Pain, Gout and Migraine Drugs

Opioid Analgesics, Controlled Substance Handling, and Overdose Protocols

Opioid analgesics are potent medications utilized to treat moderate to severe pain. Under federal law, these agents are distributed across several controlled substance schedules based on their recognized medical value and potential for abuse, psychological dependence, or physical dependence. Morphine, oxycodone, hydrocodone, hydromorphone, and fentanyl are classified as Schedule II controlled substances. Tramadol is an opioid analgesic categorized federally as a Schedule IV controlled substance. Common codeine, acetaminophen oral solutions are federally Schedule III; certain other codeine-containing liquids, such as qualifying cough preparations with no more than 200 mg of codeine per 100 mL, are Schedule V. Buprenorphine combined with naloxone is classified as a Schedule III controlled substance and is specifically indicated for the treatment of opioid use disorder.

Due to the substantial risks linked to Schedule II opioids, federal regulations impose strict security, storage, and dispensing standards. Federal regulations require Schedule II opioid stock to be kept in a securely locked cabinet or dispersed throughout non-controlled inventory to deter diversion and theft within the pharmacy. Under federal law, Schedule II prescriptions cannot be refilled under any circumstances. If a patient presents a request for a refill on a Schedule II prescription, pharmacy technicians should not process the Schedule II refill request as a refill and must promptly refer the situation to the pharmacist. Technicians may assist the workflow by preparing, counting, and labeling analgesics, but the final visual and legal verification of every prescription must always be performed by a licensed pharmacist. Additionally, under pharmacist supervision and according to specific pharmacy policy, technicians may check a prescriber's Drug Enforcement Administration (DEA) number format and check digit, but the final legal verification belongs solely to the pharmacist.

Prescription opioid analgesics carry boxed warnings addressing risks such as addiction, abuse, misuse, life-threatening respiratory depression, and accidental exposure; the warnings vary by product. An additional boxed warning applies to the concurrent use of opioids and benzodiazepines, which substantially elevates the danger of profound sedation, respiratory arrest, and death. When handling these medications, pharmacy technicians must be aware that hydromorphone is significantly more potent milligram-for-milligram than morphine. Confusing these two medications presents a serious risk of accidental fatal overdose. Chronic opioid therapy also leads to adverse effects; a critical adverse effect of chronic opioid therapy that does not diminish over time with patient tolerance is constipation.

Specialized dosage forms, such as fentanyl transdermal patches, require meticulous attention to safety. Fentanyl transdermal patches are usually replaced every 72 hours. Applying external heat sources, such as heating pads, directly over a fentanyl patch increases transdermal drug absorption and can cause a fatal overdose. After removal, used patches should be folded with the adhesive sides together and disposed of according to FDA instructions. If a patient or caregiver has questions regarding proper disposal, pharmacy technicians should refer disposal questions directly to the pharmacist. In cases where opioid-induced respiratory depression occurs, naloxone acts as a pure opioid antagonist to acutely reverse life-threatening respiratory depression caused by an opioid overdose. To increase accessibility, some naloxone nasal sprays are available over the counter, and prescription naloxone may also be supplied without an individual prescription under a standing order or statewide protocol where permitted.