The list of Schedule I includes marijuana, heroin, and LSD. We will discuss only the one currently being used for pain medication. There are forty-six states where all forms of medical marijuana are legal (Anderson & Rees, 2023). This is a controversial moment in the history of Marijuana legalization by the states because the drug is still classified as Schedule I by the Federal government. The VA and Federal Bureau of Prisons do not allow marijuana for their patients. If they have marijuana show up on a drug test, they will be penalized (VA, 2022). There is currently no consensus on what or when a change might be made, as marijuana could be reclassified (rescheduled), or perhaps as it is legal for recreational use in many states, it might be decriminalized federally (Celeste & Thompson-Dudiak, 2021). In 2017 West Virginia made medical marijuana legal for a limited number of ailments per the West Virginia Medical Cannabis Act (2017). A Provider must have special training to prescribe cannabinoids and belong to a registry of trained providers to prescribe cannabinoids in some states, including West Virginia. While there are no longitudinal studies of pain relief due to cannabinoids, there is empirical evidence that patients use them to relieve pain instead of opioids in some cases (Bicket et al., 2023). It remains to be seen if using these products for pain affects the opioid crisis (Bicket et al., 2023; Tormohlen et al., 2021).
Legal and Regulatory: In West Virginia, since 2017, Medical Marijuana use has been legalized for Cancer, HIV/AIDS, ALS, Parkinson’s disease, multiple sclerosis, spinal cord damage, epilepsy, neuropathies, Huntington’s disease, Crohn’s disease, PTSD, intractable seizures, sickle cell anemia, or severe chronic or intractable pain.
These medications have the strictest regulations when compared to other prescription drugs because they are the most likely to be abused, diverted, or addicting. They include hydromorphone, meperidine, methadone, morphine, and oxycodone.
Morphine is used to treat soft tissue pain but also has been used to treat arthritis when other medications have failed. Embeda® is a combination with naltrexone for the opioid naïve patient, 20 mg/0.8 mg PO every 24 hours. Extended-release forms of morphine, such as MS Contin, should only be used for opioid-tolerant patients accustomed to ingesting over 400 mg/day. Morphine in selected forms should be used cautiously for patients with variable respiratory diseases such as COPD, obstructive asthma, hepatic or renal dysfunction, brain injury, increased intracranial pressure, or severe hypotension.
Hydromorphone, Dilaudid is a semisynthetic, phenanthrene opioid agonist. For the treatment of persistent, severe pain that requires an extended treatment period with a daily opioid and for which alternative treatments are inadequate.
Fentanyl is supplied as a sublingual, transmucosal, and nasal spray, transdermal patches, sublingual tablets, buccal lozenge, transmucosal lozenge, intramuscular injections, transmucosal tablets, IV injections, and electrically controlled transdermal patch. Different preparations of fentanyl are not interchangeable from microgram to microgram, even if administered via the same route. With the most popular clinic-level form, the transdermal 72-hour patch, providers should use a conversion table from other opiates used in the previous 24 hours to MME's then convert to fentanyl micrograms per hour.
Patients may use short-acting opioid agonists for the first 24 hours after stopping all other opiates at fentanyl patch initiation.
Hydrocodone/Apap is a semisynthetic opiate agonist and a non-salicylate analgesic.
Opioid use requires an experienced clinician knowledgeable about the use of opioids, including the use of extended-release and long-acting opioids and how to mitigate the associated risks. All opiates have similar side effect profiles. From most to least severe, they cause all the obvious symptoms of CNS depression, such as decreased level of consciousness, increased respiratory depression, nausea, vomiting, constipation, slow gastric transit, and dry mouth. Unfortunately, hormonal, and immunological dysfunction can happen with chronic use, physical dependence, tolerance, and rarely hyperalgesia.
Schedule III drugs have a lower misuse and addiction potential than I and II. Medications in this category are often used for pain control or anesthesia. Drugs in this category may cause physical dependence but more commonly lead to psychological dependence. Examples of Schedule III substances include ketamine, opioid analgesics in this schedule include products containing not more than 90 mg of codeine per dosage unit, and buprenorphine/naloxone oral film.
These drugs are considered to have less likelihood of dependence and abuse. Carisoprodol is a centrally acting skeletal muscle relaxant and salicylate analgesic. It is used for musculoskeletal conditions such as muscle spasms. Tramadol is an opiate sometimes used for patients experiencing intractable pain because of its impact on peripheral pain pathways, partial inhibition of serotonin reuptake, and low affinity for opioid receptors. This is thought to result in less sedation, respiratory depression, and potential for tolerance; however, constipation can still be problematic because of anticholinergic adverse effects.
Medications containing codeine must have less than 200 mg of codeine per 100 mL (i.e.cough syrups). Tylenol #3® and Tylenol #4® are an oral combination of analgesics, acetaminophen mixed with codeine, which include an opioid agonist. Codeine as an opiate has all the same side effects and adverse effects as other opioids. This medication may mistakenly be less protected from children, pets, or other adults because of the Tylenol® name.
Tizanidine/Zanaflex is a centrally acting muscle relaxant similar chemically to clonidine, and works about as well as baclofen. Cyclobenzaprine/Flexeril is a muscle relaxant for acute musculoskeletal pain.
Naloxone is an opioid antagonist, a derivative of oxymorphone employed for reversing the central nervous system and respiratory depression caused by opioid overdose. Auto-injectors and nasal formulations are available to treat or prevent an overdose outside of the healthcare setting. Naloxone nasal insufflation may be used in adults, children, and even infants at both the 4 and 8mg doses.
Medicaid, Medicare, and most insurances cover Naloxone. There are free Naloxone programs nationwide and prescription cards that can reduce the costs of prescribed Naloxone to about $20.00 per kit. It should be remembered that as an opioid antagonist, it can precipitate a complete and sudden opioid withdrawal crisis for the patient. In the pain patient, too much Naloxone can also remove all analgesic effects of the opioid being reversed. This can be extremely dangerous, even fatal, for an opioid-addicted infant and extremely uncomfortable for the opioid-addicted in other age groups. Think severe instant withdrawal, a trip to the hospital to combat this may be necessary. The half-life of the nasal spray is comparable to the injection at about 2 hours. When given for fentanyl overdose, it may have to be repeated as fentanyl and other synthetic drugs, such as carfentanil related to fentanyl, are 10,000 times stronger than morphine. Naloxone should be used cautiously with patients taking buprenorphine and Cobistat concurrently with HIV protease inhibitors (PDR, 2023). As of this writing, Naloxone has been made an over-the-counter medication by the FDA.
Buprenorphine is prescribed for patient support while tapering off opioid addiction and can be combined with naloxone to make a medication called Suboxone®.
Methadone is structurally unrelated to morphine, and Methadone is a Schedule II synthetic opiate agonist. Used in medically supervised opiate withdrawal and maintenance programs; also effective for relieving severe or chronic pain. For the treatment of opiate dependence, prescribers must register and comply with the Narcotic Addict Treatment Act (NATA) [21USC 823(g)].
Flumazenil/Romazicon Is not available commercially in an intranasal spray. Therefore, the overdosed patient must be transported immediately to the hospital for care. It treats benzodiazepine overdose, reverses benzodiazepine-induced sedation, and antagonizes the actions of zolpidem. It does not reverse the actions of barbiturates, opiate agonists, or tricyclic antidepressants.