Background Ensuring continuity in pain relief in the outpatient setting or following hospital discharge is an important aspect of quality patient care. Poorly written opioid prescriptions can lead to prescriptions not being filled, inadequate pain control, and preventable suffering. This Fast Fact provides practical considerations for opioid prescriptions. See Fast Fact #89 for opioid prescribing in long term care facilities, Fast Fact #74 on proper opioid order writing, and Fast Fact #198 for further discussion of regulatory issues.

Regulations

• Review your state regulations. Different states have different rules concerning different controlled substances — amount of drug that may be dispensed, number of refills, telephone prescription requirements, etc. The National Association of Boards of Pharmacy provides helpful online resources for clinicians to get more information about their state regulations (3). For safety reasons, many insurers and states require electronic ordering of controlled substances such as opioids (1,2). Written opioid prescriptions are not accepted in many localities unless there are unusual circumstances.
• Review your state’s prescription drug monitoring program (PDMP). Before prescribing the opioid, clinicians should review the patient’s controlled substance prescription history via a state PDMP (4).

Safety measures Prescribe naloxone along with opioids on discharge or outpatient as a safety measure for patients and their community as data shows that it decreases overdoses (4).

Prescriber information The DEA and NPI numbers and the spelling of your name must be legible. For these reasons, electronic opioid prescriptions have become the standard of care. Make sure you are up to date with your institutional authentication policies and procedures.

Frequency and quantity Ensure you are prescribing the recommended frequency unless specifically indicated. 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 or prior authorization. Oxycodone ER and morphine ER will likely not be dispensed when the frequency is PRN or less than 8 hours. For immediate release opioids, many are recommended to be ordered every 3 or 4 hours as needed based on opioid pharmacokinetics. However, clinicians may not feel comfortable prescribing the number of pills necessary to cover every 3 hours in a month. Consider adding a maximum number of pills in a day to the prescription and ensure the total quantity to be dispensed is adequate for a month supply.

Strength and formulation Given specific formulations or doses may not be available, confirm with the specific pharmacy the medication is available before prescribing. Data shows that opioid availability in pharmacies varies based on social determinants (5) making this particularly important for underserved patients. Also check the available pill/tablet/patch doses when prescribing opioid strengths, as combinations of different doses may be needed. For instance, if someone is taking morphine ER 75 mg q12 hours they would require prescriptions for both morphine ER 60 mg tabs and 15mg tabs. For clear communication write: “Morphine ER 15 mg tabs. Take one tab PO q12 hours along with your 60 mg tab for a total of 75 mg every 12 hours.”

Indication: Include the indication(s) for the opioid – e.g., cancer-related pain, dyspnea, cough, etc. Pharmacies and insurance often require associated indication and ICD -10 code to process opioid prescriptions appropriately and understand rationale behind an opioid prescription.

Combination products Pay attention to products via which the patient receives extra acetaminophen or ibuprofen. Identify whether the 3000 mg/day maximum of acetaminophen will be exceeded when writing the frequency (6). Most pharmacists will not dispense doses likely to exceed the maximum daily dose of acetaminophen or ibuprofen. When in doubt, write “…not to exceed X pills in 24 hours.”

Substitutions and corrections Pharmacists will not correct an improperly written prescription. Pharmacists also will not make substitutions – for example, 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.

Partial prescription fills: Federal rules in the US allow 2 licensed pharmacists to transfer a proper electronic opioid prescription once to another pharmacy if they are not able to fulfill the prescription based on stock issues and if allowable under state laws (7). Again, be aware of your state’s regulations. In most regions, partial refills can be provided if the pharmacy does not have the full prescription amount.

Communication Patients will receive higher quality care if their clinicians closely partner with the clinical pharmacists. This is especially important when prescribing opioids. Communicate with the pharmacist before the patient is discharged or leaves your office to assure availability.

References

1. Surescripts. NATIONAL PROGRESS REPORT 2019 [Internet]. 2020 p.9. Available at: https://surescripts.com/news-center/national-progress-report-2019/ Last accessed 2/29/24.
2. The SUPPORT for Patients and Communities Act (P.L.115–271): Medicare Provisions [Internet]. Federation of American Scientists. 2019 [cited 17 April 2020]. Available from: https://fas.org/sgp/crs/misc/R45449.pdf.
3. NABP: Boards of Pharmacy. Available at: https://nabp.pharmacy/about/boards-of-pharmacy/ Last accessed February 29, 2024.
4. Dowell, D, Ragan KR, Jones CM, et al. CDC clinical practice guideline for prescribing opioids for pain – United States 2022. Recommendations and Reports 2022; 71(3):1-95. Recommendation #9.
5. Morrison, R. S., Wallenstein, S., Natale, D. K., Senzel, R. S., & Huang, L.-L. (2000).“We Don’tCarry That”—Failure of Pharmacies in PredominantlyNonwhite Neighborhoods to Stock OpioidAnalgesics. Https://Doi.Org/10.1056/NEJM200004063421406,342(14), 1023–1026.https://doi.org/10.1056/NEJM20000406342140.
6. FDA Drug Safety Communication: Prescription Acetaminophen Products to be Limited to 325 mgPerDosage Unit; Boxed Warning Will Highlight Potential for Severe Liver Failure. http://www.fda.gov/Drugs/DrugSafety/ucm239821.htm. Last accessed February 29, 2024.
7. DEA. United States Drug Enforcement Administration. September 1, 2023: Revised regulation allows DEA-registered pharmacies to transfer electronic prescriptions at a patient’s request. Available at https://www.dea.gov/stories/2023/2023-09/2023-09-01/revised-regulation-allows-dea-registered-pharmacies-transfer#:~:text=The%20final%20rule%20was%20published,state%20or%20other%20applicable%20law. Last accessed February 29, 2024.

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 by Sean Marks MD; 4th Edition in February 29, 2024, by Sean Marks MD.
Conflicts of Interest: None to report.