Preceptor Consensus Guidelines for Long-Term Prescribing of Opiates and Controlled Substances

1. Any time a patient is started on a new controlled substance, there must be an H&P documenting the patient's complaint and an exam of the relevant areas.

The use of an opiate risk assessment tool (DIRE or Opiate Risk Tool) should be documented. Also, the resident should obtain a CURES report and urine tox, and the patient should sign a pain contract. Do not start a controlled substance if the

opiate risk assessment tool says the patient is a poor candidate.

2. Any new prescription for a controlled substance, change in dosing/frequency, or abnormal patient behavior (“yellow flag”) should be discussed with the

preceptor

3. Obtain opiate risk assessment (DIRE etc), CURES report and utox at least yearly. ***Anyone on over morphine equivalent 200 mg/day, methadone

80 mg/day, or a fentanyl 75 mcg patch should be considered high risk (per APC guidelines).

4.If there is evidence of diversion, stop or quick taper all controlled medications.

5.If patient overdoses, consider quick taper of controlled medications.

6. If patient is actively using illegal substances, stop or quick taper all controlled medications and refer.

7. If patient is using prescribed medications for non-therapeutic purposes, stop prescribing and refer (we are not licensed to treat addiction with opiates or

benzodiazepines).

8. Consider that a few "yellow flag" patient issues likely equal one red flag. Multiple patient abnormalities, even in the absence of gross violations of

pain contract, may warrant discontinuation of controlled substances