COLORADO GUIDELINES OF PROFESSIONAL PRACTICE FOR CONTROLLED SUBSTANCES

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COLORADO GUIDELINES OF
PROFESSIONAL PRACTICE FOR
CONTROLLED SUBSTANCES













HEALTH CARE PROFESSIONALS
WHO PRESCRIBE, DISPENSE, AND
ADMINIS
TER

The Colorado Prescription Drug Abuse Task Force was organized in 1984 to prevent and
eliminate presc
ription drug abuse in Colorado. This non
-
profit corporation is a
consortium of private and public agencies including the Colorado Medical Society and
other medical societies, the Colorado Department of Human Services, the Colorado
Nurses
Association
, the C
olorado Veterinary Medical Association, the Colorado Hospital
Association
, the U.S. Drug Enforcement Administration and many other law enforcement
agencies, and the state regulatory boards for professional practice.


Goals of the Task Force are to: 1) deve
lop and distribution guidelines for health
professionals who administer and prescribe controlled substances, 2) implement
professional education programs, 3) improve coordination among private and public
agencies concerned about prescription drug abuse, 4)

monitor prescription drug abuse in
the state, and 5) evaluate public policy related to controlled substances.









This project was made possible by a grant from The
Alcohol and Drug Abuse Division of The Colorado
Department of Human Services.




Appre
ciation is extended to the U.S. Drug Enforcement
Administration.




The Colorado Prescription Drug Abuse Task Force
sincerely acknowledges the efforts of the Professional
Standards Committee for their dedication to the quality and
usefulness of these guide
lines.




The Colorado Prescription Drug Abuse Task Force
appreciates the efforts of the Missouri Task Force on the
Misuse,
Abuse,

and Diversion of Prescription Drugs. Their
earlier manual served as a model for this publication.

i

COLORADO GUIDELINES OF
PRO
FESSIONAL

PRACTICE FOR
CONTROLLED SUBSTANCES




HEALTH CARE PROFESSIONALS

WHO
PRESCRIBE, DISPENSE, AND

ADMINISTER




Prepared by the Professional Standards Committee

Colorado Prescription Drug Abuse Task Force




Committee Co
-
Chairpersons:

Shirley J. Terry
, M.S., R.N., CAC III, NCAC II

James Woodard, R.N., C.F.N.C.




Committee Members:

Scott Collier, DEA

James Duke, M.D.

Rita Morrill, R.Ph.

Donna Heath, B.S.N., R.N.

Charles D. Sintek, R.Ph., M.S., BCPS



Colorado Prescription Drug Abuser Task Force

Directo
r:

Jody Gingery, M.Ed, R.N.

(1984


2006)





With special acknowledgement to past Members:

Valdis Kalnins, R.Ph.

Jody Gingery, M.Ed., R.N.



Denver, Colorado







Decemb
er
1999

Third Edition

ii

PREFACE


A major goal of the Colorado Prescription Drug Abuse
Task Force is to develop guidelines which
reflect consensus about what constitutes responsible prescribing and administration of controlled
substances easily abused or misused by the patient or
the professional
. The Professional
Standards Committee was gi
ven responsibility for determining guidelines for health care
professionals who prescribe, dispense or administer controlled substances. Committee
membership is comprised
of

representatives from health care professionals and various agencies
which regulat
e health professionals.


These guidelines were reviewed by the Colorado Board of Medical Examiners, the Colorado
Board of Nursing, the Colorado Nurse Health Program of the Board of Nursing, the Colorado
Board of Pharmacy, and the Colorado Board of Dentistr
y, but they are not binding as rules or
regulations. These guidelines are meant to serve as an aid to the exercise of professional
judgment

and responsibility. They have been designed as a prevention tool. Individual patient
circumstances may support mo
dification
o
r consultation with specialists in the field. Providers
should also consult manufacturer’s prescribing information for drugs with which they are not
familiar.


Special thanks for

review and editing of the final draft goes to the following prof
essionals:

Section A:

Ben Rich, J.D., Ph.D.

Section B:

Regina Fin
k
, Ph.D., R.N.

Michael P. Ernest, M.D.

Ben Rich, J.D., Ph.D.

Ernest E. Moore, M.D.

Scott J. Hompland, D.O.

Charles E. Lee, D.D.S.

Section C:

Richard Steig, M.D.

Thomas Morgan, M.D.

Nancy Hestor, Ph.D., R.N.

Ben Rich, J.D., P
h.D.

Scott J. Hompland, D.O.

Ernest E. Moore, M.D.

Section D:

Stephen L. Dilts,

P
h.D.

Ben Rich, J.D., Ph.D.

Scott J. Hompland, D.O.

Ernest E. Moore, M.D.

Donna Lindsey, R.N., C.A.R.N., CAC III, C.E.A.P.

Section E:

Jon Bell, M.D.

Ben Rich, J.D., Ph.D.

Scott J. Hompland, D.O.

Ern
est E. Moore, M.D.

Section F:

Ben Rich, J.D., Ph.D.

The Ad Hoc Task Force on Intractable Pain in Nursing Home Residents of the Health
Fac
ilities Section of the Colorado

D
epartment of Public Health and Environment.

Section G:

This section was developed by the Ad Hoc Task Force o
n Intractable Pain in Nursi
ng
Home Residents of the Health
Facilities Section of the Colorado Department of Public
Health and Environment.


A very special thanks goes to James Duke, M.D.
,

Anesthesiologist, Denver Health Medical Center, for his
valuable con
tribution to the scripting of Section B and to Ernest E. Moore, M.D., FACS, Chief Dept. of
Surgery,
Denver

Health Medical Center, Prof. & Vice Chair of Surgery, UCHSC, for Tables B & C
included in Section B.
iii

TABLE OF CONTENTS


SECTION A

................................
................................
................................
........................

1

Responsibilities

................................
................................
................................
...............

1

Controlled Substances and the Law

................................
................................
................

2

Federal Schedules of Controlled Substances

................................
................................
..

2

Registration Information

................................
................................
................................
.

3

How to Issue a Legal Prescription

................................
................................
..................

3

Emergency Prescribing of Schedule II Controlled Substances

................................
.......

4

Recommended Prescribing Procedures

................................
................................
...........

5

Unaccepta
ble Prescribing Procedures

................................
................................
.............

7

Office Procedures
................................
................................
................................
............

9

The Four D’s

................................
................................
................................
.................

10

Clues for Screening Drug Abusers

................................
................................
...............

10

Acceptable and Unacceptable Indicat
ions for Prescribing Controlled Substances

......

12

For More Information

................................
................................
................................
...

14


SECTION B

................................
................................
................................
......................

15

Management of Acute/Trauma Pain

................................
................................
.............

15


SECTION C

................................
................................
................................
......................

30

Management of Chronic Pain

................................
................................
.......................

30


SECTION D

................................
................................
................................
......................

34

Pain Management for the Recovering or Substance Abusing Patient

..........................

34


SECTION E

................................
................................
................................
......................

43

Prescribing for the Treatment of Anxiety and Insomnia

................................
..............

43


SECTION F

................................
................................
................................
......................

45

Prescribing for the Elderly

................................
................................
............................

45


SECTION G

................................
................................
................................
......................

49

Mana
gement of Pain in Nursing Home Residents

................................
........................

49


APPENDIX A

................................
................................
................................
...................

54

Colorado Board of Medical Examiners Guidelines for Prescribing Controlled
Substances for Intractable Pain

................................
................................
.....................

54


APPENDIX B

................................
................................
................................
...................

58

Colorado Board of Medical Examiners Rule on the Prescribing of Schedule II
Stimulant Drugs

................................
................................
................................
............

58

1

SECTION A

RESPONSIBILITIES


The abuse of prescription drugs, especially controlled
substances, is a serious social and
health problem in Colorado and in the United States. As a health
care

professional, you
share responsibility for solving the prescription drug abuse and diversion problem.



Your social responsibility is to uphold the law
and help
protect society

from drug
abuse.




Your professional responsibility, which is also stated in the 1996 Colorado Board of
Medical Examiners Guidelines for Prescribing Controlled Substances for Intractable
Pain (see Appendix A)
i
s as follows: t
he Pres
criber has a legal and ethical
responsibility to prescribe controlled substances appropriately and to provide patients
with state
-
of
-
the
-
art pain management or to promptly refer them to other
professionals who can, while safeguarding against drug abuse (se
e Appendices A &
B).




Your personal responsibility is to protect your practice from becoming an easy target
for drug diversions, which could result in legal actions against you
and damage your
professional esteem.


The purpose of this guide
is
to help you
meet these responsibilities by providing a clear
and concise reference for the appropriate prescribing of controlled substances which have
a demonstrated potential for inappropriate use and dependence formation.


It is recognized that occasional clinical s
ituations may require therapeutic approaches that
do not fit exactly into the guidelines. Use of controlled substances in exception to these
guidelines may be considered after:



Careful medica
l and/or psychiatric evaluation
.



Co
nsultation for a second opini
on
.



Consideration of the use of an inf
ormed consent with your patient
.



Thorou
gh documentation of indications
.



Documented unsuccessful trials with alter
native noncontrolled substances
.


Keep in mind that this guide provides only a summary of key points. Fo
r answers to
specific questions, consult the appropriate law or agency. Sources for additional
infor
mation are listed on page
14
.

2

CONTROLLED SUBSTANCE
S AND THE LAW


A controlled substance is a drug or drug product that comes und
er the
jurisdiction

of the
F
ederal Controlled Substances
A
ct. This Act is administered by the Drug Enforcement
Administration (DEA) and specifies five different groups of drugs called schedules. The
five schedules are described below. Practitioners must

be aware of what drugs the
different schedules contain because prescribing guidelines and record keeping
requirements vary by schedule.


The Colorado Controlled Substances Act, administered by the Alcohol and Drug Abuse
D
ivision of the Colorado Department

of Human Services and the Board of Pharmacy of
the Colorado Department of Regulatory Agencies, closely parallels the federal law. In
instances where there is a difference, the more stringent law prevails.


Violations of the Federal Controlled Substances
Act may result in civil sanctions (civil
fine), criminal sanctions or action against a license. The diversion of controlled
substances may result in criminal investigation by local,
state,

or federal law enforcement
agencies. In Colorado, a memorandum of

understanding for interagency coordination
and collaboration exists among the Colorado Department of Human Services, Colorado
Department of Public Safety, Division of Registration in the Department of Regulatory
Agencies, U.S. Drug Enforcement Administrat
ion and District Attorneys in the State of
Colorado.


FEDERAL SCHEDULES OF

CONTROLLED SUBSTANCE
S


The drugs and drug products under the jurisdiction of the
Controlled

Substances Act are
divided into five schedules. All the schedules are subject to change.

Drugs may change
schedules based on evolving data related to their abuse potential. For a complete listing
of all the controlled drugs, obtain a copy of the Code of Federal Regulations. The
following are exa
mples of controlled substances.
1


Schedule I:

Drugs in this schedule have no accepted medical use in treatment in the
United States and have a high abuse potential. Examples include: heroin, LSD and
peyote.


Schedule II:
Drugs in this
s
chedule have accepted medical uses and high abuse

potential
wit
h severe psychological and physical dependence.
Some examples of Schedule II
narcotic controlled substances

are: codeine, hydromorphone (Dilaudid), meperidine
(Demerol), methadone (Dolophine), morphine and oxycodone (Percocet, Percodan,
Tylox).
Examples
of
stimulants

in Schedule II are: dextroamphetamine (Dexedrine),




1

Examples of trademark products appear in parentheses. The same applies to similar drug products of all other
pharmaceutical manufacturers within each generic drug classification.

3

methamphetamine (Desoxyn) and methylphenidate (Ritalin). Cocaine is also a Schedule
II stimulant. An example of a schedule
depressant

is secobarbital (Seconal).

Schedule III:

Drugs i
n this

Schedule have accepted medical uses and an abuse potential
less than those in Schedules

I and II. Combination products containing limited quantities
of certain narcotic drugs, such as codeine (Tylenol with Codeine, Fiorinal with Codeine),
hydrocodone (Tu
ssionex) and opium (paregoric) are in Schedule III.
Anabolic steroids

are a new category in Schedule III and include: methyltestosterone (Android),
oxandroline (Oxandrin), stanozlol (Winstrol), nandroline (Durabolin)
a
nd testosterone
(Delatestryl).


Sched
ule IV:

Drugs in this Schedule have accepted medical uses and abuse potential
less than
those

listed in Schedule III.
Depressants

in this Schedule include the
benzodiazepines, such as alprazolam (
X
anax), triazolam Z (Halcion), diazepam (Valium),
lorezepa
m (Ativan) and clorazepate (Tranxene).
Stimulants

include diethylpropion
(Tannate) and
phentermine (
I
onamin, Fastin).
Analgesics

include

propoxyphene
(Darvon) and pentazocine (Talwin Nx).
Antitussives

in Schedule IV include codeine
(Robitussin AC, Phene
rgan with Codeine).


Schedule V:

Drugs in this Schedule have an accepted medical use and an abuse potential
less than those listed in Schedule IV.
This schedule consists

primarily of preparations
containing quantities of certain narcotic drugs generally f
or antidiarrheal or antitussive
purposes.


REGISTRATION INFORMA
TION


Practitioners who prescribe,
administer,

or dispense controlled substances must register
with DEA. The registration is valid for three years, and the certificate of registration
must be
kept available for inspection at the registered location.


If a practitioner prescribes, administers or dispenses controlled substances at more than
one office, the practitioner must register each office with the DEA. Any change of
practice location must
be reported to the DEA.


HOW TO ISSUE A LEGAL

PRESCRIPTION


Prescription orders for controlled substances must be dated and signed on the day issued.
A prescription must include the following information:



Name and address of the patient (street and cit
y)



Name,
address,

and DEA registration number of the prac
titio
ner



Signature of the practi
ti
oner



Name
and quantity of drug prescribed



Directions for use

4

EMERGENCY PRESCR
IBING OF SCHEDULE II

CONTROLLED
SUBSTANCES


Adapted from DEA Regulations


In the case of a
bona fide emergency situation (see definition below), a prescribing
practitioner may give verbal authorization to a pharmacist to dispense a Schedule II
controlled substance provided that:

1.

The quantity prescribed and dispensed is limited to the amount adeq
uate to treat the
patient during the emergency period (24
-
72 hours).


2.

Prescribing or dispensing beyond the emergency period must be pursuant to a written
prescription order.


3.

The prescription order shall be immediately reduced to writing by the pharmacist
and
shall contain all information, except for the prescribing practitioner’s signature.


4.

If the prescribing practitioner is not known to the pharmacist, the pharmacist must
make a reasonable effort to determine that the oral authorization came from a
pract
itioner by verifying the practitioner’s telephone number with that listed in the
directory and/or by making other good faith efforts to ensure proper identity.


5.

Within 7 days after authorizing an emergency oral prescription order, the prescribing
practitio
ner must cause a written
, signed prescription order for emergency quantity
prescribed to be delivered to the dispensing pharmacist. The prescription order shall
have written on
its

face “Authorization for Emergency Dispensing.” The written
prescription o
rder may be delivered in person or by mail, but if delivered by mail it
must be postmarked within the 7 day period. (Title 21, Code of Federal Regulations,
Section 1306.11 (d))
However, Colorado Revised Statute 18
-
18
-
414(2)(b)
currently allows only 72 hou
rs for the written prescription order to be delivered.
On receipt, the dispensing pharmacist shall attach this prescription order to the oral
emergency prescription order wh
ich

had earlier been reduced to writing. The
pharmacist shall notify the nearest
office of DEA and the Colorado Board of
Pharmacy if the prescribing practitioner fails to deliver a written prescription order.
Failure of the pharmacist to do so shall void the authority conferred by the subsection
to dispense without a written prescript
ion order of a prescribing practitioner.


Definition
:

For the purpose of authorizing an oral prescription order of a controlled
substance listed in Schedule II of the Controlled Substances Act, the term “emergency
situation” means those situations in whic
h the prescribing practitioner determines that:



Immediate administration of the controlled substance is necessary for the proper
medical trea
tment of the intended user




No appropriate alternative treatment is available, including administration of a drug
w
hich is not a controlled substance un
der Schedule II of the Act

5



It is n
ot

reasonabl
y

possible for the prescribing practitioner to provide a written
prescription order to be presented to the person dispensing the substance prior to
dispensing.


When prescri
bing narcotic analgesics for pain, it is recommended that any deviation from
Table A, B, or

C in Section B (see pages

21
-
29
)

be thoroughly documented in the patient
record.

RECOMMENDED PRESCRIB
ING PROCEDURES


Adherence to state and federal

regulations goes

a long way in protecting your practice
from becoming a source of drug diversion and prescription drug abuse, but it should not
impair or undermine your professional responsibility to provide your patients with
prompt and effective pain relief. You can al
so protect your practice by
safeguarding

blank prescription pads, prescribing controlled substances judiciously and being on the
lookout for patient scams.


Forgery is a major cause of drug diversion. Prescriptions are forged on prescription
blanks stolen

from practitioners’ offices, hospitals and
clin
ics. Whole pads or single
sheets may be stolen. Forgers also alter legitimate prescriptions by changing the refill
instructions or quantity to be disbursed or by erasing the name of the drug prescribed and
replacing i
t

with a controlled substance.


Specific suggestions for preventing diversion and abuse of
controlled substances:



Perform and document a thorough diagnostic evaluation of the patient to include an
assessment for alcohol or drug depe
ndency. (See

Section D, page 36

for sample
screening checklist.)




Prescription pads are extremely valuable and should be treated as a wallet,
purse,

or
checkbook. Do not leave pads in unattended examining rooms, office areas or
anywhere they can be easily picked up.




Any pads used for controlled substances should be secured and used only as needed.




Have prescription blanks numbered consecutively when printed so that you can tell if
some sheets are missing.




Stock only a minimum number of pads. Keep them in your pers
onal
possession when
using them. When not in use, store surplus stock in a secured drawer or cabinet
where they cannot be easily stolen.





Report any prescription pad theft to the local police, the local pharmacy network and
the State Board of Pharmacy.


6



Write complete prescriptions with signature and date of the day of issue. Include the
full name and address of the patient, and your name
,

address, phone number and DEA
registration number.




Consider writing prescriptions only on your own personalized bla
nks.




If you use hospital blanks, be certain to fill out completely and to include all
appropriate information. Make sure your name is
legible

(print) and include your
DEA number.




Do not use plain paper for the purpose of writing a prescription.




Do not
preprint your DEA registration number on your personalized blanks. Have a
line present on the blank onto which your DEA number can be written as needed.




Indicate the number of units and strength to be dispensed by writing the Arabic or
Roman numeral and
also spell out the number of units, e.g., “10


ten”.




Indicate the number or refills for the prescription. If the acceptable number is
zero
,
write zero (0) in the appropriate blank.




If there are special considerations for the use of the prescription med
ication, be sure
to indicate this under special instructions.




Write prescriptions in ink or indelible pencil to prevent changes.




Never sign prescription blanks in advance.




Do not use blanks that are preprinted with the name of a proprietary controlled
p
reparation.




Write only one controlled substance on a single blank; pharmacist must file
prescriptions for Schedule II drugs separately.




Do not use your prescription blanks for writing notes or memos that can be erased
and the blanks used again.




In rare
instances when it may be necessary to write a prescription for a pati
e
n
t and
pick up the filled prescription for delivery,
obtain a receipt

from the patient or
immediate family and keep it on the patient’s clinical file for documentation should
the need ar
ise.




Do not use “p.r.n.” or “as directed” alone when writing prescriptions for controlled
substances. Always specify directions for administration.


7



Patiently, personally and promptly respond to all calls from pharmacists to verify
prescriptions for cont
rolled substances. A corresponding responsibility rests with the
pharmacist who dispenses the prescription order.


UNA
CCEPTABLE PRESCRIBIN
G PROCEDURES


Federal regulations (Title 21, Code of Federal Regulations (CFR) 1300 to end) clearly
specify that:



Pra
ctitioners may not issue a prescription to obtain controlled substances for
dispensing to patients; instead, practitioners must use DEA form 222 to obtain
Schedule II controlled substances for their office use. If common stocks are used, one
practitioner
must accept responsibility.




Practitioners may not issue prescriptions to dispense narcotic drugs for detoxification
or maintenance treatment of a person who is dependent on narcotic drugs unless
separately registered with the DEA, FDA and the Colorado Dep
artment of Health as a
narcotic treatment program. However, a practitioner can administer (but not
prescribe) narcotic drugs to a patient daily for up to three days while arrangements are
being made for referral to an existing narcotic treatment program.

(Title 21, Code of
Federal Regulations (
CFR
) 1306:07
[c])
.




Practitioners may not telephone a prescription for a Schedule
II controlled

substance.
See Page 4 for Procedures for Emergency Prescribing of Schedule II Controlled
Substances.


Colorado h
as ad
ditional laws that further

delineate unacceptable prescribing procedures
(Colorado Revised Statutes (C.R.S.) 12
-
36
-
117):



Prescribing,
distributing,

or giving Schedule II controlled substances to a family
member or to oneself except on an emergency basis.




Prescribing stimulant drugs (amphetamine or sympathomimetic amine drugs,
designated as Schedule II controlled substances), except for the following purposes:

-

Hyperkinesis/Attention Deficit
Disorder in children and adults

-

Narcolepsy

-

Organic brain dysfunctio
n

-

Organic affective disorder

-

Major de
pressive disorder and dysthymia

-

Reduction of side effects caused by opioid analgesics
,

especially sedation in
terminally ill patients or ot
her similarly severe conditions


-

Approved clinical investigation of the effect o
f such d
rugs within a research
protocol
(
S
ee Appendix B)


8

Prudent practice would discourage the following:



Prescribing controlled substances for a patient simply because the patient tells you
another practitioner has been prescribing it for him/her. Cons
ult the practitioner or
the hospital records, or examine the patient thoroughly and decide for yourself if a
controlled drug product should be prescribed.




Prescribing cocaine for any purpose.




Prescribing any controlled substance for yourself or a family
member. (See above for
laws regulating Schedule II controlled substances.)




Prescribing any controlled substance FOR ANYONE for whom you have no chart in
your office.


The following table outlines state and federal limitations on prescriptions for control
led
substances. Note that many limitations are more stringent for Schedule II prescriptions.



Prescription Characteristic Limitations








Schedule II

Schedules III, IV, and V
2

Mode of issuing prescription
:


Written (except in a bona fide
emergency
)
3

Verbal or Written





Refills
:


None allowed

Maximum of five within six months of
issuing prescription










2

Schedule V is an over
-
the
-
counter provision of the Federal Ac
t. All Schedule V medications require a
prescription in Colorado.

3

The drug prescribed must be limited to the amount needed to treat the patient during the emergency
period. Within 7 days, the practitioner must furnish the pharmacy with a written signed p
rescription for the
drug (see page 4, Emergency Prescribing of Schedule II Controlled Substances).

9

OFFICE PROCEDURES


Necessary Records

Practitioners must maintain records of all controlled substances received in their offices.
Federal reg
ulations require dispensing practitioners to keep records of all narcotic drugs
administered or dispensed and of other controlled substances administered or dispensed if
the patient is charged for the dispensing service. It is recommended that all control
led
substances dispensed from the office by a practitioner be recorded in a log book. Each
instance of dispensing may be recorded chronologically in the
log

book
, and each entry
should include the following information:



Name of drug



Dosage for
m and streng
th of the substance



Quantity dispensed



Name and address o
f the patient (street and city)



Date of dispensing



Name
or initials of the practitioner


Record
-
keeping
requirements
are summarized in the following table:



Type of Record

Federal Requirement

Sche
dule II records

Maintain separately from other records


Schedule III, IV, and V records


Maintain separately or readily retrievable
from other records


Inventory of controlled substances on hand


C
onduct every two years


Record
-
retention requirement


Tw
o years. Advisable to keep records on an
ongoing basis and make available for
inspection




Storage of Controlled Substances

Under Federal Law, practitioners must store controlled substances in their offices or
clinics in a securely locked, substantially

constructed cabinet or safe. Access to the
storage area should be kept to a minimum.


Any loss or theft of controlled substances or DEA order forms must be reported to the
DEA f
ield office, using DEA form 1
06. Thefts also must be reported to the local p
olice
and the Colorado Board of Pharmacy.

10

THE FOUR D’S


The American Medical Association outlines four types of practitioners who are sources
of drug diversion. If you or a colleague fit one of these categories,
it is

time to evaluate
your practice or co
nsult with one of the organizations on

page 14
.




Dishonest



or “script”


doctors, who willfully and knowingly prescribe controlled
drugs for purposes of abuse and usually for profit.




Disabled



or impaired


practitioners, whose professional competence
has been
impaired by drug abuse, alcoholism or other physical or mental disorders.




Deceived

practitioners, who unwittingly acquiesce to some patients’ insistent
demands for medication. Typically, these practitioners prescribe drugs in larger
amounts for
longer periods of time than are medically indicated.




Dated

practitioners, who have not kept pace with developments in pharmacology or
drug therapy
. These practitioners are poor
prescribers, not because they intend to be,
but because they lack information

or understanding. Th
ey may be prescribing
excessive
amounts of drugs for exceptionally long periods of time, prescribing types
of drugs that are not indicated for the condition or prescribing drugs when another
type of therapy is indicated
.
R
ecently prom
ulgated national gu
idelines such as the
Agency for
Health Care Policy and Research demonstrate that what is considered
“medically indicated” is in a state of flux. Studies document that there has been
a
problem with many prescribers
significantly
under tr
eating

pain, particularly in the
case of terminal cancer patients. The
under treatment

of pain could lead to doctor

shopping. This
under treatment

has been attributed to a number of factors, including
ignorance of currently recommended prescribing practi
ces and concerns about
regulatory

scrutiny
.


CLUES FOR SCREENING
DRUG ABUSERS


Current Behavior



Must be seen right away, very agitated
, “found you in the phone book
.




Makes a late after
noon (often Friday) appointment
.



Calls
or comes in after regular hours
.



Must have a specific narcotic drug or other
controlled substance right away
.



Gives evasive or vague answers to ques
tions regarding medical history
.



Reluctant or unwilling to
provide reference information
.



Traveling through town, visiting friends or relat
i
ves


not a permanent resident
.



Does not give a pr
imary or referring practitioner
.



Refuses laboratory

tests or specialty evaluations
.



States that specific non
-
narcotic analgesics do not work or

that they are allergic to
them
.

11



Presents characteristic types
of pain: low back, root canal, migraine headache,

abdominal, cysts and abscesses
.



Lost or stol
en prescription needs replacing
.


Medical History



May admit excessive use of coffee, cigarettes, al
cohol, other prescription drugs
.



May exaggerate medical

problem
s and simulate symptoms
.



History of f
requent trauma, burns or breaks
.



History of bizarre infection
s (malaria, tetanus, hepatitis)
.



General debilitation
.


Social History



Repeated automobile acciden
ts and/or drunk driving arrests
.



Difficulty with employment
.



Child
abuse or severe family problems
.


Psychological History



Mood disturbance
.



Suicidal thoughts
.



Lack of impulse control
.



Sexual dysfunction
.


Physical Examination



Overt debilitation
not related to medical problems
.



Patient’s complaints out of
proportio
n to physical findings
.



Unsteady gait
.



Slurred speech
.



Inappropriate

pupil dilation or constriction
.



Nystagmus
.



Unexplained sweating or chills
.



Inapprop
riate lapses in conversations
.

C
utaneous signs of drug abuse:

-

Skin tracks and related scars on the neck
, axilla, forearm, wrist, hand,
foot,

and
ankle. Such marks usually are multiple, hyperpigmented and linear. New lesions
may be inflamed.

-

“Pop” scars, small raised scars from numerous, subcutaneous injections in the
same site.

-

Abscesses,
infections,

or u
lcerations. These may be infective or chemical
reactions to injections.

12

ACCEPTABLE AND UNACC
EPTABLE

INDICATIONS FOR
PRESCRIBING CONTROLL
ED SUBSTANCES


Acceptable Clinical Indications

Contact the Alcohol and Drug Abuse Division, Colorado Department of Hum
an Services,
regarding the state rules and regulations and their interpretations pertaining to the
licensing and registration of researchers, analytical laboratories and addiction programs
using controlled substances. In instances where the state rules an
d regulations are more
stringent, they take precedence over the federal regulations.

A.

Federal law prohibits the dispensing or administering of narcotic drugs to narcotic
dependent persons for detoxification or maintenance treatment unless the practitioner
o
r clinic is separately registered with the Drug Enforcement Administration to
conduct detoxification or maintenance treatment. A practitioner may, however,
administer (but not prescribe) narcotic drugs to a person for the purpose of relieving
withdrawal s
ymptoms when necessary while arrangements are being made for referral
for treatment. Such emergency treatment may be carried out for not more than three
days and may not be renewed or extended. (Title 21, Code of Federal Regulations
(
CFR
) 1306.07
[
a
][
b
]
.
)


B.

Narcotic drugs may be administered or dispensed: 1) in a hospital to maintain or
detoxify a person as an incidental adjunct to medical or surgical treatment or
conditions other than addiction or, 2) to persons with intractable pain in which no
relief or

cure is possible or none has been found after reasonable efforts (21 CFR
1306.07
[
c
]
).


C.

When methadone is administered for treatment of (narcotic) dependence for more
than three weeks, the procedure is no longer considered treatment of the acute
withdrawal

syndrome (detoxification) but is, rather considered maintenance
treatment. Only licensed methadone programs may undertake maintenance or
detoxification treatment. This does not preclude the treatment of the patient who is
hospitalized for medical condit
ions other than addiction and who requires temporary
maintenance or detoxification treatment during the critical period of his/her stay or
whose enrollment in a licensed narcotic treatment program has been verified (see 21
CFR

1306.07[c]; 21
CFR

291.505[f]
[2]). Hospitals desiring to treat patients for
narcotic addiction using methadone must obtain the proper state and federal licenses.
If the hospital is not licensed, methadone must be supplied by a licensed program for
each administration (it c
annot be s
tored at the hospital
)
.


D.

M
ethadone may be used for maintenance treatment only by
practitioners

who have
the necessary training, experience and state/federal licenses, registrations and
approvals.


E.

Schedule II narcotic analgesics (alone or in combination wi
th non
-
narcotic
analgesics) are to be used in cases of acute or chronic pain where non
-
narcotic
analgesics (e.g.
,

acetaminophen, aspirin, non
-
steroidal anti
-
inflammatory drugs
(NSAID’s)) have a high probability of ineffectiveness. The term of use should n
ot go
beyond the period required for diagnosis and treatment of the
cause

of pain and for
13

recovery from the cause of pain. Treatment of patients with
severe chronic pain

may
include therapeutic doses of Schedule II narcotics over long periods of time or
r
egularly occurring short periods only when the patient does not take more
medication than the prescribed amount and the practitioner has the necessary training
and experience to properly diagnose and treat patients with chronic pai
n. (See
Section C
for a
more in
-
depth discussion of the management of chronic pain.)


F.

The administration of Schedule II narcotic
analgesics

is warranted to relieve moderate
to severe pain due to such conditions as terminal cancer; postoperative pain; severe
pain associated with b
iliary, renal
,

or urethral colic; pain of acute myocardial
infarction; and preoperative medication in anesthesia.


G.

Schedules III and IV narcotic combinations are appropriate for the majority of acute
pain episodes that are not controlled by the use of acet
aminophen, aspirin or
NSAID’s.


Unacceptable Clinical Indications

A.

Prescribing amphetamines for the purposes of diet control, increasing work capacity,
maintaining wakefulness other than for
narcolepsy
, to combat the normal fatigue
associated with any endea
vor, or to chemically induce euphoria (C.R.S. 12
-
36
-
117[1][p]). (See Appendix B
.
)


B.

Prescribing for the “professional patient” for abuse or resale of controlled substances.
(See pages 1
0
-
13 for clues to identification of these persons
.)


C.

Prescribing narco
tic analgesics on the specific request of the patient who may be
feigning a painful condition or unnecessarily maintaining a painful condition.


D.

Prescribing to comply with coercive tactics including eliciting sympathy or guilt,
direct threats of physical o
r financial harm or the offer of bribes. Using the names of
other practitioners, family members or friends are common tactics of drug abusers.


E.

Prescribing for detoxification or maintenance treatment of non
-
hospitalized opiate
dependent persons. Federal
and state
law limits

these treatments to practitioners with
special licenses, registrations and approvals, and limit the narcotic drug to methadone.

14

FOR MORE INFORMATION

U.S. Drug Enforcement Administration

115 Inverness Drive East

Englewood, CO 80112

(3
03) 705
-
7300


DEA registration information

(303) 705
-
7300


Division of Behavioral Health

(FKA the
Alcohol and Drug Abuse Division

Colorado Department of Human Services

3824 West Princeton Circle

Denver, CO 80236
-
3111

(303) 866
-
7400


Board of Medical Exam
iners

Colorado Division of Registrations

1560 Broadway, Suite 1350

Denver, CO 80202

(303) 894
-
7690


Board of Nursing

Colorado Division of Registrations

1560 Broadway, Suite 1350

Denver, CO 80202

(303) 894
-
2430


Board of Pharmacy

Colorado Division of Regi
strations

1560 B
r
o
adway, Suite 1350

Denver, CO 80202

(303) 894
-
7800


Board of Dental Examiners

Colorado Division of Registrations

1560 Broadway, Suite 1350

Denver, CO 80202

(303) 894
-
7800


Colorado Dental Assoc
i
ation

3690 S. Yosemite St., #100

Denver, CO

80237

(303) 740
-
6900

www.cdaonline.org


Colorado Medical Society

7351 Lowry Blvd. #110

Denver, CO 80230

(720) 859
-
1001
;(
800
)
654
-
5653

www.cms.org



Colorado Society for Osteopa
thic Medicine

600 S. Cherry St. #510

Denver, CO 80246

(303) 322
-
1752

www.ColoradoDO.org


Colorado Center for Personalized Education
for Physicians

7351 Lowry Blvd. #100

Denver, CO 80230

(303) 577
-
3232

www.cpepdoc.org


Colorado Pharmacists Recovery Network

2170 S. Parker Road, Suite 229

Denver, CO 80231

(303) 369
-
0039


Colorado Physicians Health Program

899 Logan Street, Suite 410

Denver, CO 80203

(303) 860
-
0122

800
-
927
-
01
22

www.cphp.org


Dentist Peer Assistance Program

2170 S. Parker Road, Suite 229

Denver, CO 80231

(303) 369
-
0039

866
-
369
-
0039


Nurse Peer Health Assistance Program

2170 S. Parker Rd #229

Denver, CO 80231

(303) 369
-
003
9

866
-
369
-
0039

www.peerassist.org


Peer Assistance Services

2170 S. Parker Road, Suite 229

Denver, CO 80231

(303) 369
-
0039

866
-
369
-
0039

www.peerassist.org


Colorado Prescription Drug Abuse Task Force

2170 S. Par
ker Road, Suite 229

Denver, CO 80231

(303) 369
-
0039
;(
866
)
369
-
0039

15

SECTION B

MANAGEMENT OF ACUTE/
TRAUMA PAIN


Effective management of acute pain associated with traumatic
injuries

has many benefits
for the patient, including
earlier mobilization
, hastene
d recovery, shortened hospital stay,
reduced medical cost and pr
e
vention of chronic pain states. It has been estimated,
however, that of the millions of patients experiencing pain secondary to traumatic
injuries, over half will have inadequately treated p
ain due to unrealistic management
strategies or
under
-
medication
.


Though divisions are somewhat artificial, it is useful to divide pain states into acute,
convalescing, and chronic periods. The acute phase normally lasts for a few days but
depends upon t
he extent and severity of injuries. Tissues are injured and become
inflamed and edematous, and peripheral pain receptors, known as nociceptors, are
activated. Ordinarily, pain is at its worst in this phase and requires the most aggressive,
frequent and i
nvasive treatment to be effective. In convalescence, tissue healing is well
under way as inflammation and edema resolves. Pain gradually lessens, as does the need
for analgesics, and the patient resumes daily activities. Chronic pain may ensue if
healin
g is impaired or if abnormal reflex pathways within nerve pathways develop. This
discussion focuses principally on the acute phase but these principles apply to
convalescence as well; the management of chronic
pain is discussed in Section C
.


The number a
nd
complexity of management strategies available to assist in the treatment
of acute pain are dependent upon the resources available at local health care facilities. A
number of options are listed, roughly in order of their general availability:

1.

Opioids

a
nd other analgesics (acetaminophen, non
-
steroidal anti
-
inflammatory drugs)
and adjunctive medications such as antispasmodics, anticonvulsants, antidepressants,
and benzodiazepines. These medications may be administered orally or parenterally
depending upo
n the severity of pain, the pain phase and health care
resources
.
Opioids will be discussed in greater depth subsequently.


2.

Patient controlled analgesia (PCA): a route of delivery of opioid
analgesics that

has
met with great success. The advantages inclu
de patient involvement in their
treatment and avoidance of excessively high or low serum levels of medication
(avoiding oversedation or under
-
medication of pain); the overall doses of analgesics
tend to be lower with greater patient satisfaction.


3.

Epidural

administration of
opioids

and local
anesthetics:

highly

invasive and
extremely effective. This technique requires involvement of anesthesiologists or
nurse anesthetists and an increased level of monitoring. The degree

of pain relief is
excellent, overse
dation is avoided and the patient can be mobilized. Disadvantages
include the level of nursing care required and side effects, including pruritus, nausea
and vomiting, urinary retention, hypotension, respiratory depression, local anesthetic
toxicity, etc.

16


4.

Neural blockage
-
nerve blocks: extremely effective in reli
e
ving pain, but requires a
good working knowledge of anatomy and relatively frequent redosing. Another
disadvantage is the inability to monitor nerve function once the nerve is blocked.


5.

Pain trea
tment:
4



Morphine is best for bone pain
.



Morphine plus Versed is a good combination for pain control.



Benzodiazepines & n
arcotics work well synergistically.


(Benzodiazepines enhance pain relieving quality of the narcotics by relieving

apprehension s
o that narcotics work more effectively.)


6.

Physical therapy:



A
pplication of hot or cold



E
levation



S
trengthening and range of motion exercises



O
utpatient exercise



T
herapeutic massage


7.

Cognitive
-
behavioral

interventions:



C
ounseling



R
elaxation



D
istraction



I
mag
ery



B
iofeedback



T
herapeutic massage


Opioid analgesics are the cornerstone of management of moderate to severe acute pain.
Available in a great range of potency, a preparation is available to address pain of all
severity. It is incumbent upon the pract
it
i
o
n
er to be familiar with a number of available
preparations to address all contingencies. In particular, the duration of action of the
medications must be understood to avoid over or under
-
medicating the patient. Used in
the short
-
term, some tolerance d
evelops but rarely does physical dependence or addiction
occur. The estimated incidence of addiction is approximately 0.01%.
5

Quite to the
contrary, under
-
medicating the patient out of unfounded concerns for physical
dependence may actually lengthen reco
very if the patient remains bedridden and inactive
secondary to inadequately
treated

pain. Patients with previous or current substance abuse
issues are more complicated to manage, but should never be denied adequate a
n
algesia.
(See Section D, page 34
.)





4

Moore, Ernest E., M.D., FACS

5

New England Journal of Medicine, 1980 Vol. 302, Pg. 123,
Addictions Rare in Patients Treated with
Narcotics.

17

When considering prescribing an o
pioid

analgesic
,
i
t
i
s

i
mportant to
c
hoose:



A

strong enough agent



A
t frequent enough intervals



T
itrated to the individual’s requirements


Because of

the wi
de
v
ariation
i
n
p
atient
r
esponse:



S
tart with a small but reasonable
dose



I
f appropriate to the setting, begin with intravenous dosing



I
ncrease to an effective dose over a period of time


Cues i
n
a
ssessing
r
esponse:



V
erbal



P
hysical



P
hysiologic



P
atient admits or denies adequate pain relief



I
s the patient:

-

R
elaxing or becomin
g drowsy

-

T
earing

-

P
erspiring

-

T
achycardic

-

T
achypneic

-

H
ypertensive


Diagrams A, B, C, D and E are included
to

assist the practitioner in assessing the degree
of pain and success of therapy.


Time
-
contingent scheduling rather than a “PRN” regimen is more like
ly to provide

effective pain relief as adequate serum analgesic levels are better maintained. Diagrams
A and B compare the time a patient is in a comfort zone for these alternatives. With
time
-
contingent dosing, smaller doses of medication are administer
ed more frequently
and on a regular schedule. PRN scheduling is often ineffective as the patient may be
reluctant to request treatment until analgesia has worn off. Patients themselves may also
harbor unfounded concerns about becoming dependent, denying
themselves the
advantages of adequate analgesia. Some t
i
m
e

elapses before the patient is redosed and
achieves pain relief. As prescribed doses of PRN medications are often larger, peak
levels may be excessive, overly sedating the patient.


In summary, bo
th staff and patient education are key features in successful management
of acute pain secondary to traumatic injuries.



Establish treatment priorities taking into consideration the extent and severity of
injury as well as coexisting illness
.




Choose approp
riate medications administered by the most effective and appropriate
route.


18



D
o
s
e adequately and at frequent enough inte
r
vals, in particular paying attention to
initial and subsequent responsiveness.




If treatment issues are complex, consider consultation
with specialists in pain
management.




Always convey to the patient compassion, competency, and concern.


DIAGRAMS A AND B






DIAGRAM C














0
-
10 numeric Pain Intensity Scale





0

1

2

3

4

5

6

7

8

9 10


No
Pain


Mild
Pain


Moderate
Pain


Severe
Pain


Very
Severe


Worst
Possible


19

DIAGRAM D
7

PAIN ASSESSMENT GUIDE


TELL ME ABOUT YOUR PAIN


Words to describe pain



Pain in other languages



Aching



Throbbing



Shooting


Itami
-
Japanese



Stabbing



Gnawing



Sharp


Tong
-
Chi
nese



Tender



Burning



Exhausting


Dau
-
Vietnamese



Tiring



Penetrating



Nagging


Dolor
-
Spanish



Numb



Miserable



Unbearable


Douleur
-
French



Dull



Radiating



Squeezing


Bolno
-
Russian



Crampy



Deep



Pressure









Intensity (0
-
10)


Location

If 0 is no pain and 1
0 is the worst
pain imaginable, what is your pain
now?

Where is your pain?

In the last 24 hours?





Duration Factors


Aggravating and Alleviating

Is the pain always there?

What makes the pain better?

Does the pain come & go?

What makes the pain worse
?

(breakthrough pain)


Do you have both types of pain?





How does pain affect:


Are you experiencing any other symptoms?

Sleep



䕮brgy

-

oela瑩潮獨o灳

乡畳ua⽖潭/瑩湧



f瑣桩湧

-

啲楮慲y 牥瑥湴楯t

䅰灥瑩瑥



䅣瑩癩vy

-

䵯潤

C潮獴楰慴楯i

-

p汥l灩湥
獳sC潮晵獩潮

-

tea歮k獳




Things to check:


Vital signs
-
Past medical history
-
Knowledge of pain
-
Use of non
-
invasive techniques






7

Jacox A. Carr

DB, Payne R, et al. Management of Cancer Pain. Clinical Practice Guidelines No.9
AHCPR, Publication No. 94
-
0592, Rockville, MD. Agency for Health Care Policy & Research, U.S. Dept.
of Health & Human Svcs., Public Health Svc., March 1994
-

Wong, D & Whaley,

L: Clinical Handbook of
Pediatric Nursing, ed.2, The C.V. Mosby Co., St. Louis, 1986, p. 373.

Copyright 1996, Regina Fink at Univ. of CO Health Sciences Ctr.

Supported by an educational grant from Anesta Corp. Reprinted with permission.

20

DIAGRAM E
8

PAIN ASSESSMENT


PATIENT:


DOCTOR:


DATE
:


Pain Severity:

1 2 3 4 5 6 7 8 9 10

Remarks:


Where is

the pain located?


(Indicate on illustration


I/Internal, E/External)




How long have you had the pain?

Constant


Intermittent



Describe any patterns or changes
:




What relieves the pain?




What increases the pain?




How does the pain aff
ect your:

Sleep


Appetite


Physical activity


Concentration


Emotions


Social relationships



Current analgesic regimen:







8

Reprinted with p
ermission from Janssen Pharmaceutical Research Fndt. © Medical Doctors & Designers
USA, Inc., 1994.JPI
-
DR
-
070
-
R.

21

TABLE A

ORAL AND

TRANSDERMAL NARCOTIC ANALGESICS

FOR MANAGEMENT OF ACUTE AND CHRONIC PAIN IN ADULTS
1

Prepared by Ch
arles Si
ntek, R.Ph., M.S., BCPS

Drug

Available
Strengths

Common Quantity for Prescribing

Common oral starting dose for
moderate to sever
e

pain
2

Comments

Acute Pain

Chronic Pain

Acute Pain

Chronic Pain

Morphine


CII

15, 30 mg

3
-
7 day supply

15
-
30 day supply

15 mg q 3
-
4 hr

15 mg q 3
-
4 hr

For severe pain.

Morphine controlled
-
release (MS Contin,
Oramorph SR, Kadian)


CII

15, 30, 60, 100,
200 mg

NR
3

15
-
30 day supply

NR

30
-
60 mg q 12 hr

For severe pain. Kadian is
adm
inistered once or twice a day.
Other controlled
-
release morphine
products are usually dosed bid to
tid.

Hydromorphone
(Dilaudid)


CII

2,4,8 mg

3
-
7 day supply

15
-
30 day supply

2 mg q 3
-
4 hr

2 mg q 3
-
4 hr

For severe pain.

Levorphanol tartrate

(Levo
-
Dromaran)

CII

2 mg

NR

15
-
30 day supply

NR

2 mg q 6
-
8 hr

For severe pain. Average plasma
half
-
life is 12
-
16 hr. Usual
duration of analgesia is 6
-
8 hr.

Methadone
(Dolophine)

CII

5,10 mg

NR

15
-
30 day supply

NR

5 mg q 6
-
8 hr

Fo
r severe pain. Average plasma
half
-
life 24
-
36 hr, accumulates
with repeated dosing. Duration of
analgesia ranges 6
-
12 hr.

Meperdine
(Demerol)

CII

50, 100 mg

3
-
7 day supply

15
-
30 day supply

50 mg q 3 hr

NR

For severe pain. Not
rec
ommended for chronic pain
due to short duration of action.
Toxic metabolite.

Fentanyl Transdermal
Patch (Duragesic)

CII

25, 50, 75 100 mcg

NR

15
-
30 day supply

NR

25 mcg patch applied
q 72 hr

For severe pain. Some patients
may require q 48 hr change
s in
patch.





1

Adults with weight


50 kg. Always consult manufacturer’s prescribing information for latest dosing recommendations before prescribing opioids.

2

Upper limit of dosing for chronic severe pain is determined by response. It is inappropriate to arbitrarily assign an upper l
imit

on dosage when medication is carefully titrat5red to
response or unacceptable side effects.

3

NR


Not recommended. Short acting opioids are poor choices in management of chronic severe pain except for treatment of breakthro
ugh pain not controlled by long

acting
opioids.


22

Oxycodone &
Combinations (Tylox,
Percodan, Per
c
ocet,
Roxi
codone)

CII

5 mg

3
-
7 day supply

15
-
30 day supply

5 mg q 3
-
4 hr

5 mg q 3
-
4 hr

For moderate/severe pain.

Oxycodone controlled
-
release (OxyContin)

CII

10, 20, 40 mg

N
R

15
-
30 day supply

NR

10 mg q 12 hr

For severe pain.

Hydrocodone combinations
(Vicodin, Lorcet, Lortab)
CII
I

2.
5, 5, 7
.
5,

10 mg

3
-
7 day supply

15
-
30 day supply

5 mg q 3
-
4 hr

5 mg q 3
-
4 hr

For moderate/severe pain.

Tramadol

(Ult
ram)


CII
I

50 mg

3
-
7 day supply

15
-
30 day supply

50 mg q 6 hr

50 mg q 6 hr

For moderate/severe pain. 100
mg q 6 hr is maximum dose. Not
classified as a controlled
substance.

Codeine combinations
(Tylenol with codeine,
Empirin with codeine) CIII

15,
3
0
, 60 mg

3
-
7 day supply

15
-
30 day supply

30 mg q 3
-
4 hr

30 mg q 3
-
4 hr

For moderate pain.

Propoxyphene &
combinations (Darvon,
Darvon Compound)
CIV

65 mg

3
-
7 day supply

15
-
30 day supply

65 mg q 4
-
6 hr

65 mg 4
-
6 hr

For moderate pain. Toxic
meta
bolite with long half
-
life.

Propoxyphene napsylate
c
ombinations (Darvocet) CIV

100 mg

3
-
7 day supply

15
-
30 day supply

100 mg q 4
-
6 hr

100 mg q 4
-
6 hr

For moderate pain. Toxic
metabolite with long half
-
life.








When prescribing opio
i
ds, prescribers s
hould individualize dose.

23

TABLE
A
-
1

COST OF ANALGESICS

Prepared by Ch
arles Sintek, R.Ph., M.S., BCPS

BRAND NAME

STRENGTH

COST

UNIT

GENERIC NAME

SOURCE

COST

UNIT

MS Contin

15 mg

$94.88

100

morphine CR

NA

NA

NA

MS Contin

30 mg

$180.33

100

morphine CR

NA

N
A

NA

MS Contin

60 mg

$351.85

100

morphine CR

NA

NA

NA

MS Contin

100 mg

$520.94

100

morphine CR

NA

NA

NA

MS Contin

200 mg

$954.01

100

morphine CR

NA

NA

NA

Oramorph SR

15 mg

$87.44

100

morphine CR

NA

NA

NA

Oramorph SR

30 mg

$174.67

100

morphine CR

NA

NA

NA

Oramorph SR

60 mg

$298.24

100

morphine CR

NA

NA

NA

Oramorph SR

100 mg

$456.74

100

morphine CR

NA

NA

NA

Kadian

20 mg

$501.51

500

morphine CR

NA

NA

NA

Kadian

50 mg

$167.92

60

morphine CR

NA

NA

NA

Kadian

100 mg

$298.34

60

morphine C
R

NA

NA

NA

Morphi
ne IR

15 mg

NA

NA

morphine IR

Roxane

$26.12

100

Morphine IR

30 mg

NA

NA

morphine IR

Roxane

$44.34

100

Dilaudid

2 mg

$55.46

100

hydromorphone

Roxane

$32.03

100

Dilaudid

4 mg

$84.32

100

hydromorphone

Roxane

$49.07

100

Dilaudid

8 mg

$130.32

100

hydromorph
one

NA

NA

NA

Dolophine

5 mg

$9.86

100

methadone

Roxane

$8.45

100

Dolophine

10 mg

$16.01

100

methadone

Roxane

$14.04

100

Demerol

50 mg

$78.38

100

meperidine

Roxane

$68.63

100

Demerol

100 mg

$149.10

100

meperidine

Roxane

$130.55

100

Duragesic transderma
l

25 mcg

$56.04

5

fentanyl

NA

NA

NA

Duragesic transdermal

50 mcg

$84.02

5

fentanyl

NA

NA

NA

24

Duragesic transdermal

75 mcg

$134.62

5

fentanyl

NA

NA

NA

Duragesic transdermal

100 mcg

$167.72

5

fentanyl

NA

NA

NA

Tylox

5/500

$80.45

100

oxycodone/APAP

Schein

$54.38

100

Percocet

5/325

$69.90

100

oxycodone/APAP

Schein

$25.69

100

Percodan

5/325

$72.30

100

oxycodone/ASA

Parmed

$18.95

100

Roxicodone

5 mg

$42.49

100

oxycodone

NA

NA

NA

OxyContin

10 mg

$113.69

100

oxycodone CR

NA

NA

NA

OxyContin

20 mg

$217.5
9

100

oxycodone CR

NA

NA

NA

OxyContin

40 mg

$386.08

100

oxycodone CR

NA

NA

NA

OxyContin

80 mg

$726.01

100

oxycodone CR

NA

NA

NA

Vicodin

5/500

$44.83

100

hydrocodone/APAP

Qualitest

$28.05

100

Vicodin ES

7.5/750

$49.43

1
00

hydrocodone/APAP

Qualitest

$34.40

10
0

Lorcet HD

5/500

$34.01

100

hydrocodone/APAP

Qualitest

$28.05

100

Lorcet Plus

7.5/650

$63.47

100

hydrocodone/APAP

Qualitest

$34.25

100

Lorcet 10/650

10/650

$95.04

100

hydrocodone/APAP

Qualitest

$50.72

100

Lortab 2.5/500

2.5/500

$53.99

100

hydrocodone/
APAP

Qualitest

$30.30

100

Lortab 5/500

5/500

$44.87

100

hydrocodon
e
/APAP

Qual
i
test

$28.05

100

Lortab 7.5/500

7.5/500

$47.41

100

hydrocodone/APAP

Qualitest

$33.80

100

Lortab 10/500

10/500

$62.67

100

hydrocodone/APAP

Watson

$49.24

100

Lortab ASA 5/500

5/
500

$67.86

100

hydrocodone/ASA

NA

NA

NA

Ultram

50 mg

$67.96

100

tramadol

NA

NA

NA

Tylenol/codeine #2

15 mg

$31.20

100

codeine/APAP

Qualitest

$7.56

100

Tylenol/codeine #3

30 mg

$33.91

100

codeine/APAP

Qualitest

$8.96

100

Tylenol/codeine #4

60 mg

$59.92

100

codeine/APAP

Qualitest

$17.70

100

Aspirin/codeine

30 mg

NA

NA

codeine/ASA

Qualitest

$13.09

100

Aspirin/codeine

60 mg

NA

NA

codeine/ASA

Qualitest

$18.40

100

25

Darvon

65 mg

$39.73

100

propoxyphene HCI

Qualitest

$6.61

100

Darvon
-
N

100 mg

$57.79

100

prop
oxyphene N

NA

NA

NA

Darvon Compound
-

65

65/389/32

$41.59

100

propoxyphene/CAF/ASA

Schein

$25.00

100

Darvocet
-
N 50

50/
325

$33.78

100

propoxyphene N/APAP

NA

NA

NA

Darvocet
-
N 100

100/650

$63.73

100

propoxyphene N/APAP

Qualitest

$33.74

100


Costs subject t
o change

AWP

avg. wholesale price

CAF

caffeine


CR

controlled release

APAP

acetaminophen


NA

not applicable

IR

immediate

release

ASA

aspirin



N

napsylate


26


TABLE B

RECOMMENDATIONS FOR SEVERE ACUTE PAIN AND MINOR PROCEDURES
1

LOCAL ANESTHETIC AGENTS

1%
Lidocaine

= 10 mg/ml



1% Lidocaine with epinephrine (1:100,000)

= 10

mg/ml

2% Lidocaine

=

20 mg/ml



2% Lidocaine with epinephrine (1:100,000)

=

20 mg/ml

Maximum dose: 4.5 mg/kg (without epi.) per package inserts


7 mg/kg (with epi.)



.25% Bupivacai
ne (Marcaine) =

2.5 mg/ml


Maximum dose: 2 mg/kg



The relative effectiveness of combining Marcaine with Lidocaine remains controversial at this time. Toxicities of a combina
tion of local anesthetics
may be additive.

Local anesthetic toxicity is caused

by overdose or intravascular injection of the anesthetic. Toxicity involves the cardiovascular and central nervous
systems. The CNS is usually affected first.


CNS Reactions



L
ightheadedness, tinnitus, perioral numbness, confusion



M
uscle twitching, audit
ory and visual hallucinations



T
onic
-
clonic seizure, unconsciousness, respiratory arrest


Cardiac Reactions



Hy
pertension, tachycardia



H
ypotension



S
inus bradycardia, ventricular dysrhythmias, circulatory arrest


Management of Local Anesthetic Emergencies



A
ny

change in the patients state of consciousness: administer oxygen



F
or convulsions: maintain airway; evaluate and support circulation; IV Valium


if circulatory status permits



C
irculatory depression: IV fluids; vasopressors if warranted






1

Moore, Ernest E., M.D., FACS.

27

TABLE C

PARENTERAL

PAIN RELIEF AND SEDATION IN ADULTS*

Prepared by Ch
arles Sintek, R.Ph., M.S., BCPS

OPOIDS

DOSAGE, ADMINISTRATION & ACTION

COMMENTS/PRECAUTIONS

Morphine

Usual IV dose: 2
-
5 mg IV over 5 min, may repeat with 2
-
5 mg q 5 min., then 2
-
5
mg IV q 2
-
4 hr.

For ge
riatric patients: 1
-
2 mg IV over 5 minutes may repeat with 0.5
-
2 mg q 5
min., then 0.5
-
2 mg q 2
-
4 hr.

1
-
4 mg/hr IV continuous infusion.

Average IM dose: 10
-
12 mg q 3
-
6 hr.

IV onset: 1
-
3 min. peak effect: 20 min. Duration of action: 4
-
5 hr IM, 2
-
4 hr IV.

AN
TAGONIST IS NALOXONE. All opioids potentiate the effects of
benzodiazepines and other CNS depressants. Adverse effects include
respiratory depression, apnea, myoclonus, bradycardia, and hypotension.
Active metabolite, morphine 6
-
glucuronide, accumulates

in renal impairment
and can lead to prolonged sedation. May cause GI upset and vomiting,
especially if given too fast IV push.

Fe
ntanyl

(Sublimaze)

Fentanyl 10
-
20 mcg IM/IV push is approximately equal to 1 mg of morphine.

Initial dose: 25
-
50 mcg IV over

1
-
2 min, may repeat with 25 mcg q 5 min.

For geriatric patients: 25 mcg IV over 1
-
2 minutes, may repeat with 12.5
-
25 mcg
q 5 min.

Usual dose range: 25
-
150 mcg IV over 1
-
2 min, up to 2 mcg/kg if used alone,
0.5
-
1 mcg/kg if used in combination with other
agents.

Maintenance dose usually 25% of initial dose, 25
-
100 mcg/hr IV continuous
infusion. 25
-
100 mcg/hr intermittent IV push.

High normal dose range: 3 mcg/kg/hr IV.

Doses in the range of 100
-
500 mcg/hr may be
required

to maintain adequate
sedation
for patients who are tolerant to opioids and other sedating agents.

IV onset of action: 1
-
3 min, analgesic peak action: 2
-
5 min, peak respiratory
effect: 5
-
15 min.

Average IM dose: 75
-
100 mcg q 3
-
4 hr.

Duration of action: 1
-
2 hr IM, 30
-
60 min
IV.

ANTAGONIS
T IS NALOXONE. All opioids potentiate the effects of
benzodiazepines and other CNS depressants. Causes less histamine release
than morphine. Too rapid IV administration can cause skeletal muscle and
chest wall rigidity and apnea. Respiratory depression

may last longer than
sedation. May cause nausea, vomiting, drowsiness, and dizziness. Avoid use
in severe COPD or in patients who have used a MAO inhibitor within 14 days.
Lower doses may be necessary in opioid
-
n
aive patients, the elderly, and
patient
receiving other CNS depressants.

Meperidine

(Demerol)

Meperidine 75 mg SC/IM/IV is equivalent to 10 mg morphine.

Usual dose range: 12.5
-
50 mg (0.5
-
1 mg/kg) IV over 1
-
2 min, may repeat with
10
-
15 mg q 5
-
10 min to q 1 hr.

Maximum Single dose: 150 mg.

Ma
ximum daily dose: 600 mg.

10
-
50 mg/hr IV continuous infusion.

High normal dose range: 2 mg/kg IV.

IV onset of action: 1
-
5 min, peak effect: 5
-
15 min.

Average IM dose
:

75
-
100 mg q 3
-
6 hr.

Duration of action: 3
-
5 hr IM, 2
-
4 hr IV.

ANTAGONIST IS NALOXONE.
All opioids potentiate the effects of
benzodiazepines and other CNS depressants. Adverse effects include
respiratory depression, apnea, bradycardia, hypotension, ataxia,
nervousness
,
nausea, and vomiting. Do not use in patients taking monoamine oxidase
i
nhibitors within 14 days. Normeperidine, a metabolite, accumulates in
hepatic or renal impairment and can cause tremors, muscle twitches,
hyperactive

reflexes, and seizures. Avoid meperidine in patients with renal
impairment.

Hydromorphone

(Dilaudid)

Hy
dromorphine 1.5 mg SC/IM
/
IV is equivalent to 10 mg morphine.

Usual
starting
dose: 0.5
-
1 mg IM/IV push over 1
-
2 min for opioid
naïve

patients.
Higher
dos
es may be necessary for opioid tolerant patients.

IV onset of action: 10
-
15 min, peak effect: 15
-
30
min.

Average IM dose
:

1.5
-
2 mg q 3
-
6 hr.

Duration of action: 4
-
5 hr IM, 2
-
3 hr IV.

ANTAGONIST IS N
ALOX
ONE. All opioids potentiate the effects of
benzodiazepines and other CNS depressants. Adverse effects include
respiratory depression, apnea, bradycardia
, and hypotension. High doses of
hydromorphone may produce myoclonus (muscle twitching) but to a
lesser
extent than
morphine.

28


BENZODIAZE
PINES

DOSAGE, ADMINISTRATION & ACTION

COMMENTS/PRECAUTIONS

Diazepam

(Valium)

Initially: 2
-
5 mg IM/IV push via a lar
ge vein over 1 min, may repeat with 2
-
5
mg IV q 5 min to desired sedation effect such as slurred speech.

For geriatric patients: 2 mg IM/IV over 3 minutes, may repeat 1 mg IV q 5 min.

Usual dose range: 2
-
10 mg IM/IV, not to exceed 5 mg/min. IV.

Maximum o
f 0.1
-
0.2 mg/kg or 10 mg over 1 hr.

High normal dose range: 30 mg.

IV onset of action: 1
-
5 min, peak action: 5
-
30 min, duration of action: 2
-
6 hr.
Elimination half
-
life: 20
-
40 hr. Hepatically metabolized.

ANTAGONIST IS FLUMAZENIL. Adverse effects includ
e
respiratory depression, drowsiness, confusion, and hypotension.
Use lower doses in combination with opioids or other CNS
depressants. Active metabolites can accumulate during prolonged
use. Increased duration of action can cause prolonged sedation,
es
pecially in elderly or renal or hepatic failure. Not recommended
for outpatients because extended observation may be required.
May cause burning or
phlebitis

when administered through a small
peripheral IV line. Do not administer in same line with other

medication.

Lorazepam

(Ativan)

Initially: 0.5
-
2 mg (0.05 mg/kg) IM/IV over 2 min, may repeat one
-
half the
initial IV dose q 10
-
15 min. IV doses of 0.05 mg/kg or 2 mg (whichever is
smaller) will sedate most adults.

Higher
does

of 2
-
6 mg may be necessar
y for patients who are tolerant to
benzodiazepines or opioids, or highly anxious patients.

Maximum dose: 2 mg IV, 4 mg IM.

Up to 0.06 mg/kg/hr IV continuous infusion.

IV onset of action: 20
-
40 min, peak action: unknown, duration of action: 8 hr.
Eliminati
on half
-
life: 10
-
20 hr. Hepatically metabolized.

ANTAGONIST IF FLUMAZENIL. Adverse effects include
respiratory depression, drowsiness, confusion, and hypotension.
Use lower doses in combination with opioids or other CNS
depressants. Must be diluted pri
or to IV administration. May
cause burning or phlebitis when administered through a peripheral
IV line. Preferred over diazepam for patients with hepatic or renal
impairment. Reduced doses may be indicated in elderly or
debilitated patients because they

may be more susceptible to