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Please Reply to the following 2 Discussion posts:


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After reviewing ML’s medical history, it appears that ML is addicted to pain medicine (Norco), a mixture of acetaminophen and hydrocodone used to treat moderate to severe pain. Any pain medicine used in excess of what is recommended might lead to opioid addiction. I would discuss with ML the negative consequences of drug overdose and its impact on the liver, as this medication is processed in the liver. Another concerning fact is that she takes diazepam, a CNS depressant in addition to hydrocodone, which also works on the CNS. She also admitted to drinking alcohol, which, when taken with CNS depressants, can cause respiratory distress (Witkiewitz and Vowles, 2018).

M.L.’s behaviors, such as taking up to 4-5 hydrocodone pills per day, would prompt me to schedule a DAST-10 screening for her. The DAST, which stands for drug abuse screen test, consists of ten questions that screen the patient for suspected drug misuse. Other comparable screen tests are available, including the NIDA Quick screen, which was designed by the National Institute on Drug Abuse (Shirinbayan et al., 2020). Educating the patient about Florida state legislation regarding screening for drug delivery and screening the patient with the state-mandated opioid risk tool is crucial. I would educate the patient on alternative pain management methods such as topical analgesics and the application of hot and cold packs to the affected area.

As a provider, I would evaluate the psychosocial challenges of being the major caregiver for her family, as well as her difficulty getting to her appointments. I would make a referral to a social worker and a case manager to explore what options are available for M.L. and to see if telemedicine may be a better alternative for her to lessen some of the stress associated with clinic visits. Telehealth is an excellent option for dealing with the second issue, which is the request for a 6-month prescription of a schedule II medicine.

The Florida Prescription Drug Monitoring Program, known as E-FORCSE® (Electronic-Florida Online Reporting of Controlled Substance Evaluation Program), was created by the 2009 Florida Legislature in an initiative to encourage safer prescribing of controlled substances and to reduce drug abuse and diversion within the state of Florida, according to the state of Florida (Florida Health, 2021). Before prescribing any substance control medicines, all providers must consult with the prescription drug monitoring program. Using an agreement form as a tool for Chronic Pain Management will help patients better understand about the side effects of the medication, prevent misuse, and notify the provider if anything changes.

According to the Department of Justice schedule, II medicines such as hydrocodone are not refillable. However, due to the epidemic, a practitioner can write numerous prescriptions permitting patients to get up to a 90-day supply. The practitioner must sign and specify the earliest date on which a prescription can be filled for each individual prescription when drafting these prescriptions. Prior to the epidemic, Schedule II medications could not be renewed, and Schedule III and IV restricted narcotics could only be refilled five times in six months (Prevoznik, 2020). M.L.’s hydrocodone is scheduled II, and diazepam is scheduled IV.

According to the State of Florida’s standards for dispensing controlled medicines, a written prescription for Schedule II, Schedule III, or Schedule IV must include a written and numerical notation of the quantity of the restricted substance (The 2022 Florida Statutes). The prescriber’s name, license number, contact information, DEA number, patient’s complete name, and date of birth must all be included on the prescription. Prescriptions must specify the prescription’s name, strength, precise dose, number of refills, and the amount of medication prescribed (Rosenthal, & Burchum, 2021). 

The Health and Safety Code, Schedule Parts II and IIII are rigidly enforced. Once a controlled substance is prescribed in the state of Florida, the prescriber (either a physician or an APRN) can immediately notify E-FORCSE (Electronic-Florida Online Reporting of Controlled Substance Evaluation Program), which performs Prescription Drug Monitoring in the state of Florida. Other prescribers and pharmacists may also be able to track or look up a patient’s restricted drug information once the E-FORCSE has been notified (Young et al., 2017). The Florida Legislature established E-FORCSE in 2009 to offer safe controlled substance prescribing and to minimize drug misuse (Florida Board of Nursing, 2022)

In Florida, APRNs must complete three hours of continuing education on the safe and effective prescribing of controlled medications. Furthermore, an ARNP may only prescribe or dispense a controlled drug as specified in Florida Statutes s. 893.03 if the ARNP has a master’s or doctorate degree in a clinical nursing specialty area and has received training in specific practitioner skills. Prescriptions for Schedule II restricted medications are limited to seven (7) days; however, psychiatric Nurse Practitioners are not subjected to this limitation (The 2022 Florida Statutes).


One concern here is that this patient is taking diazepam, Norco, and gabapentin, which are all CNS depressants, especially because she is caring for children. The patient also admits to consuming alcohol, which is also unsafe in combination with those medications. According to the Beers list, benzodiazepines pose an increased risk for cognitive impairment, falls, and injuries due to the decreased drug metabolism in older adults (American Geriatrics Society, 2019). Additionally, gabapentin increases the risk of sedation and respiratory depression, and it should be avoided in older populations (AGS, 2022). Alternative medications, such as NSAIDs, may need to be considered. In addition to BP and cholesterol levels, other screenings for this patient may include liver function, lung cancer screening, as well as substance abuse assessment. It is unethical and unsafe to prescribe a six month supply of drugs, especially the scheduled medications.

According to Irwin et al. (2020), pain contracts are recommended as a means to improve patient safety and decrease risk for opioid misuse. A sample agreement from the American Academy of Family Physicians is attached. In this sample contract, the patient is asked to keep her follow-up appointments in order to receive her pain medication prescription. This will allow the provider to monitor the patient regularly for any adverse effects, and make adjustments as necessary. Another critical aspect of this contract is to avoid alcohol use while using narcotics and opioids. 

            In order to ensure patient safety, the provider must first obtain a thorough history from the patient, and ask about any prescription and OTC medications that she is taking. Additionally, the CURES registry is the database that will allow providers to monitor their patients’ opioid prescription records (California DOJ, 2022).  California Health & Safety Code Section 11165(d) states that dispensers of Schedule II, III, IV, or V controlled substances need to report the dispensing information within one working day to the DOJ (California DOJ, 2022). Prior to writing a prescription, the provider must review the CURES registry to ensure that the patient is not obtaining multiple scheduled drug prescriptions from other providers.

            Diazepam is a schedule IV drug, and Norco is a schedule II drug (DEA, n.d.). In California, a prescription for a Schedule II drug can only be dispensed up to a 72-hour supply (California Legislative Information, n.d.). For Schedule II, III, and IV drugs, practitioners are required to write the prescription on state-approved prescription forms with a 12-character serial number (California DOJ, n.d.). A prescription must include the prescriber name, license number, contact information, DEA number, patient name and date of birth, patient allergies, name of medication, indication of the medication, medication strength, dose and frequency, number of tablets or capsules to dispense, and number of refills (Rosenthal & Burchum, 2021). Moreover, California Health and Safety Code requires that the patient’s address must be included in the prescription, or be made readily available (California Legislative Information, n.d.). This code also states that prescriptions for Schedule III, IV, and V can be oral or written, but schedule II must be written, except during a life-threatening emergency (California Legislative Information, n.d.). Thus, Norco requires a written prescription, while gabapentin, Losartan, Atorvastatin, and Diazepam may be ordered verbally.  

            In California, NPs are permitted to obtain their own DEA number and prescribe Schedules II through V drugs. However, they are required to practice under physician supervision and follow Standardized Procedures. Please see attachment. Per the passage of AB 890, beginning in January 2023, NPs can obtain independent practice once they have completed three years of transition to practice, and have practiced for three additional years (CA BRN, 2022).

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