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Special Prescribing Circumstances


Prescribing to Patients with Substance Use Disorder

Patients with substance use disorder with medically legitimate pain sufficient to justify opioids must be closely monitored, including through random urine drug screening, reviews using a prescription drug monitoring program, appointment visits, and consultation with a subspecialist. Addiction medicine comanagement may be necessary. Detailed documentation is vital.

Response to Potentially Aberrant Behavior

Patient treatment must be individualized, including responses to potential aberrant behavior, on the basis of the entirety of the information. Prescription forgery or theft would generally require involvement of law enforcement. Overdose would require treatment modification and at times medication discontinuation. At the other end of the spectrum, rare diversion of a few tablets to a family member for emergent, acute pain or a one-time aberrant finding on a urine drug screen may warrant a documented discussion with the patient and closer monitoring.

If it becomes apparent that the patient is not using these medications for medically legitimate purposes, the opioid dosage must be rapidly tapered.31Abusive or violent behavior by the patient also requires immediate intervention. Options include addiction medicine specialists and buprenorphine treatment. Tapering of opioid dosages and the management of substance use disorder are difficult issues and beyond the scope of this article.

Kidney, Liver, Heart, and Lung Disease

Diseases of each of these organ systems may affect or be affected by treatment with opioids and other controlled substances. Liver disease makes using acetaminophen difficult, and renal disease often prevents the use of nonsteroidal anti-inflammatory medications. When possible, use noncontrolled substance medications, and when opioids are necessary, use lower dosage strengths and quantities with very close monitoring. Additional treatments to consider may include heat or ice, exercise, physical therapy, topical analgesic creams, and alternative medicine approaches.

Dangerous Drug Combinations

Physicians must beware of dangerous drug combinations. Sometimes dangerous combination are prescribed for medically legitimate reasons, without recognition of the dangers. However, other times they are requested by the patient because they are popular in the recreational drug community and commonly diverted. These combinations place the patient at additional risk of overdose and death, as does concurrent use of alcohol and other sedating medications (both prescriptions and over-the-counter). The use of fentanyl transdermal patches and long-acting opioids in opioid-naïve patients also places the patient at a higher risk of oversedation and overdose. Dangerous drug combinations also include the following:

  • “Trinity” or “Holy Trinity”: Opioid plus benzodiazepine plus carisoprodol
  • “Sizzurp”: Promethazine with codeine cough syrup plus Jolly Rancher fruit-flavored hard candy (The Hershey Company, Hershey, PA) plus fruit-flavored soda (eg, Sprite [The Coca Cola Company, Atlanta, GA])
  • Opioids and benzodiazepines (FDA black box warning).