With the opioid epidemic, there are concerns about using controlled substances for pain management.
Dr. Mary Lyster describes how prescriptions for controlled substances work, and how South County Health manages patients who need these medications.
Selected Podcast
Controlled Substance Management and Primary Care
Featuring:
Learn more about Mary Lyster, MD
Mary Lyster, MD, MPA
Mary Lyster, MD is a family medicine specialist in Charlestown, RI and has been practicing for 31 years. She graduated from Brown Medical School in 1984 and specializes in family medicine.Learn more about Mary Lyster, MD
Transcription:
Prakash Chandran (Host): Today we’re talking about controlled substances, what they are, who prescribes them and how you can manage taking them properly. Here with us to discuss is Dr. Mary Lyster, a Primary Care physician at South County Health. Dr. Lyster, thanks so much for being here today.
Mary Lyster, MD, MPA, FAAFP (Guest): My pleasure. Thank you for inviting me.
Prakash: Of course. So, let’s start with the basics. For those that might not know, what exactly is a controlled substance and how might it differ from the over-the-counter medicine that we are used to getting at our local pharmacy?
Dr. Lyster: Yeah, there’s a huge difference. A controlled substance is a medication that’s regulated by the Federal Drug Enforcement Agency. The DEA. And the DEA is fairly strict about this. They classify them into five distinct categories or what they call schedules, depending on the drug’s medical use and the drug’s potential for abuse or dependency.
Prakash: I see, so is this – is a controlled substance something like a prescribed – any prescribed medication that is given to you by your doctor or are there specific ones that categorize themselves as controlled substances?
Dr. Lyster: Most medications prescribed by doctors are not controlled substances and the Drug Enforcement Agency limits itself to those that have the most abuse potential, so those would be pain medications like Vicodin, oxycodone, anxiety medicine, sleep medicines, Valium, Ativan, Ambien, and then also the medicines we call stimulants; the ones that are used to treat conditions like attention deficit disorder because they do have abuse potential. An over-the-counter medicine is something that can be obtained with no prescription whatsoever.
Prakash: So, who are the controlled substances that we are talking about usually prescribed by?
Dr. Lyster: A controlled substance can be prescribed by a physician, MD or DO, a nurse practitioner, and a physician assistant provided they have the appropriate licenses. Here in Rhode Island, a prescriber actually requires three licenses in order to prescribe a controlled substance. First you need a state license to practice medicine, you need a state license to prescribe controlled substances and you need a federal DEA license.
Prakash: And you mentioned some pretty heavy drugs that have the tendency or can be abused. So, when we talk about controlled substance management, what does that exactly mean? Does that mean just ensuring to the instructions on the label and nothing else? Maybe talk a little bit about that.
Dr. Lyster: That’s an excellent question and one that has changed a great deal as have the laws around it in states. And here in Rhode Island, I think we have an excellent set of guidelines and requirements. So, controlled substance management really means trying to provide the best and the safest care by thoroughly evaluating a patient, the same way we would for diabetes or a heart condition, using the best scientific evidence we have of what works best, educating patients about the risks and benefits, exploring options in addition to pills and of course, it involves obeying both state and federal laws regarding how to prescribe them, how to monitor patients and in some cases, how to restrict quantities. So, the current Rhode Island laws are very precise about what we should be doing for patients around controlled substance prescribing. Yet at the same time, gives the provider the latitude to prescribe to meet patient needs.
Prakash: So, where do you see most of the abuse happening today? Because I imagine that even if people don’t intend to overuse these substances, it might happen.
Dr. Lyster: Well I think that’s a great question and it’s kind of a call for some definitions we use around controlled substances. So, first of all, when we say abuse; abuse is an outright using a medication for a reason other than that for which it’s prescribed, such as intentionally using it to get high or selling it. Misuse on the other hand, is using a medication incorrectly, if the patient is taking it too often, or more than is directed and then the other category we deal with that could come under abuse is what we call diversion. Someone giving away or selling their medications to someone else. So, those are very distinct differences and I think abuse is something we don’t really see that often in the office and can be identified fairly quickly by using a few tools. On the other hand, if a patient is overusing their medicine because their pain isn’t relieved, that’s a different situation. The other situation that gets people into trouble is the combination of drugs. And that’s something that we as physicians have to be very diligent about. We need to know everything the patient is taking in addition to what we prescribe, what are they using over-the-counter, vitamins, herbal supplements, what are they obtaining from other providers and those are really the things that create a climate of safety for prescribing.
Prakash: I see what you are saying and it’s good to delineate between abuse and misuse. And I feel like it’s a slippery slope because when I had my wisdom teeth pulled; I felt like the dose of Vicodin that they gave me just wasn’t enough and I felt like I needed to take something else to numb the pain. And I’m sure there’s a lot of people in a similar circumstance. So, what might you recommend to them?
Dr. Lyster: Well, once again, it’s helpful to go back to some definitions and some hard evidence. You’re talking about a situation that is acute pain, which is very different from treating chronic pain. What we know is that acute pain should be treated hard and fast. Put the medicine on quickly, take care of the pain and then get rid of it quickly. That’s because the brain can have a memory for pain and the more quickly you get rid of that pain; the less likely it is to become chronic. The situation you described is something we call pseudo tolerance. Tolerance is when the body gets used to the medicine and needs more. In your case however, it sounds like the medicine you got didn’t hit your pain threshold and you needed more to relieve your pain. Not because your body was tolerant and not because you were intending its misuse.
Prakash: I see. So, what is a good framework that you feel, that people should follow when they are up against these things? It sounds like for me, it might have been okay because it’s not that chronic pain, it’s just something that wasn’t given to me that fixes that immediate pain, but is there a general framework that you feel that when people are prescribed these things that they should be really looking at so they don’t – so misuse doesn’t happen?
Dr. Lyster: There is actually a very precise format and here in Rhode Island, I just would like to give high praise to Dr. James MacDonald and the Board of Medical Licensure Discipline for outlining that for us and providing us with the tools to do it. So, it’s basically no different than any other form of good medicine. We should be taking a medical history and a physical examination that includes assessing the pain, physical, psychological, social function, personal and family history of substance abuse, alcohol abuse, identify any other conditions or diseases that may impact it. And clearly state what are we treating with this pain. In addition to that, we use certain instruments to screen patients to find out what might their abuse potential be and those identified people, who may have a tendency which is genetic toward addiction. Perhaps most importantly is the conversation we are required to have and should have with patients about the risk of opioids before prescribing, we are required to speak with patients about the risks and the benefits and give them handouts. And that’s not necessary just on the first visit, we have to do that for at least the second and third visits.
So, letting people know the risk of developing dependence or addiction, letting them know the dangers of using alcohol or other sedating medicines, highlighting that it could impair their ability to drive safely or climb a ladder, the necessity of keeping their medications secure and I think what is overlooked a lot is exploring alternative treatments; non-pain medicine, non-opioid treatments such as physical therapy. A great deal of pain is associated with things like trauma and depression. Elucidating those conditions and appropriately referring and my particular emphasis is not only on what I’m going to give the patient, but what I’m going to ask them to do on their own behalf.
Prakash: Yeah it seems like there’s a lot of responsibility also on the patient to just be their own advocate because as you said, the person that’s prescribing them has a responsibility to tell them about the side effects and the potential for the misuse; but we also really have to be proactive when we are prescribed these medications to really take care of ourselves to look at our family history. So, that’s super informative. Is there anything else that you would like us to know about controlled substance management?
Dr. Lyster: Well a couple of things that are new. We are also required to prescribe something called Narcan, you may have heard about it on the news, all firefighters, police officers, rescue personnel carry it and it’s basically antidote, should someone become over sedated or unconscious. In Rhode Island, the law requires us to prescribe it if someone is taking a combination of narcotics and sedatives or if someone is taking a narcotic alone above a certain amount and this can really be lifesaving. So, in our practice here at South County Medical Group in East Greenwich, we prescribe Narcan for every patient on a controlled substance. We educate people about it and prescribe a handout. Also recommend that they take that prescription to the pharmacy with their closest contact and that person be taught how to use it.
Prakash: Okay, that’s good to know about Narcan. So, Dr. Lyster, thank you so much for your time today. I think there’s – it’s such a comprehensive world in controlled substance and it’s important to be aware of a lot of the things that you are talking about to manage it properly and it really sounds like South County does a great proactive job in making sure that patients are informed when they are prescribed these medications. So, for more information please visit www.southcountyhealth.org, that’s www.southcountryhealth.org. This is South County Health Talks from South County Health. I’m Prakash Chandran. Thanks so much for listening.
Prakash Chandran (Host): Today we’re talking about controlled substances, what they are, who prescribes them and how you can manage taking them properly. Here with us to discuss is Dr. Mary Lyster, a Primary Care physician at South County Health. Dr. Lyster, thanks so much for being here today.
Mary Lyster, MD, MPA, FAAFP (Guest): My pleasure. Thank you for inviting me.
Prakash: Of course. So, let’s start with the basics. For those that might not know, what exactly is a controlled substance and how might it differ from the over-the-counter medicine that we are used to getting at our local pharmacy?
Dr. Lyster: Yeah, there’s a huge difference. A controlled substance is a medication that’s regulated by the Federal Drug Enforcement Agency. The DEA. And the DEA is fairly strict about this. They classify them into five distinct categories or what they call schedules, depending on the drug’s medical use and the drug’s potential for abuse or dependency.
Prakash: I see, so is this – is a controlled substance something like a prescribed – any prescribed medication that is given to you by your doctor or are there specific ones that categorize themselves as controlled substances?
Dr. Lyster: Most medications prescribed by doctors are not controlled substances and the Drug Enforcement Agency limits itself to those that have the most abuse potential, so those would be pain medications like Vicodin, oxycodone, anxiety medicine, sleep medicines, Valium, Ativan, Ambien, and then also the medicines we call stimulants; the ones that are used to treat conditions like attention deficit disorder because they do have abuse potential. An over-the-counter medicine is something that can be obtained with no prescription whatsoever.
Prakash: So, who are the controlled substances that we are talking about usually prescribed by?
Dr. Lyster: A controlled substance can be prescribed by a physician, MD or DO, a nurse practitioner, and a physician assistant provided they have the appropriate licenses. Here in Rhode Island, a prescriber actually requires three licenses in order to prescribe a controlled substance. First you need a state license to practice medicine, you need a state license to prescribe controlled substances and you need a federal DEA license.
Prakash: And you mentioned some pretty heavy drugs that have the tendency or can be abused. So, when we talk about controlled substance management, what does that exactly mean? Does that mean just ensuring to the instructions on the label and nothing else? Maybe talk a little bit about that.
Dr. Lyster: That’s an excellent question and one that has changed a great deal as have the laws around it in states. And here in Rhode Island, I think we have an excellent set of guidelines and requirements. So, controlled substance management really means trying to provide the best and the safest care by thoroughly evaluating a patient, the same way we would for diabetes or a heart condition, using the best scientific evidence we have of what works best, educating patients about the risks and benefits, exploring options in addition to pills and of course, it involves obeying both state and federal laws regarding how to prescribe them, how to monitor patients and in some cases, how to restrict quantities. So, the current Rhode Island laws are very precise about what we should be doing for patients around controlled substance prescribing. Yet at the same time, gives the provider the latitude to prescribe to meet patient needs.
Prakash: So, where do you see most of the abuse happening today? Because I imagine that even if people don’t intend to overuse these substances, it might happen.
Dr. Lyster: Well I think that’s a great question and it’s kind of a call for some definitions we use around controlled substances. So, first of all, when we say abuse; abuse is an outright using a medication for a reason other than that for which it’s prescribed, such as intentionally using it to get high or selling it. Misuse on the other hand, is using a medication incorrectly, if the patient is taking it too often, or more than is directed and then the other category we deal with that could come under abuse is what we call diversion. Someone giving away or selling their medications to someone else. So, those are very distinct differences and I think abuse is something we don’t really see that often in the office and can be identified fairly quickly by using a few tools. On the other hand, if a patient is overusing their medicine because their pain isn’t relieved, that’s a different situation. The other situation that gets people into trouble is the combination of drugs. And that’s something that we as physicians have to be very diligent about. We need to know everything the patient is taking in addition to what we prescribe, what are they using over-the-counter, vitamins, herbal supplements, what are they obtaining from other providers and those are really the things that create a climate of safety for prescribing.
Prakash: I see what you are saying and it’s good to delineate between abuse and misuse. And I feel like it’s a slippery slope because when I had my wisdom teeth pulled; I felt like the dose of Vicodin that they gave me just wasn’t enough and I felt like I needed to take something else to numb the pain. And I’m sure there’s a lot of people in a similar circumstance. So, what might you recommend to them?
Dr. Lyster: Well, once again, it’s helpful to go back to some definitions and some hard evidence. You’re talking about a situation that is acute pain, which is very different from treating chronic pain. What we know is that acute pain should be treated hard and fast. Put the medicine on quickly, take care of the pain and then get rid of it quickly. That’s because the brain can have a memory for pain and the more quickly you get rid of that pain; the less likely it is to become chronic. The situation you described is something we call pseudo tolerance. Tolerance is when the body gets used to the medicine and needs more. In your case however, it sounds like the medicine you got didn’t hit your pain threshold and you needed more to relieve your pain. Not because your body was tolerant and not because you were intending its misuse.
Prakash: I see. So, what is a good framework that you feel, that people should follow when they are up against these things? It sounds like for me, it might have been okay because it’s not that chronic pain, it’s just something that wasn’t given to me that fixes that immediate pain, but is there a general framework that you feel that when people are prescribed these things that they should be really looking at so they don’t – so misuse doesn’t happen?
Dr. Lyster: There is actually a very precise format and here in Rhode Island, I just would like to give high praise to Dr. James MacDonald and the Board of Medical Licensure Discipline for outlining that for us and providing us with the tools to do it. So, it’s basically no different than any other form of good medicine. We should be taking a medical history and a physical examination that includes assessing the pain, physical, psychological, social function, personal and family history of substance abuse, alcohol abuse, identify any other conditions or diseases that may impact it. And clearly state what are we treating with this pain. In addition to that, we use certain instruments to screen patients to find out what might their abuse potential be and those identified people, who may have a tendency which is genetic toward addiction. Perhaps most importantly is the conversation we are required to have and should have with patients about the risk of opioids before prescribing, we are required to speak with patients about the risks and the benefits and give them handouts. And that’s not necessary just on the first visit, we have to do that for at least the second and third visits.
So, letting people know the risk of developing dependence or addiction, letting them know the dangers of using alcohol or other sedating medicines, highlighting that it could impair their ability to drive safely or climb a ladder, the necessity of keeping their medications secure and I think what is overlooked a lot is exploring alternative treatments; non-pain medicine, non-opioid treatments such as physical therapy. A great deal of pain is associated with things like trauma and depression. Elucidating those conditions and appropriately referring and my particular emphasis is not only on what I’m going to give the patient, but what I’m going to ask them to do on their own behalf.
Prakash: Yeah it seems like there’s a lot of responsibility also on the patient to just be their own advocate because as you said, the person that’s prescribing them has a responsibility to tell them about the side effects and the potential for the misuse; but we also really have to be proactive when we are prescribed these medications to really take care of ourselves to look at our family history. So, that’s super informative. Is there anything else that you would like us to know about controlled substance management?
Dr. Lyster: Well a couple of things that are new. We are also required to prescribe something called Narcan, you may have heard about it on the news, all firefighters, police officers, rescue personnel carry it and it’s basically antidote, should someone become over sedated or unconscious. In Rhode Island, the law requires us to prescribe it if someone is taking a combination of narcotics and sedatives or if someone is taking a narcotic alone above a certain amount and this can really be lifesaving. So, in our practice here at South County Medical Group in East Greenwich, we prescribe Narcan for every patient on a controlled substance. We educate people about it and prescribe a handout. Also recommend that they take that prescription to the pharmacy with their closest contact and that person be taught how to use it.
Prakash: Okay, that’s good to know about Narcan. So, Dr. Lyster, thank you so much for your time today. I think there’s – it’s such a comprehensive world in controlled substance and it’s important to be aware of a lot of the things that you are talking about to manage it properly and it really sounds like South County does a great proactive job in making sure that patients are informed when they are prescribed these medications. So, for more information please visit www.southcountyhealth.org, that’s www.southcountryhealth.org. This is South County Health Talks from South County Health. I’m Prakash Chandran. Thanks so much for listening.