Sign Up
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Ohio Law Governing Drugs and Prescriptive Therapy

2 Contact Hours including 2 Advanced Pharmacology Hours and 1 Category A Hour
Listen to Audio
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS)
This course will be updated or discontinued on or before Tuesday, September 1, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


The continuing education activity was approved by the Ohio Nurses Association, an Ohio Board of Nursing approver. (OBN-001-91) ONA #2023-0000000648.
Outcomes

≥ 92% of participants will know how to prescribe controlled substances based on best practices and Ohio law.

Objectives

After completing this course, the participant will be able to:

  1. Identify state and federal laws related to prescribing drugs.
  2. Explain alternatives to opioid therapy.
  3. Outline indications and contraindications for opioids.
  4. Describe indications and contraindications for benzodiazepines.
  5. Summarize the governor's cabinet opiate action team (GCOAT) recommendations and the governor's RecoveryOhio initiative.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
  • $39 Unlimited Access for 1 Year
    (Includes all state required Nursing CEs)
  • No Tests Required
    (Accepted by most states & professions)
  • Instant Reporting to CE Broker
  • Instant Access to certificates of completion
Logo Audio
Now includes
Audio Courses!
Learn More
Restart
Restart
  • 0% complete
Hide Outline
Playback Speed

Narrator Preference

(Automatically scroll to related sections.)
Done
Ohio Law Governing Drugs and Prescriptive Therapy
0:00
0:15
 
To earn a certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Attest that you have read and learned all the course materials.
    (NOTE: Some approval agencies and organizations require you to take a test and "No Test" is NOT an option.)
Author:    Desiree Reinken (MSN, APRN, NP-C)

Introduction

This course discusses the standards and conditions concerning the authority of advanced practice registered nurses (APRNs) who are designated to prescribe drugs and therapeutic devices according to Ohio Laws and Administrative Rules. Definitions associated with this course include the following (Ohio Administrative Code [OAC] 4723-9-01, 2021):

Controlled substance: A substance, mixture, preparation, or compound included as a Schedule I-V.

Physician: Someone who holds a valid and current license issued by the Ohio State Medical Board to practice medicine and surgery or someone who holds a valid and current license to be able to prescribe drugs and therapeutic devices from a different jurisdiction.

Jurisdiction: States, territories, and political subdivisions within the United States where a legal authority, such as a board, regulates nursing practice and licensure while maintaining membership with the National Council of State Boards of Nursing (NCSBN).

Collaboration: A standard care arrangement between a physician and APRN where a physician is continuously available for communication in person or electronically.

Prescribing Authority

APRNs include certified registered nurse anesthetists (CRNA), clinical nurse specialists (CNS), certified nurse-midwives (CNM), and certified nurse practitioners (CNP). The required Ohio licensure is assumed when any APRN is mentioned in this course. The CNS, CNM, or CNP prescriptive authority must not prescribe drugs or devices that exceed the prescriptive authority of the collaborating providers or are in violation of Federal or Ohio law or rules (OAC 4723-9-10, 2022). They can prescribe Schedule II controlled substances if (Ohio Revised Code [ORC] 4723.481, 2023):

  • The patient has a terminal condition.
  • A physician initially prescribed the substance.
  • The prescription is for an amount not more than a seventy-two-hour period.

These limits do not apply if the CNS, CNM, or CNP prescribes to a patient in the following (ORC 4723.481, 2023):

  • A hospital
  • An entity owned or controlled, in whole or in part, by a hospital
  • A healthcare facility operated by the Department of Mental Health and Addiction Services or the Department of Developmental Disabilities
  • A nursing home that is licensed
  • A county home or district home certified under the Medicare or Medicaid program
  • A hospice care program
  • A community mental health services provider
  • An ambulatory surgical facility
  • A freestanding birthing center
  • A federally qualified health center
  • A federally qualified health center look-alike, as defined in section 3701.047
  • A health care office or facility operated by the board of health of a city or general health district or the authority having the duties of a board of health
  • A site where a medical practice is operated and the practice has physician ownership and provides direct patient care
  • A residential care facility 

The exclusion is that a CNS, CNM, or CNP cannot prescribe Schedule II controlled substances from a convenience care clinic regardless of the owners (ORC 4723.481, 2023). A CNS, CNM, or CNP cannot delegate the administration of controlled substances listed in the formulary to a person not otherwise authorized to administer medication (ORC 4723.489, 2017). ORC 4723.489 has a revision effective in 2024. That revision does not change any prescriptive regulations in this discussion (ORC 4723.481, 2024).

An APRN, designated as a CNS, CNM, or CNP, may provide a drug/therapeutic device to a patient, whether a sample or a partial or complete supply if (OAC 4723-9-08, 2021):

  • The drug/therapeutic device is not excluded in the formulary outlined in rule 4723-9-10
  • If the drug is a controlled substance, the requirements of 4729.291 are met
  • If the drug is a dangerous drug, other than a sample drug, the nurse affixes labeling to the container as specified in rule 4729:5-19-02
  • The nurse complies with 4723-9-12 regarding procedures/standards for review of Ohio Automated RX Reporting System (OARRS) reports
  • The nurse maintains a written record of drugs/therapeutic devices the nurse supplied as required by rule 4729:5-19-04
  • The nurse maintains current knowledge of and complies with state/federal laws and rules for supplying drugs/therapeutic devices

An APRN, designated as a CNS, CNM, or CNP, may supply a patient with a sample drug only if, in addition to the requirements outlined in the paragraph above, the following requirements are met (OAC 4723-9-08, 2021):

  • The sample drug complies with section 3719.81 of the Revised Code, including the requirement that the sample be supplied free of charge.
  • The requirements of rule 4729:5-19-02 of the Administrative Code are met if the sample is a dangerous drug.

Also, an APRN, designated as a CNS, CNM, or CNP, may supply naloxone, according to 4723.488 of the Revised Code, and may provide a partial or complete drug supply to treat gonorrhea, chlamydia, or trichomoniasis as specified in 4723.4810 of the Revised Code (OAC 4723-9-08, 2021).

Prescription of Opioids

Acute pain fades with healing, is related to tissue damage, interferes with normal function, and is not expected to persist for more than six weeks. Sub-acute pain persists for more than six weeks but less than twelve weeks. Chronic pain persists after treatment and occurs periodically or continually. Terminal conditions are not considered as chronic pain (OAC 4723-9-10, 2022).

Extended-release or long-acting opioids cannot be prescribed for acute pain. Non-opioid treatment options must be considered before prescribing an opioid. The prescription must be for a minimum quantity and potency needed for the expected pain duration. Three days or less is usually enough. Adults can have a seven-day supply with no refills, and minors can have a five-day supply with no refills. An explanation must be documented if the prescription is extended (OAC 4723-9-10, 2022).

The total morphine equivalent dose (MED) for treating acute pain cannot be more than an average of 30 MED per day, except when done with consultation with a provider before prescribing. The rationale has to be documented (OAC 4723-9-10, 2022).

For subacute or chronic pain, non-opioid treatment must be considered and documented if not chosen. The prescription must be for a minimum quantity and potency needed for the expected pain duration. Before prescribing, the APRN must complete an OARRS check. A prescription for naloxone should be offered if the patient (OAC 4723-9-10, 2022):

  • Has a history of overdose
  • Is also taking benzodiazepine, sedative hypnotic drug, carisoprodol, tramadol, or gabapentin
  • Has a concurrent substance use disorder
  • The dosage exceeds 80 MED 

For example, John is a 54-year-old patient who is being prescribed morphine after a long fall off a ladder that resulted in a compound fracture of the arm. Because of a history of back pain from a serious motor vehicle accident a few years previously, John also has a prescription for tramadol that he uses. With the potential for the use of both of these medications concurrently, John should be offered a prescription for naloxone.

Providers should consider offering a prescription for naloxone if the dosage exceeds 50 MED.

When treating a patient with opioid analgesics above the dose average of 50 MED daily, periodically follow up and document the patient's functionality, progress toward treatment objectives, adverse drug reactions, and indicators of addiction, drug abuse, or diversion. Before increasing an opioid dose above an average of 50 MED, review and update the assessment. If the patient already exceeds an average of 50 MED, consider a consultation with a specialist, getting a medication therapy management review by a pharmacist, or consulting with an addiction specialist (OAC 4723-9-10, 2022).

Before increasing the opioid dosage above an average of 80 MED, a written pain management agreement must be agreed upon with the patient. The APRN cannot prescribe an opioid at the dose of an average of 120 MED or above. An exception is if the APRN is nationally certified in pain management, hospice and palliative care, oncology, hematology, or coursework in hematology, leading to oncology certification. An exception is if the prescription is based on a written recommendation from a physician certified in hospice, palliative care, oncology, or hematology. The APRN must get a written recommendation before prescribing if the patient is already using this high dose (OAC 4723-9-10, 2022).

The sub-acute and chronic pain MED requirements do not apply when an opioid analgesic is prescribed to a hospice patient or patient with a terminal condition (OAC 4723-9-10, 2022). The Ohio Board of Nursing provides a Prescribing Process Flow chart at this link. The Ohio Board of Nursing provides other prescribing resources here.

Prescription of Opioids to Minors

An adult has to give written consent for the treatment of minors. A minor is anyone under 18 who is not emancipated. The consent should be recorded on a form known as the "Start Talking!" consent form. The form must contain the following (ORC 3719.061, 2023):

  • The name, quantity, and amount of the opioid analgesic being prescribed
  • A statement indicating that a controlled substance is a drug or other substance that the United States Drug Enforcement Administration (DEA) has identified as having a potential for abuse
  • A statement certifying that the prescriber discussed medical treatment with the minor and the consenting adult
  • The number of refills, if any, authorized
  • The signature of the consenting adult 

Before issuing a prescription of opioids to a minor, the prescriber will assess the history or current mental health problem, substance abuse disorder, or if the patient is under treatment for these conditions. Discussions with the minor and the consenting adult must include (ORC 3719.061, 2023):

  • The risks of addiction and overdose
  • The increased risk of addiction of minors with both mental health and substance abuse disorders
  • The dangers of taking opioid analgesics with benzodiazepines, alcohol, or other central nervous system depressants
  • Education on the patient counseling information on the labeling 

These restrictions do not apply when an opioid analgesic meets any of the following (ORC 3719.061, 2023):

  • The treatment is associated with or incident to a medical emergency.
  • The treatment is associated with or incident to surgery, regardless of whether the surgery is performed on an inpatient or outpatient basis.
  • In the prescriber's professional judgment, waiting to meet requirements may be a detriment to the minor's health or safety.
  • The treatment is rendered in a hospital, emergency facility, ambulatory surgical facility, nursing home, pediatric respite care program, residential care facility, freestanding rehabilitation facility, or similar institutional facility.
  • The prescription is issued at the time of discharge from a facility, excluding a prescriber's office.

Ohio Automated RX Reporting System

When prescribing a controlled substance that is a Schedule II, III, IV, and V, an APRN shall consider the following (OAC 4723-9-12, 2021):

  • Potential for abuse
  • The possibility that the drug may lead to dependence
  • The possibility the patient will obtain the drug for nontherapeutic use or distribute it to other persons
  • The potential existence of an illicit market for the drug 

When considering these possibilities, the APRN should use sound clinical judgment and consider obtaining and reviewing an OARRS report. The APRN must obtain and review an OARRS report when a patient shows any of the following red flags (OAC 4723-9-12, 2021):

  • Selling prescription drugs
  • Forging or altering a prescription
  • Stealing or borrowing reported drugs
  • Increasing the dosage of reported drugs in amounts that exceed the prescribed amount
  • Suffering an overdose, intentional or nonintentional
  • Having a drug screen result that is inconsistent with the treatment plan or refusing to participate in a drug screen
  • Having been arrested, convicted, or received diversion or intervention instead of conviction for a drug-related offense while under the APRN's care
  • Receiving reported drugs from multiple prescribers without a clinical basis
  • Traveling with a group of other patients to the APRN's office, where all or most of the patients request controlled substance prescriptions
  • Traveling an extended distance or from out of state to the APRN's office
  • Having a family member, friend, law enforcement officer, or healthcare professional express concern related to the patient's use of illegal or reported drugs
  • Known history of chemical abuse or dependency
  • Appearing impaired or overly sedated during an office visit or examination
  • Requesting reported drugs by a specific name, street name, color, or identifying marks
  • Frequently requesting early refills of reported drugs
  • Frequently losing prescriptions for reported drugs
  • History of illegal drug use
  • Sharing reported drugs with another person
  • Recurring visits to non-coordinated sites of care, such as emergency departments, urgent care facilities, or walk-in clinics, to obtain reported drugs 

A 12-month OARRS report must be reviewed before initially prescribing an opioid analgesic or benzodiazepine to a patient. An OARRS report is also needed when prescribing opioid analgesics to treat sub-acute and chronic pain. If the patient continues to receive opioid analgesics or benzodiazepines after the initial prescription, review an OARRS report at least every 90 days. An OARRS report is not required if the patient is (OAC 4723-9-12, 2021):

  • In hospice
  • Terminal
  • In a hospital, nursing home, or residential care facility
  • If the drug is not prescribed for more than seven days
  • If prescribed for treatment of non-terminal cancer or another condition associated with non-terminal cancer, except if prescribed for sub-acute or chronic pain 

Review an OARRS report after treatment for more than ninety days if the treatment includes prescribing reported drugs that are not opioid analgesics or benzodiazepines. Review an OARRS report annually as long as the reported drug is being prescribed. If an OARRS report indicates red flags, consult with a physician before prescribing the drug (OAC 4723-9-12, 2021).

The APRN's delegate may request OARRS reports. However, they have to be personally reviewed by the APRN. Assessment of the OARRS report, including consulting with the collaborating physician, should be documented in the patient record. Requested reports should cover at least the twelve months prior to the date of the request. If the APRN practices in an Ohioan county adjoining another state, the APRN or the delegate should request a report of any information available in the drug database pertaining to prescriptions issued to the patient in the state that adjoins the Ohioan county. If an OARRS report is unavailable, the APRN should document the reason the report is unavailable in the patient's record (OAC 4723-9-12, 2021).

If the APRN who prescribed/provided a drug to a patient determines that the patient may be diverting or abusing the drugs, the APRN should consult with a physician before prescribing more drugs at the next patient visit. Consultation with the physician should include a review of the patient's progression toward the objectives of treatment, reviewing the patient's functional status, and a review of the reasons why the APRN is concerned the patient is diverting or abusing the drugs. The consultation with the physician may result in a patient treatment program that includes more office visits and drug screens, an outline of the consequences of non-compliance, and the possibility of utilizing different treatment options. Another option is a referral to a substance abuse specialist (OAC 4723-9-12, 2021).

For example, Matthew, an APRN, suspects that Lisa, a patient he prescribes an opioid to, is abusing the drug. Matthew consults with his collaborating physician the evening before Lisa's appointment. Matthew details the red flags he believes indicate that Lisa is abusing the drug. After the consultation with the physician, it was decided that Matthew would update the treatment agreement and inform Lisa that there would be more frequent office visits and urine drug screens.

Governor's Cabinet Opiate Action Team

The Governor's Cabinet Opiate Action Team (GCOAT) made recommendations for the Management of Acute Pain Outside of Emergency Departments. While these recommendations were made in 2016, a more recent version has not been published.

Treatment options are recommended based on the quality of pain as follows:

  • Somatic Pain
    • Acetaminophen
    • Non-steroidal anti-inflammatory drugs (NSAIDs)
    • Corticosteroids

Alternatives include the following: gabapentin/pregabalin, skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, and tricyclic antidepressants (GCOAT, 2016).

  • Visceral Pain
    • Acetaminophen
    • NSAIDs
    • Corticosteroids

Alternatives include the following: dicyclomine, skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors, topical anesthetics, and tricyclic antidepressants (GCOAT, 2016).

  • Neuropathic Pain
    • Gabapentin/pregabalin
    • Serotonin and norepinephrine reuptake inhibitors
    • Tricyclic antidepressants

Alternatives include the following: other antiepileptics, baclofen, bupropion, low-concentration capsaicin, selective serotonin reuptake inhibitors, and topical lidocaine (GCOAT, 2016).

Short-term opioids may be first-line therapy in specific circumstances, like immediately post-operative. Opioids should usually be used as adjuncts to additional therapies rather than alone (GCOAT, 2016).

Governors RecoveryOhio Initiative

Executive Order 2019-01D, signed by the governor on January 14, 2019, created the RecoveryOhio Initiative. This cabinet-level organization provides guidance on addiction support and mental health resources in Ohio, coordinates recovery-focused initiatives, serves as an information hub on addiction and mental health, and engages service providers in supplying information and education.

The RecoveryOhio Initiative has a 2024-2027 strategic plan that involves three phases: engage and discover, analysis, and implementation planning.

In the engage and discover phase, meetings were held with community stakeholders to identify opportunities and insights. From these meetings, guiding principles were established and included (RecoveryOhio, 2024):

  • A human-centered approach.
  • Creating diverse partnerships.
  • Establishing a vision, mission, responsibilities, roles, structure and reporting standards.
  • Embracing objectivity.
  • Measuring performance with clear goals and metrics.
  • Being culturally relevant.
  • Standardizing processes and measures.
  • Developing communication strategies.
  • Accommodating unique and diverse needs.
  • Being mindful of indicators of potential adverse events.

Phase two involved analysis of the insights, opportunities, and principles identified in the engage and discovery phase. From the analysis, phase three, or implementation planning was outlined.

The deliverable of this phase involves a three-year road map that outlines seven initiatives to be created and improved upon between 2024 and 2027. These seven initiatives include the following (RecoveryOhio, 2024):

  • Establishing an Advisory Council governance model
  • Create/promote a continuum of care information portal
  • Developing predictive analytics with a toxicology data dashboard
  • Developing a statewide data reporting dashboard
  • Establishing collection standards for field data
  • Creating/providing access to prevention education and resources
  • Delivering prevention programming for youth/families

Each initiative has a problem statement, an outcome, and a scope, with the overall goal of removing barriers and enhancing care (RecoveryOhio, 2024).

Federal Laws and CDC Recommendations

The Food and Drug Administration (FDA) is responsible for assuring the safety of the drug supply in the United States. It requires pharmacies to confirm that prescribers and organizations they work with are licensed and registered with the FDA. Under the FDA, the hospital must investigate and handle suspicious or known illegitimate prescriptions (Centers for Disease Control and Prevention [CDC], 2022).

The DEA regulates the distribution of controlled substances. The DEA is responsible for enforcing laws and regulations related to controlled substances. They also have the authority to bring about criminal or civil charges to individuals or organizations involved in the illicit traffic of controlled substances. The Controlled Substance Act requires a schedule of controlled substances. The list describes chemicals that may be classified as controlled substances. The Department of Justice, DEA, Diversion Control Division maintain the current list of Controlled Substances Schedule.

The Environmental Protection Agency (EPA) helps ensure the proper disposal of pharmaceutical waste. This protection prevents pharmaceutical waste in the environment, such as in the ground and drinking water. The EPA has regulations that the pharmacy must follow. The CDC published guidelines in 2016 that were updated in 2022. They are similar to Ohio law. Those recommendations are available in the CDC Guideline for Prescribing Opioids for Chronic Pain.

Non-Pharmacologic Options

NSAIDs have risks, and some patients cannot tolerate NSAIDs due to side effects and pre-existing co-morbid conditions. Therefore, it is necessary for some patients to utilize non-pharmacologic options.Examples of non-pharmacological therapy are:

  • Ice, heat, positioning, tone and strengthening, movement restriction, bracing, wrapping, splints, stretching, and directed exercise are available through physical therapy. Examples of exercise may include aquatic, aerobic, and resistance training. Occupational therapy may also be helpful.
  • Relaxation therapy, massage therapy, yoga, meditation, tactile stimulation, acupuncture/acupressure, chiropractic adjustment, manipulation, transcutaneous electrical nerve stimulation (TENS), and osteopathic neuromuscular care.
  • Biofeedback, cognitive behavioral therapy, counseling, talk therapy, and hypnotherapy, including imagery and distraction.
  • Music and art therapy.

Non-opioid medications should be used with non-pharmacologic therapy. When initiating pharmacologic treatment, educate patients on the proper use of medication, the importance of maintaining other therapies, such as non-pharmacologic options, and expectations for the duration and degree of symptom improvement.

For example, Sarah, a 47-year-old patient, sprained her ankle while working in her yard. She prefers not to take NSAIDS because of the gastrointestinal side effects, such as nausea and vomiting, that she experiences. In talking with her provider, it was decided the best form of treatment for her sprained ankle includes physical therapy and TENS.

Opioids

Opioids are indicated for acute pain resulting from severe injuries, medical conditions, surgical procedures, or when non-opioid options are ineffective or contraindicated. When opioids are used for chronic pain, treatment is typically started with a short-acting drug, and the drug is titrated upwards to control pain while side effects are monitored. After determining the dose of the drug required to provide adequate pain relief with minimal side effects, the drug can be converted to a sustained release form and administered once or twice a day. When a long-acting drug is used, a breakthrough drug can be given. Dosage and scheduling should be based on the most recent manufacturer's recommendations. Extended use may lead to dependence, and these drugs should be tapered. Caution should be taken with dosages for patients with renal or hepatic impairment. Opioids have the potential for abuse, addiction, and diversion. Driving, operating machinery, or performing other hazardous tasks while taking an opioid is unsafe.

Side Effects

Opioid drugs are associated with multiple side effects, including constipation, nausea, vomiting, pruritus, abdominal cramping, sedation, and mental status changes. Numerous interventions are available to reduce side effects (Paul et al., 2021).

Constipation is a frequent issue in those who use opioids. Risk factors for constipation include those with intra-abdominal pathology and those who eat a low-fiber diet. Those on opiates should be encouraged to increase fiber intake, drink plenty of fluids, and be encouraged to exercise. Stool softeners (e.g., docusate sodium) and stimulants (e.g., bisacodyl) may be needed to manage constipation. An osmotic laxative such as polyethylene glycol or lactulose may also be considered, and it may be added to stool softeners/stimulants for resistant constipation. An antiemetic drug can help treat nausea. Antihistamines can treat pruritus.

Opioids are associated with drowsiness and other mental status changes. Patients do develop tolerance to these symptoms over time. Reducing the dose may lessen the mental status changes. An adjunctive drug may be added to allow a lower dose of opioids to manage the pain. Rarely the use of a stimulant can be used to manage sedation due to opioid use.

Respiratory depression may occur, but it is uncommon if used carefully. Starting low and slowly titrating the dose will reduce the risk of respiratory depression. Problems arise with rapid titration, the addition of another drug that may suppress the respiratory drive (benzodiazepine, alcohol, or a barbiturate), or the patient overdoses. Sedation precedes respiratory depression, so when starting a patient on opioid therapy, encourage them to take the first dose in the office to be monitored or in the presence of a responsible adult who can help monitor the patient (Paul et al., 2021).

Drugs

Morphine can be given orally, rectally, intravenously, subcutaneously, or intramuscularly. It comes in tablet, suppository, and parenteral solution. Morphine also comes in a controlled-release form, a sustained-release form, and an extended-release form. Morphine should not be used in those with a hypersensitivity to morphine, those with toxin-mediated diarrheal disease, and those with severe/acute asthma, paralytic ileus, or severe respiratory depression. The extended-release form should not be used in those with gastrointestinal obstruction. The extended-release forms of morphine are not interchangeable. Changing from one drug to another should be done only by those with experience (Murphy et al., 2023).

Fentanyl can be given as an injection, transdermal patch (Duragesic®), an oral transmucosal lozenge (Actiq®), a sublingual tablet (Abstral®), a sublingual spray (Subsys®), a buccal tablet (Fentora®), a buccal film (Onsolis®) and a nasal spray (Lazanda®). The transdermal patch is used in opioid-tolerant patients with moderate to severe pain and is changed every 72 hours; it is indicated for around-the-clock pain management in those with severe chronic pain. Fentanyl transmucosal and intranasal is indicated for cancer pain (DEA, 2016).

Contraindications include hypersensitivity, toxin-mediated diarrheal disease, and paralytic ileus. It should not be used for short-term pain or post-operative pain and should not be used for those who have severe respiratory disease. The transmucosal and nasal forms of fentanyl are typically only used by specialists for opioid-tolerant cancer patients (Ramos-Matos et al., 2023).

The patch form should not be exposed to external heat, as this may increase the absorption of the drug. Also, patients with a fever may notice an increase in the absorption of the drug. The patch should only be applied to intact skin; it contains aluminum and must be removed before magnetic resonance imaging (MRI). Caution should be taken to remove a previous patch before applying a new patch to avoid overdose. Depending on patch type, cutting patches can sometimes be done but may adversely affect their adhesiveness. In the case of reservoir patches, such as fentanyl, it can potentially lead to harmful immediate drug release (Fu et al., 2024).

Oxycodone is a Schedule II controlled substance available in controlled and immediate-release tablets. It also comes as an oral concentrate and oral solution. Oxycodone is often combined with NSAIDs. Oxycodone is contraindicated in those with paralytic ileus, significant respiratory depression, hypercarbia, acute or severe bronchial asthma, and gastrointestinal obstruction. Caution should be used in those with biliary tract impairment, such as acute pancreatitis, as it may lead to constriction of the sphincter of Oddi. It may lead to an elevation of intracranial pressure (ICP) and should be used carefully for those with intracranial lesions, elevated ICP, or a head injury (Sadiq et al., 2024).

Hydrocodone is a Schedule II controlled substance. It is available as a combination pill with a non-narcotic analgesic and by itself in an extended-release form. The combination pill has a short-acting version of hydrocodone. Contraindications to hydrocodone include paralytic ileus, severe asthma, severe respiratory depression, and hypercarbia (Cofano et al., 2024).

Tramadol is a Schedule IV controlled substance. It is indicated for those who do not need a rapid onset of pain relief. When prescribing tramadol to older adults, use the lower end of the dosage range and titrate slowly. Extreme caution should be utilized with the extended-release form in those over 75 years. Patients may experience withdrawal symptoms from tramadol, including nausea, diarrhea, anxiety, pain, sweating, tremors, and rigor. Decrease the dosage slowly to reduce the risk of withdrawal symptoms. Tramadol has been shown to increase the risk of seizures. This risk is increased in those who take serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptics, other opioids, or drugs that lower the seizure threshold. The risk may also be increased in those with seizures or who are at risk for seizures, such as those with a central nervous system infection, cancer, a history of head trauma, or while patients are going through drug or alcohol withdrawal (Subedi et al., 2019).

Oxymorphone is a Schedule II controlled substance. It can be given intravenously, subcutaneously, intramuscularly, or orally. Hydromorphone can be given orally, rectally, subcutaneously, intramuscularly, or intravenously. The oral drug comes in standard and extended-release forms. Parental and oral doses are not equivalent. The parenteral dose is five times more potent than the oral dose. The long-acting form (Exalgo) is used for opioid-tolerant patients with chronic severe pain (DEA, 2022).

Methadone can be given intravenously, subcutaneously, intramuscularly, or orally. Methadone has a high risk of overdose. It has a half-life of up to five days and may accumulate in the body. Methadone may also prolong the QT interval, leading to cardiac arrhythmias, especially at doses higher than 120 milligrams (mg) daily. Methadone should be used for severe pain that has not been responsive to other agents and only by clinicians with specific training in using methadone. Methadone is also used in detoxification (Durrani & Bansal, 2024).

Tapentadol (Nucynta®, Nucynta® ER) is available in immediate-release and extended-release. It is indicated for diabetic peripheral neuropathy (Freo et al., 2019). Propoxyphene has been taken off the market in the United States as it has been linked with fatal cardiac arrhythmias (FDA, 2018). Meperidine (Demerol) is not recommended as a first-line agent for chronic pain as it is associated with high central nervous system toxicity rates (Yasaei et al., 2023).

Buprenorphine, a Schedule III synthetic opioid, is utilized to treat pain and opioid use disorder. There is a moderate-to-low potential for physical dependence with this drug. Buprenorphine can be administered via a sublingual tablet, buccal film, intravenous or intramuscular injections, and as a subcutaneous or subdermal implant. This drug is also available combined with naloxone in the form of a sublingual tablet. This drug should be tapered or reduced gradually. Adjunctive agents may be necessary to assist with tapering. Adverse effects may include central nervous system depression, nausea and vomiting, memory loss, dizziness, drowsiness, and headache. Contraindications to buprenorphine include known hypersensitivity. Caution is necessary in patients with gastrointestinal obstruction and respiratory depression. Dosages must be altered in patients with liver dysfunction (Kumar et al., 2024).

Benzodiazepines

All benzodiazepines are Schedule IV controlled substances. Benzodiazepines are indicated for alcohol withdrawal, epileptic seizures, generalized anxiety disorder, insomnia, and panic disorder. They have the potential for abuse, addiction, and diversion. Driving, operating machinery, or performing other hazardous tasks while taking a benzodiazepine is unsafe. Alcohol may potentiate these effects. Patients who are co-prescribed benzodiazepines and opioids are at higher risk of overdose (Mcdonald et al., 2017). Dosage and scheduling should be based on the most recent manufacturers' recommendations.

Benzodiazepine should be prescribed for a short course of treatment, no more than two to four weeks. Expectations of clinical benefits must be clear. Do not escalate the dosage without a clear clinical benefit (Mcdonald et al., 2017).

Side Effects

Side effects of benzodiazepines include the following (Mcdonald et al., 2017):

  • Drowsiness
  • Sleepiness
  • Dizziness
  • Amnesia (forgetfulness)
  • Confusion
  • Constipation
  • Nausea
  • Sexual dysfunction
  • Unsteadiness when walking or standing
  • Unusually slow and shallow breathing
  • Vision problems, such as blurred or double vision 

Stop the drug if side effects are not tolerable. Benzodiazepines should be tapered, not abruptly stopped. Withdrawal symptoms may occur with abrupt discontinuation. These symptoms may include convulsions, cramps, insomnia, sweating, tremors, and vomiting. Some people develop a paradoxical reaction to benzodiazepines. This reaction is the opposite of what would be expected. Symptoms can include the following (Mcdonald et al., 2017):

  • Agitation
  • Becoming very anxious
  • Developing hallucinations
  • Difficulty sleeping
  • Exhibiting bizarre behavior
  • Taking unnecessary risks

Drugs

Xanax, also known as alprazolam, is a Schedule IV drug and a commonly prescribed psychotropic; it is often indicated for anxiety and panic disorders. Off-label, it may be used for depression and insomnia. Xanax is available as a regular release and an orally disintegrating tablet. This drug is contraindicated in known hypersensitivity. Using Xanax in patients with pulmonary disease should be avoided, and caution is necessary when using it concurrently with central nervous system depressants, as respiratory depression may result (George & Tripp, 2023).

Ativan, also known as lorazepam, is a benzodiazepine often utilized for anxiety. It has many off-label uses. It is available in various forms, including solutions, extended-release capsules, and tablets. Common adverse effects include sedation, respiratory depression, dizziness, and irritability. Ativan is contraindicated with known hypersensitivity to the drug or other benzodiazepines, in neonates, in patients with respiratory impairment, and in those with sleep apnea. Respiratory status should be monitored closely (Ghiasi et al., 2024).

Klonopin, or clonazepam, is another benzodiazepine often utilized in anxiety and panic disorders. It also has many off-label uses. This medication comes in the form of an orally disintegrating tablet or an immediate-release tablet. Contraindications for Klonopin include known hypersensitivity, narrow-angle glaucoma, and liver disease. Concurrent use with other benzodiazepines may result in respiratory depression and death (Basit & Kahwaji, 2023).

Valium, or diazepam, is a benzodiazepine often used for anxiety disorders and seizures. It comes as an oral tablet, oral solution, intravenous injection, rectal gel, and nasal spray. Close monitoring is necessary if given to patients with renal and hepatic impairment. Contraindications include known hypersensitivity, under six months of age, respiratory impairment, hepatic insufficiency, and myasthenia gravis (Dhaliwal et al., 2023).

Restoril, also known as temazepam, is a benzodiazepine that is used to treat sleep-related disorders and is available in powder forms, liquid, gel, and hard or soft capsules. It has off-label uses, such as for anxiety and panic-related disorders. Restoril is contraindicated in pregnancy and should be used cautiously in patients with narrow-angle glaucoma, sleep apnea, renal and hepatic insufficiency, and those who have major depressive disorder (Fluyau et al., 2024).

Conclusion

The use of controlled substances has risks for the prescriber and the patient. Abuse, misuse, drug diversion, and overdose are potential complications of opioid use.

Prescribers must be knowledgeable in pain assessment, knowledge of addiction, and the appropriate management of pain. Multiple techniques are essential to implement to reduce the risks associated with opioid therapy, including informed consent, controlled substance agreements, screening for drug abuse, patient education, teaching patients about proper storage and disposal of drugs, and monitoring patients using controlled substance monitoring programs.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
No TestAttest that you have read and learned all the course materials.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • Basit, H., & Kahwaji, C. I. (2023). Clonazepam. In: StatPearls. StatPearls Publishing. Visit Source.
  • Centers for Disease Control and Prevention (CDC). (2022). Addiction Medicine Primer. Centers for Disease Control and Prevention. Visit Source.
  • Cofano, S., Patel, P., & Yellon, R. (2024). Hydrocodone. In: StatPearls. StatPearls Publishing. Visit Source.
  • Dhaliwal, J. S., Rosani, A., & Saadabadi, A. (2023). Diazepam. In: StatPearls. StatPearls Publishing. Visit Source.
  • Drug Enforcement Agency (DEA). (2016). FENTANYL (Trade Names: Actiq®, FentoraTM, Duragesic®). Drug Enforcement Agency. Visit Source.
  • Drug Enforcement Agency (DEA). (2022). OXYMORPHONE. Drug Enforcement Agency. Visit Source.
  • Durrani, M., & Bansal, K. (2024). Methadone. In: StatPearls. StatPearls Publishing. Visit Source.
  • Fluyau, D., Ponnarasu, S., & Patel, P. (2024). Temazepam. In: StatPearls. StatPearls Publishing. Visit Source.
  • Food and Drug Administration (FDA). (2018). FDA Drug Safety Communication: FDA recommends against the continued use of propoxyphene. Food and Drug Administration. Visit Source.
  • Freo, U., Romualdi, P., & Kress, H. G. (2019). Tapentadol for neuropathic pain: a review of clinical studies. Journal of pain research, 12, 1537–1551. Visit Source.
  • Fu, Q., Han, N., Li, N., Gui, L., Shi, C., Rong, P., Zeng, F., Rao, H., Chen, Y., & Cancer Rehabilitation and Palliative Treatment Professional Committee of Hubei Anti Cancer Association. (2024). Guidelines for Rational Clinical Use of Fentanyl Transdermal Patch. Drug design, development and therapy, 18, 233–255. Visit Source.
  • George, T. T., & Tripp, J. (2023). Alprazolam. In: StatPearls. StatPearls Publishing. Visit Source.
  • Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2024). Lorazepam. In: StatPearls. StatPearls Publishing. Visit Source.
  • Governor's Cabinet Opiate Action Team. (2016). Ohio Guideline for the Management of Acute Pain Outside of Emergency Departments. Governor's Cabinet Opiate Action Team. Visit Source.
  • Kumar, R., Viswanath, O., & Saadabadi, A. (2024). Buprenorphine. In: StatPearls. StatPearls Publishing. Visit Source.
  • McDonald, J. V., Ayers, V., & Paquin, J. (2017). Practical Considerations for Prescribing Benzodiazepines and Opioids. Rhode Island medical journal (2013), 100(7), 30–32.
  • Murphy, P. B., Bechmann, S., & Barrett, M. J. (2023). Morphine. In: StatPearls. StatPearls Publishing. Visit Source.
  • Ohio Administrative Code (OAC) 4723-9-01. (2021). Definitions. Ohio Administrative Code. Visit Source.
  • Ohio Administrative Code (OAC) 4723-9-08. (2021). Safety standards for personally furnishing drugs and therapeutic devices. Ohio Administrative Code. Visit source.
  • Ohio Administrative Code (OAC) 4723-9-10. (2022). Formulary; standards of prescribing for advanced practice registered nurses designated as clinical nurse specialists, certified nurse-midwives, or certified nurse practitioners. Ohio Administrative Code. Visit Source.
  • Ohio Administrative Code (OAC) 4723-9-12. (2021). Standards and procedures for review of OARRS. Ohio Administrative Code. Visit Source.
  • Ohio Revised Code (ORC) 4723.481. (2023). Authority of APRN designated as clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner to prescribe drugs and therapeutic devices. Ohio Revised Code. Visit Source.
  • Ohio Revised Code (ORC) 4723.481. (2024). Authority of APRN designated as clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner to prescribe drugs and therapeutic devices. Ohio Revised Code. Visit Source.
  • Ohio Revised Code (ORC) 4723.489. (2017). Delegated authority to administer drugs. Ohio Revised Code. Visit Source.
  • Ohio Revised Code (ORC) 3719.061. (2023). Prescription of opioids to minors. Ohio Revised Code. Visit Source.
  • Paul, A. K., Smith, C. M., Rahmatullah, M., Nissapatorn, V., Wilairatana, P., Spetea, M., Gueven, N., & Dietis, N. (2021). Opioid Analgesia and Opioid-Induced Adverse Effects: A Review. Pharmaceuticals (Basel, Switzerland), 14(11), 1091. Visit Source.
  • Ramos-Matos, C. F., Bistas, K. G., & Lopez-Ojeda, W. (2023). Fentanyl. In: StatPearls. StatPearls Publishing. Visit Source.
  • RecoveryOhio. (2024). 2024-2027 Strategic Plan: Executive Summary. RecoveryOhio. Visit Source.
  • Sadiq, N. M., Dice, T. J., & Mead, T. (2024). Oxycodone. In: StatPearls. StatPearls Publishing. Visit Source.
  • Subedi, M., Bajaj, S., Kumar, M. S., & Yc, M. (2019). An overview of tramadol and its usage in pain management and future perspective. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 111, 443–451. Visit Source.
  • Yasaei, R., Rosani, A., & Saadabadi, A. (2023). Meperidine. In: StatPearls. StatPearls Publishing. Visit Source