 months) and chronic (>3 months). It can be administered by first responders and emergency medical providers as well as bystanders. Complete a Board of Registered Nursing-Approved Controlled Substance II (CS II) Authority Course. From an administrative or regulatory perspective, misuse may be prevented with additional regulation. Spine Journal, 14(7), 1175-1182. doi:10.1016/j.spinee.2013.10.037, City of New York Dept of Health. (2015, July 21). Cases have been reported of severe neonatal respiratory depression, withdrawal, and flaccidity, but no teratogenicity has been observed, although animal studies showed issues with skeletal ossification at high doses. Zolpidem (Ambien) was category C in the old system due to lack of evidence. If opioids are to be used for acute pain, as recommended by the state of New York and the CDC, all prescription quantities should be limited to no more than seven days in duration, and most can and should be limited to three days (NYSDoH, 2017). Acute pain is oftentimes self-limiting, and if non-pharmacological treatment can be used effectively, it is recommended over medications. Mid-Level Practitioners Authorization by State. Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool. Most chronic pain patients have a comorbidity of depression, and are twice as likely to commit suicide as non-pain patients, so a consistent use of a depression screening tool is imperative to ensure adequate treatment of any comorbid psychiatric conditions that may be under or untreated (Buhrman, 2015). Commonly used tools for pain rating include the verbal rating scale (allow patient to choose from 3 to 6 adjectives to describe their pain ranging from no pain to severe pain), a numerical rating scale (allow patient to choose a number between 0 and 10), a picture scale (uses multiple facial expressions indicating increasing levels of discomfort) and a visual analog scale. Implications of Controlled Substance Prescribing. The cost of UDT should also be considered, discussed with the patient, and included in the provider agreement. Retrieved August 23, 2018, from, Fudin, J., Raouf, M., Wegrzyn, E. L., & Schatman, M. E. (2018). Oftentimes, there exists limited formal pain management education in most advanced nursing programs. By the end of this module, the reader should be able to: According to the 2016 National Survey on Drug Use and Health conducted by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration, 3.3 million people age 12 and older were current misusers of prescription pain medications, and an estimated 11.5 million people misused pain medications in the past year. Additional components of the history should include a family history, a social history, a drug and alcohol use history, and a depression screening. There is data supporting the prescribing or offering of naloxone, as potential overdose reversal agent, in high-risk patients exhibiting disturbing signs or symptoms of drug misuse that the prescriber deems aberrant. For anxiety treatment, there are medications available to treat anxiety that are not controlled substances and therefore less risky, such as buspirone (Buspar), which binds to serotonin and dopamine D2 receptors. Finally, an opioid abuse risk assessment tool, a urine drug test (UDT), and a review of your state’s prescription drug monitoring program (PDMP) should be completed before any controlled substance prescriptions are given. As with most medical conditions, treatment should begin with a comprehensive history and physical, including information and assessment specific to pain. Fitzgerald Health Education Associates, Inc.(FHEA) TNP members are eligible for a 15% discount when you enroll in Fitzgerald Health Education courses including certification review courses. Overview: This course complies with the Florida Board of Nursing requirement for 3 continuing education hours of controlled substance education in each biennial license renewal. Physicians should seek their patients' participation in decisions about withdrawing or withholding life-sustaining treatment early enough in the course of illness to give patients a meaningful opportunity to have their wishes and values respected. 50 MME/day is about 50 mg of hydrocodone or 33 mg of oxycodone per day. 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. Retrieved August 17, 2018, from, New York State Department of Health. Other risks of benzodiazepine use during pregnancy includes postnatal withdrawal symptoms, neonatal flaccidity, respiratory and feeding difficulties, and hypothermia. Opioid Overdose. We are now approaching this deadline, and it is nearly five years since federal regulations changed. The use of electronic databases to track controlled substance prescriptions, or PDMPs has become widespread (now available in 49 states, Washington DC, and Guam). Retrieved August 23, 2018, from, New York State Task Force on Life and the Law. In the presence of a new medical condition or problem requiring a controlled substance prescription, prescribers in New York may prescribe a 5-day supply of controlled substance medication to a patient without performing a physical exam only in the case of an emergency if the prescriber has a prior relationship with that patient (NYSDoH, N.D.). 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. In 2016, an estimated 1.8 million people aged 12 and older had a prescription pain medication use disorder. Certainly, these calculators can have their limitations and complicated exceptions (Fudin, 2018). This should be done in a balanced manner that acknowledges the importance of avoiding drug diversion. Goals should be agreed upon prior to treatment initiation (see PPA section above for further details on this) as well as a plan for discontinuation of treatment if benefits do not outweigh risks and there is no clinically meaningful improvement in pain and function. You know the health care field changes rapidly. Each quiz may be repeated a maximum of 3 times. The uses of these drugs will be discussed, particularly in pediatric and geriatric populations. Any letters sent to patients should be included in the patient’s electronic medical record (EMR), and any phone calls made or received should be carefully documented by office staff. If female, the risk of neonatal withdrawal syndrome if the patient were to become pregnant should also be included (Hudspeth, 2016). Retrieved August 17, 2018, from, National Institute on Drug Abuse. Controlled substances encompass a wide variety of medications from pain relievers to diet medications. In this presentation, the participant will learn about the latest trends in drugs of abuse including illicit drugs, alcohol, prescription drugs and designer drugs. 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. Clinical Aspects of Drugs of Abuse Across the Lifespan 9 contact hours of continuing education (which includes 9 hours of pharmacology), 9 contact hours of continuing education (which includes 9 hours of pharmacology), All NP state regulatory agencies (i.e., State Boards of Nursing) and national certifying bodies (e.g., ANCC, AANP, AACN, PNCB, and NCC). If at any point, risks or harm outweigh benefits, opioids should be tapered to a lower dose or gradually discontinued and other treatments optimized. As a benefit of membership, CANP offers a Controlled Substance II (CS II) Study Materials and Exam home study course at no charge to members. Extreme caution should be used when prescribing methadone, which is extremely complicated to dose, and tapentadol, which is a centrally acting analgesic with an added mechanism of norepinephrine reuptake inhibition in addition to its mu-receptor agonism (USFDA Center for Drug Evaluation and Research, 2018). My search for affordable controlled substance related CME led me to the following five resources. RNs and LPNs are required 20 contact hours every two years. Provider approved by the California Board of Registered Nursing, Provider Number CEP 15436, for the specified number of contact hours. Most PPAs specify that the patient is expected to use a single prescriber for all of their controlled substance needs, but some may simply limit the patient to one prescriber for pain medicine, but allow the patient to obtain prescriptions from other providers for other controlled substances such as benzodiazepines, testosterone, stimulants for ADHD/ADD, etc (Hudspeth, 2016). They may include family or group therapy and expand to also focus on interpersonal relationships and life skills. Other common schedule II opioids prescribed for moderate or severe pain include. Safe prescribing of controlled substances mandates that the Advanced Nurse Practitioner is aware of State and Federal laws regulating this process. Retrieved August 17, 2018, from, National Institute on Drug Abuse. Assessment of depression in medical patients: A systematic review of the utility of the Beck Depression Inventory-II. Document every time PDMP reports are reviewed and any concerning findings. While it is an effective opioid antagonist, it has no reversal effect on tramadol, alcohol, CNS depressants, or stimulants. Prescription Drug Monitoring Program (PDMP/PMP) Basics. The California Board of Nursing requires that advanced practice nurses complete a minimum 3-hour approved CE course and has a very specific set of education objectives that must be met in order for nurse practitioners to prescribe Schedule II controlled substances. In this presentation, rules for prescribing each of the controlled substances will be discussed. Safety concerns with the Centers for Disease Control opioid calculator. Controlled substances including opiates, sedatives, stimulants, antidiarrheals, weight loss drugs, and anabolic hormones will be discussed with respect to their use, prescribing rules, and safety. Learning Objectives—Introduction to Controlled Substances. Get up-to-date information to expand your practice with online advanced nursing courses from For those with CNS depressant use disorder, great care needs to be taken to avoid sudden cessation of these medications. Mild pain likely does not warrant an opioid, but non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen should be trialed first., Hudspeth, R. S. (2016). To understand the rules for controlled substances prescribing in each of the schedules. In fact, the state of New York specifies this requirement in its prescriptive rules and regulations (section 80.63). Advanced practice nurses have been professionally trained to effectively and safely prescribe medications to both treat and manage medical conditions as a component of their overall treatment plan and care. To understand State and federal laws that apply to the authority to prescribed Controlled Substances, REMS, and ethical and fiscal considerations of CS prescribing. Pursuant to Title 21, Code of Federal Regulations, Section 1300.01(b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Federal and state laws continue to evolve to support safe use of controlled substances, while prescriptive authority of various practitioners is expanding. Approved controlled substances education for Nurse Practitioners. To register for a training, click here. (2014). While naloxone does cross the placenta, no adverse effects were seen in animal studies and the benefits of overdose reversal are thought to outweigh the risks. If no drug take-back program is readily available, used or unwanted fentanyl patches and other medication can be flushed down the toilet if necessary. The Beck Depression Inventory (BDI), the 9-Item Patient Health Questionnaire Depression Module (PHQ-9) and the Profile of Mood States have been shown effective in the screening of chronic pain patients (Choi, 2014 and Wang, 2013). This course is now approved by the California Board of Registered Nursing for initial furnishing requirements, as well as continuing education. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. To discuss manners in which to decrease controlled substance abuse and diversion, including REMS, Dear prescriber letters and prescription drug monitoring programs. PubMed Clinical Q&A. Additional nonopioid medications, such as neuropathics gabapentin and pregabalin or antidepressants such as venlafaxine, duloxetine, or tricyclic antidepressants should also be considered. Retrieved Aug 21, 2018, from, Qaseem, A., Wilt, T. J., Mclean, R. M., & Forciea, M. A.
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