The DEA has warned pharmacists to watch for Red Flags in controlled prescriptions, and we’ll show you what they are and how to use them therapeutically in practice.
CHRIS AIKEN: The DEA has deputized us to enforce regulations around controlled substances, but they haven’t exactly made those regulations clear. Today, we’ll bring some needed clarity with the 7th Psychopharm Commandment: Controlled Substances Shall Be Controlled.
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief and the author of the Depression and Bipolar Workbook.
KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
CHRIS AIKEN: On May 11, 2023, the COVID-19 public health emergency will come to an end, but there’s another public health emergency that we’re still in the middle of: The opioid crisis. Both of these emergencies have impacted the regulation of controlled substances, and we are on the front lines of that regulation. Today we’ll offer guidance on how to navigate controlled regulations in this emergency climate with the 7th Psychopharm Commandment, but first a replay of the previous 6:
1. Do not worsen mental illness with psych meds, like don’t use antidepressants during mania or psychostimulants in psychotic disorders.
2. Avoid stopping meds abruptly, particularly benzodiazepines, serotonergic antidepressants, and lithium. Patients rank withdrawal problems as one of their top concerns. Unless there’s a dire need to get off the med – like a lamotrigine rash – we recommend stopping psych meds gradually over at least 2 weeks.
3. And that brings us to #3: Stop lamotrigine if any rash develops in the first 3 months of treatment with it. Even mild rashes can progress to fatal ones, and you can’t be sure which way this wind is blowing.
4. Watch out for lithium toxicity by staying on top of drug interactions, dehydration, and your patients age and renal function.
5. Do not give benzodiazepines to patients who have an elevated risk of opioid overdose deaths – benzos increase the overdose risk 4-fold.
Rewind to our Sept-Nov 2022 episodes for more details on the first 5, and we picked up in March with the rest:
6. Honor thy MAOI interactions, and keep up to date on them. Some of the foods and drugs that were prohibited in the old guidelines are safer than we thought.
And today’s #7. Controlled substances shall be controlled.
But first, a preview of the CME test for this episode.
1. Why does the DEA consider cash-paying patients a red flag for substance misuse?
A. Uninsured patients are more likely to misuse drugs
B. Patients involved in criminal activity may be laundering money through cash
C. These patients avoid using credit cards and checks to disguise their identity
D. Patients who have filled excessive controlled substances may pay cash to avoid scrutiny by health care insurance of their prescription patterns
KELLIE NEWSOME: Public health emergencies are a product of 9/11. In the wake of the terrorist attacks, the government realized that its various agencies were not talking to each other, allowing big problems to slip through the small cracks. As part of the reorganization, they granted the secretary of health and human services the power to declare public emergencies, and use that power to pull in other agencies toward a coordinated response. The first use of this power was August 31, 2005, a week into Hurricane Katrina. Since then it has mainly been used for natural disasters and infectious outbreaks, but on October 26, 2017 it was invoked for the opioid crisis, and that state of emergency has been renewed every 3 months thereafter.
That crisis has not ended. Opioid overdose deaths stabilized after the declaration, at around 45,000 per year, but they shot up again during COVID, nearly doubling – up to 80,000 deaths in 2021. The drugs that we prescribe have also got caught up in the problem – first with benzodiazepines, and more recently with psychostimulants. Stimulant overdose deaths have shot up in the past few years, and most of these deaths have involved stimulant-opioid combinations. Most of the stimulants we’re talking about here involve street drugs – methamphetamine – and most of the synthetic opioids that are fueling the death rates are obtained from the streets rather than prescriptions, but that doesn’t change the response.
CHRIS AIKEN: Medicine is a private matter, and patients are used to thinking of it that way. A personal act between them and their physician, and maybe their insurance if someone else is paying for it. But controlled substances are not private. So when I start one I set the stage by telling the patient the prescription is not just between me and them – there’s a third party that watches every prescription – the state DEA – and I won’t be able to prescribe it if anything is amiss there. I’ll print out expectations for them to sign, like no early refills and not getting the drug from multiple prescribers.
And I’ll tell them about the controlled monitoring program. Every state now has a controlled monitoring system – including Missouri – who was the latest and last to sign on in June of 2021, although I understand the Missouri system is not fully operational just yet.
These programs have a long history – the first continuously operating prescription monitoring program was set up in California in 1939. The system was nearly brought down by a Supreme Court challenge in 1977, but the court decided that states do have the authority to collect information on controlled prescriptions as part of its policing powers.
KELLIE NEWSOME: The point here is to set the stage and depersonalize the matter. If treatment goes well, you’ll develop a strong alliance with your patient. You will genuinely care about them, look for their strengths, and grow to like them, but you can’t let those biases stand in the way of your judgment around controls. You may think your patient is kind and well-meaning, and maybe he’s even referred a dozen of his friends to see you, but the DEA is not going to consider those variables when the push comes to shove.
And that push is shoving more and more. Even if you think your prescriptions are appropriate, other doctors who sees them, and the pharmacists who fills them, may not. And if one of those professionals calls you to question the script, consider yourself lucky. The alternative is much worse – we are hearing about people turning their colleagues into the boards or the DEA without giving them the benefit of the doubt.
Last December the DEA started to crack down on pharmacies that were filling inappropriate prescriptions for controlled substances. The DEA has given pharmacists a list of red-flags to watch for, and they are worth knowing. They are
Patients who pay cash at their appointment or for their medication, even if they have insurance. It’s not really about the “cash” – it’s any form of private pay. What’s going on is that the patient may be trying to avoid scrutiny by their health care insurers, who will notify pharmacists when a patient is filling unusual doses or combinations of controls at various locations.
CHRIS AIKEN: The DEA has its own secret language, which you need to know in order to interpret their rules, and you need to follow those rules in order to keep your license. Here’s a primer:
- “Cash” means private pay, including credit cards and checks.
- “Narcotic” means opioids, and only opioids, while in common use – and in Webster’s dictionary - “narcotic” means any drug with an abuse potential.
KELLIE NEWSOME: Here’s some more red flags from the DEA vaults:
Patients who are on multiple controlled substances, particularly benzos and stimulants, or any combination of benzos, stimulants, and opioids. The DEA has singled out one combination that they call the “Holy Trinity”: a benzo, an opioid, and a muscle relaxant like soma, which is particularly popular among recreational users for its rapid euphoric effects. This flag is so red that the DEA has recently prosecuted pharmacists for filling this combination without first investigating whether the prescriptions are for a proper medical use.
High quantities and high dosages. Pharmacists are trained to look out for providers whose prescriptions venture outside the norms, so if you’re prescribing 120 mg of Adderall best to add a note in the prescription explaining why.
High volumes, broad reach. Most clinicians don’t think of themselves as operating a “pill mill,” but if you are prescribing a lot of controlled substances and a lot people drive in from out of state to get them, an outside observer might think you are. If – on the other hand – you are running a nationally recognized center for treatment resistant ADHD or panic disorder, best to let your pharmacy partners know that what you’re doing is legit.
Patients who seek early refills. When you write for a PRN medication, dispense a limited amount and add that it is a 30-day supply. Otherwise the patient may interpret that “alprazolam every 6 hours for anxiety” as – literally – every 6 hours – taking too much and running out early.
CHRIS AIKEN: Here’s how to weave “as needed” benzo into the psychotherapy for anxiety. This is what I’ll tell a patient when I want them to take a benzo as needed for anxiety, but don’t want them to over-use it. First, I tell the patient that even though a doctor has prescribed it does not mean that it’s good for them. Doctors prescribed alcohol for many years – we were quite popular during prohibition – until alcohol was replaced by benzodiazepines in 1960. This benzodiazepine has similar effects to alcohol in the brain, but unlike alcohol it doesn’t harm the body below the neck. So, while it will certainly help in an emergency, and is much safer than a shot of vodka, it is not a cure and is not good for the brain. Unlike most other psychiatric meds, benzos do not have neuroprotective effects. With chronic use, PET scans of the brain look no better – and sometimes worse.
So these are to use in emergencies – like when you’re anxiety is so bad that you can’t function or you’re thinking of going to the emergency room. And that is where the cure lies. Anxiety is normal, and in the wrong circumstances, even high anxiety is normal. So when does anxiety become a disorder? Anxiety disorders are really about prioritization. If you have to present at work tomorrow and you haven’t prepared, anxiety is normal. But if you worry about every little thing and can’t prioritize the forest from the trees, that’s generalized anxiety disorder. When I write for a benzo PRN, I never write “PRN anxiety.” I write “PRN severe anxiety.” I’ll explain that to patients like this: “When you feel anxious, ask yourself if it’s the worst anxiety you can imagine. Is it really an emergency. If it is, take the lorazepam, but when you do, look at the pill and say, “Dr. Aiken told me this really isn’t good for me – and I only get 10 tablets a month – do I really want to take it now?”
KELLIE NEWSOME: Regulations abound in medicine, and it’s up to us to make them therapeutic rather than counter-therapeutic. By limiting early refills on benzodiazepines, patients learn to see things in perspective, which is part of the recovery from anxiety. I’ll also tell patients with phobias, “don’t take the benzo if you are staying in bed and avoiding the things you are afraid of. Only take it if it is helping you get out there, live more fully, and face your fears.”
Join us next week where we’ll uncover more red flags that are buried in the DEA website, and talk about what to do when you see them.
Now for the study of the day.
There’s a lot of myths surrounding bupropion (Wellbutrin) – that it causes insomnia, seizures, and anxiety. It does cause those, but several reviews of large trials have concluded that it doesn’t cause them any more than the average antidepressant. This new study backs that up.
Zachary Poliacoff and colleagues from the Univeristy of South Florida compared rating scale data for patients who started either bupropion or an SSRI from 8457 patients from a national telehealth company. This wasn’t a randomized controlled trial, but it was large and real-world, and they tried to overcome the lack of randomization by comparing patients who were matched by diagnosis, severity, and demographic factors. In the end, bupropion was no more likely to raise anxiety levels than an SSRI.
KELLIE NEWSOME: Get daily research updates like this through Dr. Aiken’s linkedin or twitter feed - @ChrisAikenMD.
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