Controlled Substance Prescribing Guidelines

BENZODIAZEPINE PRESCRIBING: [ INDICATION ] Diagnosis: [GAD / Panic Disorder / Insomnia / Other: ___] FDA-approved: [Y/N] Symptom severity: [___/10] Functional impairment: [Describe] [ PRIOR TREATMENTS TRIED ] Non-pharmacological: [CBT / Sleep hygiene / Mindfulness — dates: ___] Non-controlled medications: [SSRIs / Buspirone / Trazodone / Gabapentin — responses: ___] Rationale for benzodiazepine over alternatives: [___] [ PRESCRIBING DETAILS ] Drug: [Alprazolam / Lorazepam / Clonazepam / Diazepam / Other: ___] Dose: [___] Frequency: [PRN / Daily / BID] Quantity: [___] (Days supply: [___]) [ RISK ASSESSMENT ] Age ≥65: [Y/N] — If Y: Beers Criteria discussion documented Substance use disorder history: [Y/N] Current opioids: [Y/N] — If Y: Overdose risk discussed Alcohol use: [None / Social / Heavy] Falls risk: [Low / Moderate / High] [ DURATION PLAN ] Intended duration: [Short-term ≤4 weeks / Intermittent PRN / Chronic with monitoring] Planned reassessment: [Date — if chronic: every ___ months] Taper plan if discontinuing: [Discussed: Y/N] [ MONITORING ] PDMP checked: [Date: ___] UDS: [Not indicated / Ordered: ___] Next visit: [Date: ___] Functional assessment: [Returning to work / Improved functioning / No change] [ INFORMED CONSENT ] Risks discussed: [Dependence / Cognitive impairment / Falls / Respiratory depression with opioids] Alternatives discussed: [CBT / Buspirone / SSRIs / Trazodone] Patient agrees to: [Not drive until effects known / Not combine with alcohol / Secure storage] Treatment agreement signed: [Y — date: ___] Patient questions: [Answered / None]

ADHD DIAGNOSIS CONFIRMATION: [ DIAGNOSTIC CRITERIA ] DSM-5-TR criteria met: [ ] ≥6 inattentive symptoms (children) / ≥5 (adults ≥17) [ ] ≥6 hyperactive/impulsive symptoms (children) / ≥5 (adults) [ ] Symptoms present before age 12 [ ] Symptoms present in ≥2 settings (home, school, work) [ ] Clear functional impairment [ ] Not better explained by another condition Symptoms onset: [Age ___] Duration: [___ years] — [Chronic / Persistent] Settings: [Home and school/work confirmed] Functional impairment: [Academic / Occupational / Social / Other] [ ASSESSMENT TOOLS ] ASRS-v1.1 Part A: [Score ___/24] — [≥4 positive = screen positive] Vanderbilt (if child): [Score ___] Collateral information: [Parent report / Teacher report / Work supervisor / Spouse] Prior diagnosis: [Confirmed by records / Self-reported only] [ DIFFERENTIAL RULED OUT ] [ ] Anxiety disorders (can mimic inattention) [ ] Mood disorders (hypomania can look like hyperactivity) [ ] Substance use (stimulant use vs. ADHD) [ ] Sleep disorders (sleep deprivation → inattention) [ ] Medical causes: [TSH normal / Vision checked / Hearing checked] [ ] Personality disorders (particularly BPD) Rationale for ADHD vs. alternatives: [___]

STIMULANT PRESCRIBING: [ CARDIAC SCREENING ] Personal cardiac history: [None / Murmur / Arrhythmia / Cardiomyopathy] Family history: [Sudden cardiac death <50: Y/N] [Arrhythmia: Y/N] Current symptoms: [Chest pain: N] [Palpitations: N] [Syncope: N] [SOB: N] Vitals: BP [___] HR [___] ECG obtained: [Y — normal / N — low risk, no symptoms] [ SUBSTANCE USE SCREENING ] Personal SUD history: [None / Remote / Active — if active: contraindicated] Current substance use: [None / Cannabis / Alcohol / Other] Diversion risk: [Low / Moderate / High — factors: ___] PDMP: [Checked — no concerning patterns] [ MEDICATION SELECTION ] First-line trial: [Methylphenidate / Amphetamine] Formulation: [IR / ER / ODT] Starting dose: [___] Titration plan: [Increase by ___ every ___ weeks to target dose ___] [ MONITORING PLAN ] Follow-up: [Every 2-4 weeks initially] Vitals: [BP/HR every visit] Height/weight (children): [Every visit — growth charts] Sleep: [Screened every visit] Mood: [Screened every visit — watch for mania/psychosis] Effectiveness: [VAS or rating scale] [ DIVERSION PREVENTION ] Treatment agreement: [Signed — includes non-sharing, single prescriber, single pharmacy] Early refill policy: [Discussed — requires police report if lost/stolen] UDS: [Random — frequency: ___] PDMP: [Every visit] Pill counts: [If indicated] PHARMACY: Patient confirmed pharmacy: [Name, address] EScript: [Y / Paper (patient preference/state requirement)] Quantity: [30 days / 90 days if stable] Refills: [0 — new script each month / 2 if 90-day]

PATIENT ON CHRONIC OPIOID ANALGESICS: [ CURRENT OPIOID REGIMEN ] Prescriber: [PCP / Pain management / Other] Medication: [Oxycodone / Hydrocodone / Morphine / Fentanyl / Other] Dose: [___ mg/day] MME: [___ mg/day] — [<50 / 50-90 / >90] Duration: [Acute / Chronic >90 days] [ PSYCHIATRIC CONSIDERATIONS ] Depression risk: [Screened — PHQ-9: ___] // Chronic opioid use associated with depression; high MME = higher risk Anxiety risk: [Screened — GAD-7: ___] Sleep apnea risk: [Screened — STOP-BANG: ___] [ SAFETY CONCERNS ] Concurrent benzodiazepine: [Y/N] — If Y: Overdose risk discussed with patient Alcohol use: [Screened — AUDIT-C: ___] Sedating psychiatric meds: [Trazodone / Quetiapine / Mirtazapine — additive risk] Naloxone prescribed: [Y — patient has / Discussed — patient declined] [ BUPRENORPHINE FOR OUD ] // If treating OUD with buprenorphine: Induction date: [___] Current dose: [___ mg/day] FDA ceiling: 24mg/day (rarely need >16mg) PDMP: [Checked — no other opioids] Counseling: [OBOT / Office-based therapy] [ INTERACTIONS ] QTc prolongation risk: [Methadone + antipsychotics / TCAs — ECG obtained: ___] Serotonin syndrome risk: [Tramadol/tapentadol + SSRI/SNRI/MAOI] Respiratory depression: [Opioid + benzo + sedating antipsychotic] Constipation: [All opioids — bowel regimen discussed: ___]

SLEEP MEDICATION SELECTION: [ STEP 1 — NON-PHARMACOLOGICAL ] Sleep hygiene addressed: [Y — specific changes: ___] CBT-I offered/referred: [Y/N] Sleep restriction discussed: [Y/N] [ STEP 2 — NON-CONTROLLED OPTIONS ] Trazodone: [25-100mg — start low, watch for orthostasis, priapism rare] Mirtazapine: [7.5-15mg — good if comorbid depression/anxiety, weight gain] Doxepin: [3-6mg — low-dose, histamine blockade] Melatonin: [3-10mg — OTC, circadian rhythm disorders] Ramelteon: [8mg — melatonin receptor agonist, no abuse potential] [ STEP 3 — CONTROLLED (IF INDICATED) ] Z-drugs: [Zolpidem / Eszopiclone / Zaleplon] • Schedule IV, risk of dependence, complex sleep behaviors • Limited to short-term use (2-4 weeks ideally) • Lower doses in women (FDA), elderly • Rebound insomnia common Benzodiazepines: [Temazepam / Estazolam] • Not first-line for sleep • Risk of dependence, cognitive effects, falls • FDA warns against combining with opioids [ STEP 4 — DIFFERENTIAL DIAGNOSIS ] Sleep apnea ruled out: [STOP-BANG screening: ___ / Sleep study: ___] Restless leg syndrome: [Screened — ferritin checked: ___] Circadian rhythm disorder: [Delayed sleep phase — melatonin timing] Substance-induced: [Alcohol / Cannabis / Caffeine / Stimulants] Psychiatric: [Anxiety / Depression / Mania / PTSD nightmares] Medical: [Pain / GERD / Hyperthyroidism / Medications] [ MONITORING ] Efficacy: [Falling asleep faster / Staying asleep / Both] Next-day impairment: [None / Mild / Significant — dose adjustment?] Complex sleep behaviors: [Sleepwalking / Eating / Driving — rare but serious] Tolerance: [Developing / Stable] Duration: [Limit to ≤4 weeks if possible / Reassess regularly]

OPIOID RISK TOOL (ORT): | Question | Score (Female) | Score (Male) | |-----------------------------------------------|----------------|--------------| | Family history of substance abuse (any) | 3 | 3 | | Family history of alcohol abuse | 3 | 3 | | Family history of illegal drug abuse | 3 | 3 | | Family history of Rx drug abuse | 4 | 4 | | Personal history of substance abuse (any) | 3 | 3 | | Personal history of alcohol abuse | 3 | 3 | | Personal history of illegal drug abuse | 4 | 4 | | Personal history of Rx drug abuse | 5 | 5 | | Age between 16-45 years | 1 | 1 | | History of preadolescent sexual abuse | 3 | 0 | | Psychological disease (ADHD, OCD, bipolar, etc)| 2 | 2 | | Depression | 1 | 1 | SCORING: Low risk: 0-3 | Moderate risk: 4-7 | High risk: ≥8 INTERPRETATION: • Low: Standard monitoring • Moderate: Enhanced monitoring, consider alternative • High: Avoid opioids if possible; if necessary, maximum monitoring

SOAPP-R: Patient self-report tool with 24 items (5-point scale) Key domains assessed: • History of substance abuse • Legal problems • Psychological disease • Social support • Stress • Mood SCORING: • ≥7: High risk for aberrant medication-related behavior • 4-6: Moderate risk • ≤3: Low risk // Available at: https://www.nationalrehab.org/patient-assessment

UDS FREQUENCY GUIDELINES: [ LOW RISK ] Baseline: At intake Random: Every 3-6 months Change: With any dose change or concern [ MODERATE RISK ] Baseline: At intake Random: Monthly to quarterly Change: With any change [ HIGH RISK / KNOWN SUD ] Baseline: At intake Random: Weekly to monthly initially Change: Every visit [ TRIGGER EVENTS — ORDER IMMEDIATELY ] [ ] Early refill request [ ] Reported lost/stolen medication [ ] Behavioral changes [ ] New provider in PDMP [ ] Unexpected negative for prescribed drug [ ] Positive for non-prescribed substance PDMP FREQUENCY: [ ] Every visit for controlled substances [ ] At minimum every 3 months [ ] Before every new prescription

CONTROLLED SUBSTANCE DOCUMENTATION CHECKLIST: REQUIRED FOR EVERY PRESCRIPTION: [ ] Legitimate medical purpose established [ ] Within scope of practice [ ] Patient relationship established [ ] Appropriate examination performed [ ] Medical record maintained [ ] Diagnosis documented with ICD-10 [ ] Informed consent obtained [ ] Risk/benefit discussed [ ] PDMP checked (within 24 hours) [ ] Treatment agreement on file (if CS) [ ] Monitoring plan documented C-II SPECIFIC: [ ] Written prescription (no refills) [ ] Emergency dispensing documented (if applicable) [ ] Partial fill rules followed DOCUMENT RETENTION: Medical records: [Kept for ___ years per state law] Controlled substance records: [Additional requirements per DEA] PDMP printouts: [Saved in chart / Not required if documented] Treatment agreements: [On file — dated and signed] // "If it's not documented, it didn't happen"

BENZODIAZEPINE TAPER PROTOCOL: [ INDICATION FOR TAPER ] [ ] Patient request [ ] Dependence without therapeutic benefit [ ] Side effects outweigh benefits [ ] Duration >4 weeks (planned taper) [ ] Safety concern (falls, cognitive impairment) [ ] Concurrent opioid use [ TAPER RATE ] Slow taper: Reduce by 10-25% every 1-2 weeks Very slow (high dose/long-term): Reduce by 5-10% every 2-4 weeks Patient preference: [Patient prefers faster/slower] [ CONVERSION ] If on short-acting (alprazolam, lorazepam): Consider converting to longer-acting (diazepam, clonazepam) [ SYMPTOM MANAGEMENT ] Withdrawal symptoms expected: [Insomnia / Anxiety / Tremor / Seizure risk] Supportive medications: [Hydroxyzine / Propranolol / Gabapentin] Non-pharmacological: [CBT / Relaxation / Sleep hygiene] [ MONITORING ] Visit frequency: [Every 1-2 weeks initially] UDS: [Monitor for self-medication with alcohol/other substances] Patient support: [Involve family / Care coordinator / Therapist] [ TAPER SCHEDULE EXAMPLE ] Clonazepam 2mg BID: Week 1-2: 1.5mg BID Week 3-4: 1mg BID Week 5-6: 0.5mg BID Week 7-8: 0.5mg daily Week 9-10: 0.25mg daily Week 11-12: 0.25mg every other day Week 13: Discontinue // Adjust based on patient tolerance — slower is better for success

STIMULANT TAPER: [ WHEN TO TAPER ] [ ] Misuse/diversion confirmed [ ] Side effects intolerable [ ] No benefit after adequate trial [ ] Patient request [ ] Switching medication [ TAPER SCHEDULE ] Typically faster than benzos — can reduce by 25-50% weekly Switch to shorter-acting to assess need [ WITHDRAWAL EXPECTED ] Fatigue, increased appetite, irritability, "brain fog" Duration: Days to weeks depending on duration of use [ ADHD SYMPTOMS ] Will return — ensure alternative treatment plan