Author(s): Colleen Dunwoody MS, RN and Robert Arnold MD
Background Assuring continuity in pain relief in the outpatient setting or following hospital discharge is an important aspect of patient care. Poorly written prescriptions or orders can be inconvenient for the patient as well as the clinician, but can also lead to prescriptions not being filled, inadequate pain control, and patient suffering. This Fast Fact will touch on some practical considerations in writing opioid prescriptions. See also Fast Fact #89 for writing orders for patients in long term care facilities, #74 for a general discussion of proper opioid order writing, and #198 for further discussion of regulatory issues.
Regulations Different states have different rules concerning controlled substances: amount of drug that may be dispensed, number of refills, faxing of orders and telephone prescriptions, and requirements for special prescription forms or blanks. Review your state regulations. See the website below for state-by-state listings.
Legibility The DEA number and name must be legible. Print your name after your signature or otherwise indicate the spelling of your name on a personalized prescription.
Frequency Consider if the frequency you are prescribing is the recommended frequency. Third party payers may not pay for medications prescribed to be taken more frequently than recommended in the literature. For example, transdermal fentanyl patches changed q48 hours and oxycodone ER q8 hours may not be paid by insurers without a specific reason. Oxycodone ER and morphine ER may not, and should not, be dispensed when the frequency is PRN or less than 8 hours.
Strength There are more than two dozen combination opioids available; it is good practice to always write the correct strength for combination opioids (e.g. oxycodone/acetaminophen 5 mg/325 mg). Be sure the check the available pill/tablet doses when prescribing long acting opioids. When writing prescriptions for different strengths, it is helpful for both the patient and pharmacist to specify that on the prescriptions. For instance, if someone is taking morphine ER 75 mg q12 hours they would require prescriptions for both morphine ER 60mg tabs and 15mg tabs, one should write: “Morphine ER 15 mg tabs. Take one tab PO q12 hours. Take along with your 60 mg tabs to make a total of 75 mg every 12 hours.”
Acetaminophen Consider whether the 4000 mg/day maximum can be exceeded when writing the frequency. Most pharmacists will not dispense doses likely to exceed this recommended maximum daily dose. If there is any doubt one should write “…not to exceed X pills in 24 hours.”
Tampering Write the number after the numeric ‘10’ (ten) to prevent someone altering the prescription (e.g. changing 10 to 40 by changing a 1 to a 4).
Substitutions and Corrections Pharmacists will not correct an improperly written prescription, and some may not accept prescriptions that have obvious corrections (e.g. items crossed out) because there is no way of knowing who did the correction. Nor will a prescription for an opioid be filled when written on a prescription printed with "not for controlled substances". Pharmacists also will not make substitutions; if you write for ‘morphine ER 80 mg,’ the pharmacist will not fill it since the medicine is not available as an 80 mg tablet.
Communication When prescribing opioids that are infrequently used or in high doses, communicate with the pharmacist before the patient is discharged or leaves your office to assure availability. Pharmacists prefer communication from physicians and nurses in advance so medications can be stocked.
Pain & Policy Studies Group. Madison, WI. Available at: http://www.painpolicy.wisc.edu/. State profiles available at: http://www.painpolicy.wisc.edu/domestic/state_profiles/index.html.
Fast Facts and Concepts are edited by Drew A Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: firstname.lastname@example.org. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.
Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition was edited by Drew A Rosielle and published October 2007. Current version re-copy-edited April 2009.
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Dunwoody C and Arnold R. Writing Discharge and Outpatient Opioid Prescriptions, 2nd Edition. Fast Facts and Concepts. October 2007; 94. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_094.htm.
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
ACGME Competencies: Patient Care, Practice-Based Learning and Improvement, Systems-Based Practice
Keyword(s): Pain – Opioids