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 and NPI numbers and your 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 to 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      Identify whether the 3000-4000 mg/day maximum will be exceeded when writing the frequency.  Pay extra attention to combination products via which the patient may be receiving extra acetaminophen.  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.

** In 2011, the FDA and acetaminophen manufacturers announced plans to lower the recommended maximum daily dose from 4000 mg to 3000 mg/day due to rare instances of hepatotoxicity for patients receiving 4000 mg daily.  As of June 2015 the official prescribing information has not been updated to reflect those announced changes.  However, in 2014, the FDA urged all acetaminophen drug manufacturers to halt production of combination products with more than 325 mg of acetaminophen per dosage in order to help curb acetaminophen toxicity.

References   

1.     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.

1. New Initiative to Help Encourage Appropriate Use of Acetaminophen. McNeil Consumer Healthcare. Available at: http://www.tylenol.com/page2.jhtml?id=tylenol/news/newdosing.inc.  Accessed August 2, 2012.
2. FDA Drug Safety Communication: Prescription Acetaminophen Products to be Limited to 325 mg Per Dosage Unit; Boxed Warning Will Highlight Potential for Severe Liver Failure.  http://www.fda.gov/Drugs/DrugSafety/ucm239821.htm.  Accessed June 2015.

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; 3rd Edition June 2015. Re-copy-edited April 2009. Updated in June 2015 by Sean Marks MD with acetaminophen dose changes.