Safe Opioid Prescribing and Controlled Substance Policies

  • Daniel G. TobinEmail author
  • Ernie-Paul Barrette


Chronic opioid therapy is frequently utilized when patients suffer from persistently severe and disabling pain, but it is often associated with a myriad of prescribing challenges and clinical risks. This chapter explores the potential risks and benefits of chronic opioid use and how to anticipate, prevent, and mitigate these risks in a busy academic outpatient clinic.


Opioids Chronic pain Controlled substances 


  1. 1.
    Institute of Medicine (U.S.). Committee on Advancing Pain Research Care and Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, D.C.: National Academies Press; 2011. Google Scholar
  2. 2.
    Roehr B. US needs new strategy to help 116 million patients in chronic pain. BMJ. 2011;343:d4206.CrossRefPubMedGoogle Scholar
  3. 3.
    Breuer B, Pappagallo M, Tai JY, Portenoy RK. U.S. board-certified pain physician practices: uniformity and census data of their locations. J Pain. 2007;8(3):244–50.CrossRefPubMedGoogle Scholar
  4. 4.
    Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a national institutes of health pathways to prevention workshop. Ann Intern Med. 2015;162(4):276–86.CrossRefPubMedGoogle Scholar
  5. 5.
    Committee on Advancing Pain Research Care, Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press; 2011. Report No.: 030921484X.Google Scholar
  6. 6.
    Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–30.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Painter JT, Crofford LJ. Chronic opioid use in fibromyalgia syndrome: a clinical review. J Clin Rheumatol. 2013;19(2):72–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of P. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–30.CrossRefPubMedGoogle Scholar
  9. 9.
    Tobin DG, Andrews R, Becker WC. Prescribing opioids in primary care: safely starting, monitoring, and stopping. Cleve Clin J Med. 2016;83(3):207–15.CrossRefPubMedGoogle Scholar
  10. 10.
    The Opioid Epidemic: By the Numbers: Department of Health and Human Services; 2016 [updated June, 2016].
  11. 11.
    Bronstein K, Passik S, Munitz L, Leider H. Can clinicians accurately predict which patients are misusing their medications? Austin; 2011. American Pain Society 30th Annual Scientific Meeting; 18–21 May 2011.Google Scholar
  12. 12.
    Webster LR. Opioid-induced constipation. Pain Med. 2015;16(Suppl 1):S16–21.CrossRefPubMedGoogle Scholar
  13. 13.
    Brennan MJ. The effect of opioid therapy on endocrine function. Am J Med. 2013;126(3 Suppl 1):S12–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145–61.PubMedGoogle Scholar
  15. 15.
    McCance-Katz EF, Sullivan LE, Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: a review. Am J Addict. 2010;19(1):4–16.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Paulozzi L, Dellinger A, Degutis L. Lessons from the past. Injury Prev. 2012;18(1):70.CrossRefGoogle Scholar
  17. 17.
    Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315–21.CrossRefPubMedGoogle Scholar
  19. 19.
    U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA warns about serious risks and death when combining opioid pain or cough medicines with benzodiazepines; requires its strongest warning 2016 [updated 31 Aug 2016].
  20. 20.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–45.CrossRefPubMedGoogle Scholar
  21. 21.
    American Psychiatric Association. DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association; 2013. xliv, 947p.Google Scholar
  22. 22.
    Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569–76.CrossRefPubMedGoogle Scholar
  23. 23.
    Longo LP, Parran T, Johnson B, Kinsey W. Addiction: part II. Identification and management of the drug-seeking patient. Am Fam Physician. 2000;61(8):2401–8.PubMedGoogle Scholar
  24. 24.
    Eichorn D, Lesenskyj A, Maxwell C, Moore S, Cruciani R. (195) The feasibility and value of using the SOAPP(R)-R to predict substance abuse in an outpatient pain clinic. J Pain. 2016;17(4S):S24.CrossRefGoogle Scholar
  25. 25.
    Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–42.CrossRefPubMedGoogle Scholar
  26. 26.
    Nicolaidis C. Police officer, deal-maker, or health care provider? Moving to a patient-centered framework for chronic opioid management. Pain Med. 2011;12(6):890–7.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Krebs EE, Lorenz KA, Bair MJ, Damush TM, Wu J, Sutherland JM, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009;24(6):733–8.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Penko J, Mattson J, Miaskowski C, Kushel M. Do patients know they are on pain medication agreements? Results from a sample of high-risk patients on chronic opioid therapy. Pain Med. 2012;13(9):1174–80.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    McGee S, Silverman RD. Treatment agreements, informed consent, and the role of state medical boards in opioid prescribing. Pain Med. 2015;16(1):25–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Tobin DG, Keough Forte K, Johnson McGee S. Breaking the pain contract: a better controlled-substance agreement for patients on chronic opioid therapy. Cleve Clin J Med. 2016;83(11):827–35.CrossRefPubMedGoogle Scholar
  31. 31.
    Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, Turner BJ. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152(11):712–20.CrossRefPubMedGoogle Scholar
  32. 32.
    King S. How useful are patient opioid agreements and urine drug testing? | Psychiatric Times 2011.
  33. 33.
    Cotugna N, Vickery CE, Carpenter-Haefele KM. Evaluation of literacy level of patient education pages in health-related journals. J Community Health. 2005;30(3):213–9.CrossRefPubMedGoogle Scholar
  34. 34.
    U.S. Department of Justice, Office of Diversion Control, Title 21 Code of Federal Regulations - PART 1300 - DEFINITIONS 2015.
  35. 35.
    United States. Congress. Senate. Committee on Health Education Labor and Pensions. Prescription drug abuse and diversion: the role of prescription drug monitoring programs: hearing before the Committee on Health, Education, Labor, and Pensions, United States Senate, One Hundred Eighth Congress, second session, on examining drug abuse prevention issues, focusing on the role of prescription drug monitoring programs, and federal privacy standards for PMPS, September 23, 2004. Washington: U.S. G.P.O.: For sale by the Supt. of Docs., U.S. G.P.O.; 2005. iii, 57p.Google Scholar
  36. 36.
    Centers for Medicare and Medicaid Services. Tamper resistant prescriptions 2013 [updated April 9, 2013].
  37. 37.
    Nelson LS, Perrone J. Curbing the opioid epidemic in the United States: the risk evaluation and mitigation strategy (REMS). JAMA. 2012;308(5):457–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65(1):1–49.CrossRefPubMedGoogle Scholar
  39. 39.
  40. 40.
    Dasgupta A. Urinary adulterants and drugs-of-abuse testing. MLO Med Lab Obs. 2003;35(2):26–8, 30–1.PubMedGoogle Scholar
  41. 41.
    Cone EJ, Bigelow GE, Herrmann ES, Mitchell JM, LoDico C, Flegel R, et al. Non-smoker exposure to secondhand cannabis smoke. I. Urine screening and confirmation results. J Anal Toxicol. 2015;39(1):1–12.CrossRefPubMedGoogle Scholar
  42. 42.
    Röhrich J, Schimmel I, Zörntlein S, Becker J, Drobnik S, Kaufmann T, et al. Concentrations of delta9-tetrahydrocannabinol and 11-nor-9-carboxytetrahydrocannabinol in blood and urine after passive exposure to Cannabis smoke in a coffee shop. J Anal Toxicol. 2010;34(4):196–203.CrossRefPubMedGoogle Scholar
  43. 43.
    Niedbala RS, Kardos KW, Fritch DF, Kunsman KP, Blum KA, Newland GA, et al. Passive cannabis smoke exposure and oral fluid testing. II. Two studies of extreme cannabis smoke exposure in a motor vehicle. J Anal Toxicol. 2005;29(7):607–15.CrossRefPubMedGoogle Scholar
  44. 44.
    Tobin DG. A rational approach to opioid use disorder in primary care. Cleve Clin J Med. 2017;84(5):385–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Martin BC, Fan MY, Edlund MJ, Devries A, Braden JB, Sullivan MD. Long-term chronic opioid therapy discontinuation rates from the TROUP study. J Gen Intern Med. 2011;26(12):1450–7.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    National Guideline Clearinghouse. Interagency guideline on opioid dosing for chronic non-cancer pain: an educational aid to improve care and safety with opioid therapy. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2010.
  47. 47.
    U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Partners in integrity: what is the prescriber’s role in preventing the diversion of prescription drugs 2014.
  48. 48.
    U.S. Food and Drug Administration. Disposal of unused medicines: what you should know 2017 [updated April 21, 2017].

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Yale-New Haven HospitalYale University School of MedicineNew HavenUSA
  2. 2.Barnes Jewish HospitalWashington University School of MedicineSt. LouisUSA

Personalised recommendations