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Clinical Take-Aways

  • Controlled substances (opioids, sedative-hypnotics, stimulants, and testosterone replacement therapy) are defined legally, not medically. Most have the potential for addiction, serious side effects, or both.

  • Many clinicians worry that encounters with patients taking opioids for chronic pain will be conflict-ridden. In reality, most such patients defer to clinicians’ recommendations for pain management, agree with clinicians’ treatment recommendations, and try to be responsible users of pain medicines.

  • The approach to the clinical negotiation is different for opioid-naïve patients requiring treatment for severe acute pain (limit the treatment course); patients on long-term opioids for chronic pain (focus on functional goals); and patients who exhibit signs of a substance use disorder (taper opioids and refer for SUD treatment).

  • In negotiating with patients taking other (nonopioid) controlled substances, the governing principles are to do a good intake exam; inform the patient about risks and benefits of treatment; and monitor the patient’s progress closely.

  • Clinicians should:

    • Be mindful of their own emotions, attitudes, and prejudices when providing care to patients using controlled substances.

    • Show that they take the patient’s distress seriously through careful history-taking, elicitation of the patient’s perspective, and empathic statements.

    • Assess the patient’s risk for harms related to controlled substance use.

    • Work collaboratively to establish treatment goals.

    • Develop a goal-directed treatment plan that emphasizes functional progress rather than pill-counting.


Categories of Controlled Substances

Controlled substances are drugs that are monitored and regulated by the federal government due to their potential for abuse and physical dependence. A wide variety of medications are classified as controlled substances, including opioids, sedative-hypnotics, stimulants, and androgens. They can be effective for managing symptoms that impact patients’ quality of life (e.g., pain, fatigue, insomnia) but also are associated with substantial side effects and risks for dependency and abuse. As a result, clinician-patient communication about the use of controlled substances presents a number of challenges for effective clinical negotiation. Much of what we say in this chapter will focus on clinician-patient communication and decision-making related to opioid use for pain management. However, we will also discuss negotiation related to other controlled substances. We conclude with suggestions for effective communication regarding controlled substances, coupled with examples of both “good” and “bad” communication specific to pain management.

In the United States, controlled substances are classified by the FDA into one of five different categories or schedules, ranked according to medical indications, safety, and potential for abuse and dependence. The FDA periodically adds new drugs to these schedules and moves drugs from one schedule to another. Schedule I medications are those deemed by the FDA to have no legitimate medical use and so cannot be legally prescribed by clinicians or dispensed by pharmacies. The most commonly used Schedule I drug is cannabis, which is now legal in many individual states but cannot be prescribed by clinicians. In contrast, Schedule V drugs are ...

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