≥ 92% of participants will know how to prescribe controlled substances based on best practices and Ohio law.
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.
≥ 92% of participants will know how to prescribe controlled substances based on best practices and Ohio law.
After completing this course, the participant will be able to:
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.
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).
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):
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):
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).
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.
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.
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).
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.
An adult has to give written consent for the treatment of minors. A minor is anyone under 18 who is not emancipated.
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.
These restrictions do not apply when an opioid analgesic meets any of the following (ORC 3719.061, 2023):
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):
When considering these possibilities, the APRN should use sound clinical judgment and consider obtaining and reviewing an OARRS report.
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.
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:
Alternatives include the following: gabapentin/pregabalin, skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, and tricyclic antidepressants (GCOAT, 2016).
Alternatives include the following: dicyclomine, skeletal muscle relaxants, serotonin-norepinephrine reuptake inhibitors, topical anesthetics, and tricyclic antidepressants (GCOAT, 2016).
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).
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.
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):
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.
Each initiative has a problem statement, an outcome, and a scope, with the overall goal of removing barriers and enhancing care (RecoveryOhio, 2024).
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.
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.
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).
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.
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).
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).
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).
All benzodiazepines are Schedule IV controlled substances.
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).
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.
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).
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.
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.