Drug Diversion and Safe Administration of Controlled Substances for Nurses in West Virginia Nursing CE Course

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 Drug Diversion Training and Best Practices for Prescribing Controlled Substances for Nurses in West Virginia 

 Disclosure Statement

This module provides a detailed overview of the safe and effective administration of controlled substances for registered nurses (RNs) and advanced practice registered nurses (APRNs) in West Virginia (WV), in compliance with the state regulations and evidence-based guidelines for the prevention of prescription medication misuse and diversion, challenges in managing chronic pain, and best practices for prescribing controlled substances.

Upon completion of this module, learners should be able to:

• explore the epidemiology of controlled substance misuse and diversion within the US
• identify risk factors for potential substance misuse and diversion
• identify the three different classes of controlled substances most commonly misused, including indications, risks, benefits, common adverse effects, and alternatives for opioids, central nervous system (CNS) depressants, and stimulants
• discuss safe prescribing based on best practices, clinical experience, and evidence-based guidelines
• discuss acute and chronic pain management and special considerations for controlled substance use in specific populations (e.g., older adults, pregnant individuals, and cancer patients) and end-of-life care
• describe the prevention, screening, and signs of potential substance use and addiction, and describe the appropriate response to and current treatment options for substance use and addiction
• describe the West Virginia requirements for prescribing controlled substances and the Controlled Substance Automated Prescription Program (CSAPP)

Since the 1990s, the use of controlled substances has increased to epidemic proportions. Understanding the contributing factors and management strategies for this epidemic requires comprehension of relevant terminology (refer to Table 1) (Centers for Disease Control and Prevention [CDC], 2024b; Dydyk et al., 2024; Strain, 2022).

Table 1

Key Terminology and Definitions

The US opioid epidemic began in the 1990s when attitudes toward pain management and opioid safety shifted from conservative prescribing to widespread use (Lyden & Binswanger, 2019). Previously, these medications were primarily reserved for end-of-life care and severe cancer pain. However, patient advocacy groups and pain specialists, including the American Pain Society (APS), began to raise awareness of the inadequate treatment of non-cancer pain and the underutilization of pharmaceutical opioids, leading to a movement to treat pain as the "fifth vital sign." As a result, in 2001, the Joint Commission (TJC) set new pain management standards, which tied patient satisfaction and health care quality to pain control (Baker, 2017). In addition, pharmaceutical companies falsely reassured the medical community that patients would not become addicted to therapeutic opioids (CDC, 2024d; SAMHSA, 2018). The increased awareness of pain management and the widespread marketing campaigns of pharmaceutical companies resulted in skyrocketing numbers of opioid prescriptions. In 2010, opioid prescribing peaked at 225 million prescriptions dispensed, equating to 81.2 prescriptions per 100 persons. In addition, between 1999 and 2009, opioid misuse began to increase, and mortality rates involving pharmaceutical opioids rose nearly four times (Guy et al., 2017).

Opioid prescribing rates stabilized in 2012 and slowly declined over the next 5 years (Lyden & Binswanger, 2019). However, as providers attempted to control the overprescribing of pharmaceutical opioids, many patients turned to diversion/illicit market sale of prescribed meds and illicit (e.g., heroin) and synthetic opioids (e.g., fentanyl [Duragesic]). Medication overdose is a leading cause of accidental death in the US, with opioids being the most common medication type (Regina et al., 2025). In 2017, the opioid crisis was declared a nationwide public health emergency, joining forces with the US Department of Health and Human Services (HHS, 2017) to increase grant funding toward developing novel strategies to impede this growing and deadly problem. These efforts have brought a new level of urgency to the matter, but the problem persists and must be addressed uniformly across the health care system. Since 2018, overdose deaths have continued to rise, peaking in 2022 before experiencing a decline in 2023. Nursing is the nation's largest health care profession, caring for more patients than any other profession, so nurses serve vital roles in this process. Nurses and nurse prescribers must understand the signs, symptoms, and treatment of acute and chronic pain and the signs and symptoms of medication misuse (American Nurses Association, 2018; National Center for Health Statistics, 2024; Regina et al., 2025). For more information, refer to the NursingCE course The Nurse's Role in the Opioid Epidemic.

Scope of the Problem: The Misuse of Controlled Substances

According to the National Center for Drug Abuse Statistics [NCDAS], prescription medications are the third most misused category of substances in the US, following marijuana and cocaine. Within the past 30 days, 45.8% of American adults used prescription medication (legally or not), with 16.3 million individuals misusing prescriptions annually. Medication overdose is a public health crisis, with overdoses increasing by 540% between 1999 and 2022. Opioids are a primary driver of medication overdose deaths, with 107,941 people dying from a medication overdose in 2022, with 82,000 (76%) involving opioids. Synthetic opioids (fentanyl [Duragesic] and fentanyl analogs) accounted for 90% of these overdose deaths. Deaths from multiple medications have also increased, and individuals who have had one overdose are more likely to have another. Individuals aged 25 to 64 had the highest overdose death rates, while those 65 and older had the lowest rates. Overdose death rates were also highest among Indigenous Peoples and lowest among Asian Americans. Although opioid prescribing rates in the US have been declining since 2012, approximately 125 million opioid prescriptions were dispensed in 2023, with a wide variation across states (CDC, 2025a, 2025b; NCDAS, n.d.).

According to the 2023 National Survey on Drug Use and Health conducted by the SAMHSA (2024b):

• More than 8.9 million people misused prescription opioids in the last year.
• 1.4 million misused prescription pain relievers for the first time.
• 5.7 million had an opioid use disorder (OUD).
• 660,000 people used heroin in the last year.

The most commonly misused medications were hydrocodone (Vicodin, Lortab, Norco) products, with 3.6 million individuals misusing these in 2023. Oxycodone (OxyContin, Percocet, Roxicodone) was the second most frequently misused medication for pain, accounting for 2.6 million individuals. Of these individuals, 70.9% of users reported misuse to manage physical pain, whereas 8.1% reported misuse to "feel good" or "get high." Regarding how the medication was acquired, more than 39.1% of respondents reported obtaining it through a relative or friend, whereas 47% had a valid prescription written by a licensed prescriber (SAMHSA, 2024b).

An estimated 224 people die daily from opioid overdose, and these numbers continue to rise. Data across the US indicate that West Virginia has the nation's highest age-adjusted mortality rate due to medication overdose. WV has 80.9 deaths per 100,000 individuals, followed by the District of Columbia (64.3 per 100,000), Tennessee (56 per 100,000), Delaware (55.3 per 100,000), Louisiana (54.5 per 100,000), Maine (54.3 per 100,000), Kentucky (53.2 per 100,000), New Mexico (50.3 per 100,000), Vermont (45.9 per 100,000), and Ohio (45.6 per 100,000). The lowest adjusted mortality rates were in South Dakota (11.3 per 100,000), Nebraska (11.8 per 100,000), and Iowa (15.3 per 100,000). According to the CDC, the mortality rate of overdose in WV is nearly 2.5 times higher than the national average (32.6 deaths per 100,000). The national opioid dispensing rate has declined from 46.8 prescriptions per 100 persons in 2019 to 37.5 prescriptions per 100 persons in 2023. Dispensing rates vary widely across the states, with West Virginia historically having the highest dispensing rates. Recent data shows that the southern states currently have the highest dispensing rates, including Arkansas (71.5 per 100 persons), Alabama (71.4 per 100 persons), Mississippi (63.1 per 100 persons), and Louisiana (62.7 per 100 persons). West Virginia currently has a rate of 46.4 per 100 persons (CDC, 2024a, 2024d, 2025c; Merino et al., 2019; Spencer et al., 2024).

Risk Factors for Potential Misuse

The progressive rise in prescription medication misuse across the US is a byproduct of the complex interplay of many contributing factors. However, the CDC credits the increased prescribing of opioid analgesics as the most dominant contributing factor to the significant increase in medication availability and misuse potential. According to the HHS, additional societal and environmental factors include aggressive marketing by the pharmaceutical industry, the explosion of illegal web-based pharmacies that disseminate these medications without proper prescriptions and surveillance, and greater societal acceptance of medication use for a growing number of conditions (CDC, 2024e; HHS, 2019).

Personal risk factors for potential medication misuse include untreated psychiatric disorders, younger age, past or current substance use (including alcohol and tobacco use), family history of SUD, and family or societal environments that encourage these behaviors. While prescription medication misuse can happen at any age, it more commonly begins in teens or young adults. However, opioid mortality is higher in middle-aged people with comorbid SUD and psychiatric conditions. Prescription medication misuse in older adults is a growing problem, especially when combined with alcohol. Having multiple health problems and taking multiple medications can put the older adult population at risk of misusing medications or becoming addicted. Also, a lack of knowledge about prescription medications and their potential harm heightens the risk within this population (Dydyk et al., 2024; Horn et al., 2025; NIDA, 2020; Strain, 2022; SAMHSA, 2024b).

In WV, the rationale for the heightened opioid epidemic is premised on a combination of sociocultural and economic factors, the primarily rural area, limited access to health care services, a depressed economy, a lack of education, and the high rate of prescribing and dispensing of prescription opioids. Prescribing practices such as prescribing a higher dose than needed and prescribing for longer than needed increased the risk of misuse. Efforts to address the high rates of misuse and overdose deaths in WV have been complicated by misunderstandings and beliefs about addiction, causing delayed entry into treatment and recovery programs (Merino et al., 2019; US Department of Labor, n.d.; West Virginia Department of Health and Human Resources, 2020).

Controlled Substances: The Basics

According to NIDA, the three classes of medication that are most commonly misused include opioids, CNS depressants (i.e., tranquilizers, sedatives, and hypnotics), and stimulants. These are considered controlled substances because they act in the CNS, can cause physical and psychological dependence, and have various health consequences when used in high doses or for long durations of time. The Controlled Substances Act of 1970 established five schedules, which delineate progressive abuse potential. Schedule I medications have the highest abuse potential and currently have no medical use due to the lack of accepted safety data from the US Food and Drug Administration (FDA). Schedule II medications also have a high potential for abuse that can lead to serious physical and psychological dependence. Schedule III medications have less abuse potential and are accepted for medical use when abuse may lead to moderate to low physical dependence or high psychological dependence. Schedule IV medications have less abuse potential than Schedule I-III and are often used to treat anxiety or seizures. Schedule V medications are considered to have the least abuse potential. Opioids were developed for pain control and function by binding to mu-opioid receptors in the CNS to reduce or block the pain signal to the brain. They also affect receptors in the respiratory and gastrointestinal (GI) tract and are occasionally used to treat diarrhea and coughing. There are synthetic opioids, such as fentanyl (Duragesic), and naturally derived opioids from the opium poppy plant. Tramadol (Ultram) is a Schedule IV synthetic opioid commonly used to treat mild to moderate pain. Codeine is frequently prescribed to treat mild to moderate pain or coughing, either alone or in combination with acetaminophen (Tylenol) as part of cough and cold formulas (Aro et al., 2023; NIDA, 2016, 2020; Ortiz & Preuss, 2024). Schedule II medications have a high potential for misuse, with the potential for physical and psychological dependence. Common Schedule II opioids prescribed for moderate or severe pain include:

• hydrocodone (Vicodin, Lortab, Norco): commonly combined with acetaminophen (Tylenol), the most frequently prescribed opioid in the US
• oxycodone (OxyContin, Percocet, Roxicodone): available as an immediate-release (IR) or extended-release (ER) formula, fast onset
• morphine sulfate (MSContin): available as an IR or ER, PO/intravenous (IV)
• oxymorphone (Opana, Opana ER): available as an IR or ER, long half-life
• hydromorphone (Dilaudid, Exalgo ER): made from morphine, but with a faster onset, PO/IV
• fentanyl (Duragesic): transdermal patch lasting 72 hours, also available as IV (Preuss et al., 2023; DEA, n.d.-b)

Adverse reactions to opioid use include respiratory depression, drowsiness, mental confusion, nausea/vomiting, dizziness, headaches, fatigue, pruritus, pinpoint pupils, urinary retention, and constipation. Because these medications can induce euphoria, especially when taken at higher doses than prescribed or ingested via snorting or injection, they are at high risk for misuse and addiction. There is also an increased risk of developing medication tolerance and hyperalgesia (i.e., increased sensitivity to pain caused by damage to nociceptors or peripheral nerves with long-term use of opioids) (Azadfard et al., 2023; Dydyk et al., 2024; Strain, 2022).

CNS depressants are a class of medications that include tranquilizers, sedatives, and hypnotics and are often used to treat anxiety and sleep disorders. CNS depressants increase the activity of the neurotransmitter gamma-aminobutyric acid (GABA), producing a drowsy or calming effect. A few examples include benzodiazepines, such as lorazepam (Ativan), diazepam (Valium), clonazepam (Klonopin), alprazolam (Xanax), triazolam (Halcion), and estazolam (Prosom). These are categorized as Schedule IV medications and are typically prescribed to treat general anxiety, panic attacks, acute stress reactions, muscle spasms (diazepam [Valium]), seizure disorders (clonazepam [Klonopin]), and sleep disorders (triazolam [Halcion], estazolam [Prosom]). In general, this group requires great caution and is indicated for short-term use only due to the high risk of tolerance, dependence, and addiction. Concurrent use of benzodiazepines and opioid pain medications should be avoided due to the additive risks of these groups (NIDA, 2016; Washington State University, 2022).

Non-benzodiazepine sleep medications include zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata). These act on the same GABA type A receptors in the brain as traditional benzodiazepines but with a different chemical structure, which is thought to result in fewer side effects and a lower risk of dependence. However, these medications can cause headaches, amnesia, dizziness, and nightmares. Melatonin—a safer short-term option for insomnia—is an over-the-counter (OTC) supplement that boosts the body's natural sleep hormone levels. Ramelteon (Rozerem) is a prescription option that acts as a synthetic melatonin antagonist, binding to MT1 and MT2 receptors and helping induce sleep without any misuse or addiction potential (Elsevier, 2024; NIDA, 2016).

Buspirone (Buspar) is a pharmacologic option for the management of anxiety that is not a controlled substance; it works by binding to serotonin and dopamine D2 receptors. Buspirone (Buspar) is generally better tolerated than benzodiazepines, with less drowsiness and lower misuse potential. Barbiturates, such as mephobarbital (Mebaral), phenobarbital (Luminal), and pentobarbital (Nembutal), are less commonly used medications for anxiety and sleep disorders due to their high risk of overdose. However, they are still used in seizure disorders and during surgical procedures. All CNS depressants can induce drowsiness, confusion, and poor coordination. These medications should never be stopped abruptly but tapered slowly due to the risk of withdrawal symptoms, seizures, or other harmful effects. Barbiturate withdrawal can be especially dangerous and potentially life-threatening. In the case of a benzodiazepine overdose, flumazenil (Romazicon, a benzodiazepine antagonist) may be administered via an IV by emergency medical personnel (NIDA, 2016; Skibiski et al., 2024; Wilson & Tripp, 2023).

Stimulants like methamphetamine, dextroamphetamine (Adderall, Dexedrine), and methylphenidate (Ritalin, Concerta) are classified as Schedule II medications. They function by enhancing the effects of the brain neurotransmitters norepinephrine and dopamine, thereby increasing alertness, attention, motivation, cognition, and energy. Stimulants can also provoke vascular constriction, leading to increased heart rate, blood pressure, and respiratory rate; dilated airway; jitters; elevated blood glucose; and sleep disturbance. When misused, these medications can cause euphoria related to increased brain dopamine activity. Abruptly stopping a stimulant can cause withdrawal, which is characterized by depression, fatigue, and sleep disturbance. Repeated misuse of stimulants has been associated with feelings of hostility, paranoia, and psychosis, and overdose can lead to hyperthermia, arrhythmias, cardiovascular arrest, or seizures (Farzam et al., 2023; NIDA, 2016).

Guidelines for Safe Prescribing Practices

One of the greatest challenges for prescribers is distinguishing between legitimate and illegitimate prescriptions of controlled substances. Given the unique risks associated with controlled substance use, misuse, and potential medication interactions, all providers must adhere to best practices for prescribing guidelines. The West Virginia Expert Pain Management Panel's Safe & Effective Management of Pain Guidelines extend the 2016 CDC's Guidelines for Prescribing Opioids for Pain, updated in 2022 (refer to Table 2). Together, these guidelines use the highest level of evidence-based practice regarding the safe prescribing, dispensing, monitoring, and risk reduction strategies for using controlled substances amid the rising opioid epidemic (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; WV SEMP, 2016).

Risk Reduction and Screening 

Treatment must begin with a comprehensive history and physical, including a detailed assessment specific to pain. It should include a complete list of current and past medical conditions, current medications, and how they are taken. Obtaining a copy of the patient's records from previous providers is advised whenever possible. A review of systems (ROS) should include questions related to controlled substance use and any side effects, such as nausea, constipation, cognitive changes, or other impairments. Next, a thorough and consistent pain assessment should be performed, including pain severity rating, location, quality, duration, treatment history, and aggravating/alleviating factors. Because pain severity is subjective, it is ideal to consistently use one tool to evaluate pain during each visit to allow for more accurate trend identification. The most commonly used tools for pain include the verbal rating scale (which allows patients to choose from three to six adjectives to describe their pain ranging from no pain to severe pain), a numerical rating scale (which allows patients to select a number between 0 and 10), a picture scale (uses multiple facial expressions indicating increasing levels of discomfort), and a visual analog scale (VAS; Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025).

Additional history components should include a detailed review of family history (substance use/misuse or psychiatric diagnoses), social history (socioeconomic status, employment status, education level, living situation, and dependents), prior substance and alcohol use, as well as a depression screening. The patient's history regarding drug and alcohol use should include past or present use of tobacco, alcohol, illicit drugs, and the misuse of any OTC or prescription medications in the past, including details such as timing, duration, the substance of choice, treatment obtained, and pending legal decisions (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025).

Many patients with chronic pain also have a diagnosis of clinical depression and are twice as likely to attempt suicide as non-pain patients. Therefore, the consistent use of a depression screening tool is imperative to ensure adequate treatment of any comorbid psychiatric conditions that may be undertreated or untreated. The Beck Depression Inventory (BDI), the 9-Item Patient Health Questionnaire Depression Module (PHQ-9), and the Profile of Mood States are helpful for depression screening among chronic pain patients. In addition, all patients being considered for chronic opioid therapy should first undergo screening for risk of substance misuse using an opioid misuse risk assessment tool (refer to Table 2). These tools can help guide patient stratification according to risk level and inform the appropriate degree of structure and monitoring required in the treatment plan. Also, patients who have been taking opioids for extended periods should be routinely screened using appropriate tools (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; Williams & Nieuwsma, 2025).

Table 2

The WV SEMP Guideline Recommendations

(Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; WV SEMP, 2016)

Regardless of the tool chosen, prescribers must be trained correctly in its execution and interpretation. As outlined earlier in this module, a high-risk screening score and/or the presence of additional risk factors should alert prescribers to consider patient referral to specialty care, such as a pain management clinic, a higher-skilled facility, or a medical group with more extensive experience and expertise in treating pain in complex, higher-risk patients (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025).

WV SEMP guidelines also advise patients to undergo a urine drug test (UDT) at baseline and monitor compliance with prescribed medications if diversion or misuse is suspected. UDT can be a helpful tool but is imperfect, as false positives can happen. Hydration, medication dosage, metabolism, body mass index (BMI), urine pH, duration of use, and individual medication pharmacokinetics can affect the results. Manufacturer impurities have shown hydrocodone (Vicodin, Lortab, Norco) amounts in oxycodone products. Poppy seeds or the herb Papaveris fructus may cause a false-positive morphine result. A negative result for a prescribed medication could indicate the patient was not taking the medication (at the correct dose or at all) or indicate false negative results. A positive result for an unexpected medication could mean the patient took the medication illicitly, it is a metabolite of another prescribed medication, or the positive result was false. For patients assigned female at birth, consider screening for pregnancy concurrently via a single urine sample/specimen. The urine drug screening/testing results must be available before or at the point of treatment decisions (Dowell et al., 2022; Dydyk, Sizemore & Haddad et al., 2023; Horn et al., 2025; WV SEMP, 2016).

Finally, a complete physical exam must be performed and documented appropriately before any prescriptions are written, and exams should be done periodically throughout the treatment course. A physical examination is required in WV before prescribing all controlled substances, as a valid practitioner-patient relationship must be established. Under §60A-2-206 of House Bill 2768 (passed March 9, 2019), a practitioner must conduct and document the results of a physical examination every 90 days for any patient for whom they continue to treat with any Schedule II opioid medication. The physical examination should be relevant to the specific diagnosis and course of treatment. It should assess whether maintaining the course of treatment would be safe and effective for the patient. Furthermore, in WV, a pharmacist has the right to refuse to dispense a prescribed medication based on a reasonable belief that there is no practitioner-patient relationship (Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; West Virginia Legislature, 2019).

Prescription Drug Monitoring Program

Most states (49 states, Washington DC, and Guam) have established statewide electronic databases or prescription drug monitoring programs (PDMPs) to track and monitor opioid prescriptions. The PDMP collects designated data on controlled substances dispensed to each patient. This program is intended to improve opioid prescribing, inform clinical practice, and protect high-risk patients. The PDMP is housed and operated by a state regulatory, administrative, or law enforcement agency. The housing agency disseminates information from the database to individuals who are authorized to receive the information for purposes identified by state law. States arrange individual systems to track and monitor prescriptions, but the details about use, access, medication inclusion, and the regulations and implications for prescribers vary greatly. Most states also have a method to access the patient's records in other or neighboring states (CDC, 2024c; D'Souza et al., 2024).

The key to the efficacy of PDMP systems is the mandate that all providers must check the system before initiating opioid therapy. The goal is to determine if the patient is receiving opioid dosages or dangerous combinations that place them at risk for overdose. States differ in how frequently providers are mandated to monitor this system and which controlled substances are included. Reporting systems help reduce the diversion of illegitimate opiate prescriptions (CDC, 2024c; D'Souza et al., 2024).

West Virginia Monitoring Program

In 2013, WV launched the RxDataTrack Controlled Substance Automated Prescription Program (CSAPP). The CSAPP is an online database that complies with the Health Insurance Portability and Accountability Act (HIPAA), allowing for the tracking and reviewing of controlled substance prescription history to assist with diversion at the prescriber, pharmacy, and patient levels (West Virginia Board of Pharmacy [WVBOP], n.d.). According to WV SEMP Guidelines (2016), all licensees who dispense Schedule II, III, and IV controlled substances to residents of WV must provide the dispensing information to the WVBOP every 24 hours. In addition, according to WV Code §60A-9-5 of House Bill 2768, all practitioners who prescribe or dispense Schedule II, III, or IV controlled substances must:

• Register with the WV Controlled Substances Monitoring Program and maintain access.
• Access the CSAPP upon initially prescribing or dispensing any pain-relieving controlled substance for a patient and at least annually after that.
  • Providers working in pain management clinics must check the CSAPP at the initiation of controlled substance therapy and at least every 90 days after that (Dydyk, Sizemore, & Trachsel et al., 2023; WVBOP, n.d.; West Virginia Legislature, 2019).

The statute cites an exemption for patients treated for cancer-induced pain and pain associated with a terminal illness. Since the CSAPP system complies with HIPAA Privacy and Security Rules, access is granted only to prescribers and dispensers who have been credentialed and agree to confidentiality requirements for access to and use of the information. For WV, this includes physicians, pharmacists, dentists, veterinarians, physician assistants, advanced practice nurses, other prescribers and dispensers, and opioid antagonist/non-control reporting users or provider delegates (Dykyk, Sizemore, & Trachsel et al., 2023; WVBOP, n.d.; West Virginia Legislature, 2019).

Informed Consent and Treatment Agreements

A treatment agreement or a patient and provider agreement (PPA) should be obtained before the initial opioid prescription. The PPA underscores the critical importance of the proper use of prescribed pain medications, outlining the standards of care and the expectations of treatment. It promotes collaboration and mutual commitment from both parties, sets realistic expectations with measurable functional goals for therapy, and states why the agreement may be terminated. At a minimum, it should address the potential side effects, possible overdose, respiratory depression, development of physical dependence or tolerance, medication interactions, inadvertent ingestion by children or others, and medication misuse by the patient, their household contacts, or friends. Furthermore, prescribing policies should be clearly defined, including the number and frequency of refills, policy on early refills, and procedures for lost, damaged, or stolen medications. It should indicate how medication refills and changes should be requested and obtained by the patient and handled by the office staff and providers (Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; WV SEMP, 2016).

If UDTs or pill counts are performed periodically, the PPA should address this topic. Prescribers should explain how the test results will be interpreted, confirmed, and used, including their effects on the continuation of treatment. The cost of UDT should also be considered, discussed with the patient, and included in the provider agreement. The risk of neonatal withdrawal syndrome during a potential pregnancy should also be included for patients assigned female at birth. The PPA can also establish informed consent, or there may be a separate document for informed consent. Regardless, informed consent must cover the nature of the specific medication prescribed, potential risks, benefits, and the desired outcomes and functional goals of treatment. The agreement should be updated if medications change during treatment. Most PPAs specify that the patient is expected to use a single prescriber for all their controlled substance needs, but some may limit the patient to one prescriber for pain medicine (Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; WV SEMP, 2016).

Documentation

Documentation is critical when prescribing controlled substances for safety and legal reasons. Documentation in the medical record should be clear and concise and include all details outlining dose adjustments or medication changes with associated justifications and equivalency calculations, the effectiveness of treatments based on consistent pain assessments repeated at each visit, and any adverse effects and related treatments. Documentation should also specify whether the patient is adhering to the treatment plans as outlined in the PPA and include results of any UDTs or pill counts. Any concerning or aberrant behavior should be carefully documented with as much detail as possible. Interviews with family members and caregivers can also be included in documentation records with a clear plan for resolution and/or future monitoring. All written communication with patients should be included in the patient's electronic medical record (EMR), and office staff should carefully document any phone calls made or received. Document every time PDMP reports are reviewed and whether any concerning findings are noted. Any decision to terminate care needs to be documented thoroughly (Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025).

Management of Acute and Chronic Pain

Alleviation of pain and suffering has always been a fundamental tenet of medical care. Pain occurs in two main categories: acute (under 3 months) and chronic (over 3 months); treatment and management options differ significantly between these groups. Acute pain is often self-limiting; if nonpharmacological treatment can be used effectively, it is recommended instead of medication use. Nonpharmacological treatments such as heat, ice, massage, acupuncture, and spinal manipulation have low- to moderate-quality evidence but negligible risk. If pharmacological treatment is required, treatment should start with non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen [Advil, Motrin], naproxen [Aleve, Naprosyn, Vimovo]), acetaminophen (Tylenol) and/or skeletal muscle relaxants such as carisoprodol (Soma) and cyclobenzaprine (Flexeril). GI and cardiovascular risks are associated with NSAID use; however, celecoxib (Celebrex) and nabumetone (Relafen) are gastroprotective in the short term. Studies have also shown that adding misoprostol (Cytotec), a proton pump inhibitor, or an H2 blocker is gastroprotective for short-term use. Naproxen (Aleve, Naprosyn, Vimovo) and meloxicam (Mobic) appear to be the safer options in terms of cardiovascular risk. Systemic corticosteroids do not have significant evidence to support their effectiveness or use and have substantial adverse effects, especially for diabetic patients (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Mariano, 2025).

Other treatments often used successfully for pain management include cognitive behavioral therapy (CBT), exercise therapy, and physical therapy. These treatments should be tried first or incorporated with any pharmacological treatment that is deemed appropriate. Additional nonopioid medications, such as gabapentin (Neurontin) and pregabalin (Lyrica), or antidepressants such as venlafaxine (Effexor), duloxetine (Cymbalta), or tricyclic antidepressants should also be considered. Opioid treatment should only be added when these treatments are deemed inadequate, and the potential benefits of opioids outweigh the risks (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Mariano, 2025).

If opioids are prescribed for acute pain, CDC prescribing guidelines advise limiting the initial prescribing of opioids to between 4 and 7 days. They also advise against co-prescribing opioids and benzodiazepines due to the high risk of overdose when used together. The PDMP database should be reviewed initially for all patients receiving opioid prescriptions. The initial opioid prescription should be considered a trial, with a follow-up appointment scheduled to review effectiveness and success based on established treatment goals. As with any new prescription medication, all current medications should be reconciled for potential interactions, and any medication allergies/sensitivities should be reviewed. Moderate pain can often be managed with weaker opioids such as codeine (Tylenol #3) or tramadol (Ultram), which is a synthetic analog of codeine with a low affinity for opioid receptors. Treatment for severe pain should start with a more potent oral opioid such as hydrocodone (Vicodin, Lortab, Norco), oxycodone (OxyContin, Percocet, Roxicodone), morphine (MS Contin), or hydromorphone (Dilaudid, Exalgo ER). Fentanyl (Duragesic) and methadone (Methadose, Dolophine) should be avoided as first-line options due to their dosing challenges. IR medications with a half-life of 2 to 4 hours should be started initially for opioid-naive patients until the dose is stabilized. Dose adjustments may be necessary as often as every 2 to 3 days. ER or long-acting (LA) formulas with a half-life of 8 to 12 hours from the same family are commonly added later if long-term use is required (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023).

Chronic pain treatment (excluding cancer patients and end-of-life care) should always start with and include non-pharmacologic and nonopioid treatment options. When initiating opioid therapy for severe pain that requires daily, around-the-clock, long-term opioid treatment, the lowest dose possible should be given, beginning with a short-acting opioid and/or rotating to an LA/ER if indicated. The lowest effective dose of IR opioids should be used initially, avoiding ER or LA versions until a stable dose has been established. Primary care providers should reassess the risks and benefits of treatment when prescribing more than 50 morphine milligram equivalents (MME) per day and carefully justify prescribing more than 90 MME/day. According to the CDC, the risk of overdose is at least doubled in patients taking 50 MME/day or more as compared to patients taking less than 20 MME/day. Fifty MME/day is about 50 mg of hydrocodone (Vicodin, Lortab, Norco) or 33 mg of oxycodone (OxyContin, Percocet, Roxicodone) per day. Prescribers should become familiar with and maintain access to an opioid dosage calculator regularly to help determine a patient's current MME, change dosages, and transition between different medications using equivalent dosages. Several dose calculators are available free of charge online, including on the CDC and Centers for Medicare & Medicaid Services websites. Note that these calculators have their limitations and exceptions (CDC, 2016; Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025).

To account for variability in the pharmacologic properties of each medication and patient individuality, extreme caution should be used to limit the risk of accidental overdose or underdose when transitioning between opioids. Follow-up appointments should occur within 1 to 4 weeks of starting opioids or dose increases to assess benefits and any harms; once a patient is stable, follow-up visits can occur every 3 months. If risks or harms outweigh benefits at any point, opioids should be tapered to a lower dose or gradually discontinued, and other treatments should be optimized (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025).

If methadone (Methadose, Dolophine) is used, the prescriber must be able to provide evidence of appropriate education to manage this medication. The half-life of methadone is significantly longer than morphine (8 to 59 hours), with lipophilic storage, so great care should be taken with this medication to treat pain safely. Its low cost and ease of availability often make methadone (Methadose, Dolophine) an attractive option if used carefully by a skilled and experienced prescriber. In WV, nurse practitioners, physician assistants, and physicians can certify patients for medical marijuana. Patients must have documentation of a qualifying diagnosis, such as severe chronic pain or opioid use disorder. Prescribers must have a valid state license and DEA registration number, complete a 4-hour state-approved course in medical marijuana, and then register with the state to certify patients. Patients are diagnosed and certified by a registered prescriber and then must register with the WV State Department of Health to obtain a registry ID card to purchase medical marijuana products. This pain control option may help limit the use of opioids, even for patients with acute or postoperative pain (Dowell et al., 2022; Durrani & Bansal, 2024; Horn et al., 2025; Office of Medical Cannabis, n.d.).

Special Considerations: Older Adults and Pregnant Patients

Special considerations should be applied when prescribing for populations at potentially higher risk for harm, including older adults (over 65) or those who are pregnant. While pain is more commonly reported by older adults due to natural aging, advancing age is often accompanied by physiological changes that affect medication absorption, metabolism, and excretion. Older adults can also have renal or hepatic insufficiency, which can impair the excretion of medications, leading to toxicity or other adverse effects. In addition, older adults may have an increased risk of falls and fractures related to opioids, and clinicians are advised to consider a patient's fall risk when selecting and dosing potentially sedating medications such as tricyclic antidepressants, antiseizure medications, or opioids. Clinicians should weigh the risks and benefits of the use, dose, and duration of agents such as acetaminophen (Tylenol) and NSAIDs when treating older adults. The side effect profiles can be especially devastating in this population. Some guidelines recommend topical NSAIDs for localized osteoarthritis (e.g., knee osteoarthritis) over oral NSAIDs for patients aged 75 years and older to minimize systemic effects (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Galicia-Castillo & Weiner, 2024; Horn et al., 2025).

When less harmful alternative pharmacological and nonpharmacological modalities are ineffective, the CDC's best practice opioid guidelines encourage prescribers to initiate therapy with controlled substances at the lowest possible dose and gradually increase only as needed (i.e., "start low and go slow"). For older adults receiving opioids, it is also advised to initiate a bowel program to prevent constipation. The American Geriatrics Society Beers Criteria (BC) of potentially inappropriate medication use in older adults advocates avoiding certain medications in this population (Dowell et al., 2022). Included in the most recent version are the following critical recommendations (American Geriatrics Society BC Update Expert Panel, 2023).

• Benzodiazepines should be avoided for insomnia, agitation, or delirium due to the associated fall risk and high rate of physical dependence.
• Non-benzodiazepine, benzodiazepine receptor agonist hypnotics (eszopiclone [Lunesta], zaleplon [Sonata], zolpidem [Ambien]) should be avoided for insomnia.
• Opioids should be avoided by those with a history of falls or fractures.
• Antipsychotic medications should be avoided as a first-line treatment for delirium unless the patient is a threat to self or others due to the increased risk of stroke and mortality in older adults with dementia and olanzapine (Zyprexa) syncope.
• Tricyclic antidepressants and skeletal muscle relaxants (cyclobenzaprine, [Flexeril] carisoprodol [Soma]) should be avoided or used with caution secondary to anticholinergic effects.
• Indomethacin (Indocin, Tivorbex) and ketorolac (Toradol, PO/IV) should be avoided due to the risk of GI bleeding and kidney damage; instead, use celecoxib (Celebrex), nabumetone (Relafen), naproxen (Aleve, Naprosyn, Vimovo), or ibuprofen (Advil, Motrin) in combination with a proton pump inhibitor for GI prophylaxis.

While opioid use in pregnancy is not well studied, it can be associated with risks to both the pregnant person and the fetus. Some studies have shown an association between opioid use in pregnancy and neural tube defects, congenital heart defects, preterm delivery, poor fetal growth, stillbirth, and the potential for neonatal opioid withdrawal syndrome. In 2014, the FDA removed the older system of ranking medications for those who are pregnant (Categories A, B, C, D, and X) and now requires specific information about pregnancy safety (including during labor and delivery), safety while breastfeeding, and safety for people assigned female or male at birth of reproductive potential. Opioids are excreted in breast milk and increase the risk for CNS and respiratory depression in infants if taken by individuals while breastfeeding. These risks can be minimized by using the lowest effective dose to control pain. Regardless, every patient should be well informed of the potential risks before receiving any opioid or controlled substance prescriptions. Acetaminophen (Tylenol) can be used safely in pregnancy and while breastfeeding. Due to the risk of bleeding and premature ductal closure, pregnant patients should avoid NSAIDs, especially during the first trimester and after 30 weeks of gestation. NSAIDs appear safe to use during breastfeeding, however. Benzodiazepines should be avoided in pregnant and breastfeeding patients, as they cross the placenta and are excreted in breast milk. In pregnancy, they increase the risk of congenital abnormalities, primarily during the first trimester (Dowell et al., 2022; Leek & Arif, 2023; Lockwood & Magriples, 2025).

Special Considerations: Cancer Patients and End-of-Life Care

The treatment of cancer pain is highly complex, and each patient's disease prognosis, concurrent medications, and goals of care should be carefully considered for all decision-making. The treatment of pain within the specialty care of patients who are terminally ill does not typically conform to the aforementioned regulations. In the care of these patients, there is less concern for misuse or addiction, allowing for a greater focus on effective pain relief. Concerns specific to these populations include overdose risk, respiratory depression, and potential loss of consciousness or hastening death. According to the National Consensus Project (NCP) for Quality Palliative Care clinical practice guidelines, medications should be increased gradually and only as tolerated, with the full consent of the patient or their proxy medical decision-maker/guardian or via an intact living will or advance directive. The patient and/or their caregivers should be fully informed of the potential risks of increased opioid doses. If the patient and their family prioritize pain relief over the length of life, the care team should accept and respect that decision. Generally, clinicians should never withhold needed pain medication from terminally ill patients for fear of hastening death if they have received informed consent from the patient to do so. Loss of consciousness should not be assumed to be caused directly by high doses of opioids in a patient near the end of life if those doses have been stable or slowly increasing, especially in chronic cancer pain (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; NCP for Quality Palliative Care, 2018).

Prevention of Medication Misuse

Prevention of the misuse of controlled substances starts with prescribers, especially ensuring formal continuing education regarding the indications, risks, and benefits of these medications and safe prescribing practices that guide medical decision-making to limit risk to patients and communities. An honest dialogue with each patient regarding the risks, benefits, treatment goals, treatment alternatives, and expectations of both parties before prescribing can help prevent the misuse of potentially dangerous medications. This includes utilizing informed consent and PPAs, with updates and changes to these documents as treatment is adjusted over time. A strong professional relationship with the network of local pharmacists can also aid prescribers in monitoring altered, falsified, or otherwise suspicious-looking prescriptions. For patients, misuse can best be prevented by taking all medications exactly as prescribed and discussing any changes with the prescriber before making them (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; NIDA, 2016).

Manufacturers of medications are studying and trialing various methods to make medications less vulnerable to misuse; these methods are called abuse-deterrent formulations (ADFs). ADFs include physical or chemical barriers to prevent dissolving, grinding, or crushing; agonist/antagonist combinations; aversive substances added that are released if the product is manipulated or taken in a way other than directed; implanted delivery systems or injectables that release long-acting medication slowly; or new molecular entities/prodrugs that render a medication inactive unless it is taken orally. Additional regulations may prevent misuse. For example, in 2014, hydrocodone (Vicodin, Lortab, Norco) was recategorized as a Schedule II medication by the DEA. Research is ongoing regarding targeting alternative pathways, such as the endocannabinoid system. Further research is needed on the effective treatment of chronic pain and risk factors for SUD (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Horn et al., 2025; NIDA, 2016; Rosenquist, 2025).

Safe Storage and Disposal

Patients should be counseled about the importance of the safe storage of medications to avoid intentional or accidental use by anyone other than the patient for whom they were prescribed. Proper medical disposal helps eliminate excess quantities of controlled substances and reduce the likelihood that these medications will be diverted. According to the FDA, any expired or unnecessary medications should be deposited at a registered take-back event/location or disposed of in the household trash (pills should be mixed with dirt, coffee grounds, or cat litter and sealed in a bag, and all empty pill bottles should be thrown away separately after covering all prescription details). If no medication take-back program is readily available, used or unwanted fentanyl (Duragesic) patches and other medication can be flushed down the toilet if necessary (FDA, 2025).

In WV, statewide take-back events have been promoted and scheduled regularly to accept expired, unused, and unwanted medication. WV also created the Dispose Responsibly of Prescriptions (DRoP) program, which provides permanent medication drop boxes to law enforcement agencies across the state to reduce the public's access to unused prescription medication (Office of Inspector General [OIG], 2019; Office of the WV Attorney General, n.d.).

Signs and Symptoms of Medication Misuse

Recognizing and responding to indicators of medication misuse are important nursing responsibilities that can help reduce prescription medication misuse and diversion. Signs that a patient may be misusing or diverting their controlled substances include rapid increases in the doses of medications needed, frequent or unscheduled refill requests, repeated excuses about prescriptions or medication being lost or stolen, multiple visits to multiple providers or pharmacies, resistance to nonopioid and nonpharmacological treatment options, frequent after-hours calls to the on-call prescriber, or multiple trips to the emergency department (ED) resulting in prescriptions. Prescribers should avoid the common pitfall of assuming a well-liked or well-known patient is at a lower risk for misuse. Patients who repeatedly delay needed or planned surgeries and opt instead to treat an otherwise correctable condition with medications should be monitored closely (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Dydyk, Sizemore, & Trachsel et al., 2023; Horn et al., 2025).

The COMM tool (refer to Table 2) is a 17-item questionnaire for patients currently being prescribed opioids or other controlled substances. It formally and objectively assesses for signs and symptoms of misuse, psychiatric disorders, deceitfulness, noncompliance, and high-risk behavior patterns. In most cases, surveillance of controlled substance users should also include regular monitoring of the state's PDMP, UDT, and/or pill counts. These monitoring methods should be clearly defined in the PPA and explained to the patient. Finally, an open, face-to-face conversation between the prescriber or another member of the health care team and the patient regarding their pain, treatment plan, and current medication usage—along with an invitation for questions or concerns using open-ended questions and non-judgmental language—is crucial for patient screening. Data support the prescribing or offering of naloxone (Narcan) as a potential overdose-reversal agent. This is appropriate for high-risk patients exhibiting signs of medication misuse. Careful consideration should be made regarding a referral to a pain management center or an addiction specialist for high-risk patients. If not, documentation about why this was not done needs to be thorough. If treatment is transferred to another prescriber or if medication is tapered and stopped safely, this information needs to be communicated directly to the patient, with a full explanation and detailed documentation in the patient's chart (Dowell et al., 2022; Dydyk, Sizemore, & Haddad et al., 2023; Dydyk, Sizemore, & Trachsel et al., 2023; Horn et al., 2025).

Termination Strategies for Chronic Opioid Therapy (COT)

As with the treatment of any medical condition, the goal of terminating COT is to restore health and resume pre-illness activities of daily living. Termination is an intentional process that occurs when a patient has achieved most of the functional goals of treatment and/or when therapy must end for other reasons. According to the Federation of State Medical Boards (2024), continuation, modification, or termination of opioid therapy for pain is contingent on "the clinician's evaluation of (1) evidence of the patient's progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of [SUD] and/or diversion" (p. 14).

The most common reasons for COT termination include the achievement of the functional goals of therapy and/or when therapy must end for other reasons (e.g., treatment policy nonadherence, follow-up nonadherence, or concern for misuse or diversion). Appropriate termination helps avoid feelings of betrayed trust, prevents harm, and conveys intentionality. The PPA plays a critical role in this process, so termination must be addressed comprehensively in the initial contractual agreement and updated accordingly. Termination always carries the risk of exposing the patient to severe pain (Kim, 2023; Perfolizzo et al., 2019).

For acute pain, the WV SEMP guidelines encourage providers to help patients develop and identify functional SMART (specific, measurable, attainable, realistic, and timely) goals. Developing end-of-therapy goals for pain based on the expected time frame of the healing process (i.e., postoperative pain) reduces the potential for misuse and long-term issues. For chronic pain management, functional goals are often more difficult since the resolution of the syndrome or the elimination of pain is not expected to occur. However, reasons for the potential termination of therapy should be part of the treatment plan. Termination should be discussed at three stages of treatment: during the initial consultation (and when devising the PPA), during treatment, and before ending the intervention (WV SEMP, 2016). Strategies for termination of COT include the following (Dydyk, Sizemore, & Haddad et al., 2023; Dydyk, Sizemore, & Trachsel et al., 2023; Horn et al., 2025; Perfolizzo et al., 2019).

• Establish open, honest communication and dialogue with the patient from the point of the initial consultation.
• Comprehensively address termination in the informed consent and PPA process and readdress or refer to them as necessary during therapy.
• Set SMART goals at the beginning of treatment.
• Balance clinical judgment and individualization; incidents or events that cause concern regarding a pain agreement need to be interpreted in context.
• Opioid tapering should be performed after a discussion with the patient. There are multiple ways to taper an opioid; generally, the longer a patient has been on opioids, the longer a successful taper will take.
• Avoid terminating the relationship when a patient is in crisis without a referral to a specialized facility and a warm handoff to the receiving provider. If a patient is terminated while in crisis, it could reasonably be considered abandonment and escalate negative behaviors.
• As part of the termination preparation process, each patient should be given information about other resources (e.g., community resources, support groups, nonpharmacological pain modalities) with appropriate documentation.

Treatment of Medication Misuse and Addiction

SUD is multifaceted but can be effectively treated. Treatment must be multifactorial and individual, often involving detoxification, counseling, and medications. For OUDs and addiction, this combination is referred to as medication-assisted treatment (MAT). The goal of treatment is to correct the imbalance in brain pathways that mediate reward, decision-making, impulse control, learning, and other functions to restore the patient to a normal affective state. Behavioral treatment such as CBT or contingency management often helps change previous thinking patterns and behavior and teaches coping strategies and avoidance of triggers to limit the risk of relapse. Some programs may also include incentives for adherence, while family or group therapy expands the focus to include interpersonal relationships and life skills. Medications used in OUD treatment can alleviate withdrawal symptoms and limit cravings, thus reducing the risk of relapse (SAMHSA, 2021, 2024c). Medication options for OUDs are as follows (SAMHSA, 2021, 2024c).

• Buprenorphine (Buprenex, Sublocade) is a partial opioid agonist (binds to receptors but only partially activates) used to reduce cravings. Prescribers must be certified to prescribe, and it is available as an implantable or once-monthly injection.
• Methadone (Methadose, Dolophine) is a synthetic opioid agonist that has been used for over 40 years to help limit symptoms of withdrawal/cravings. It is available only through specially licensed opioid treatment programs (OTPs), limiting its availability.
• Naltrexone (Vivitrol) is an opioid antagonist (prevents opioids from binding to and activating receptors) that is used for addiction treatment. It is available as a long-acting injection and can be prescribed by any licensed prescriber. However, it requires patients to detoxify/abstain for 7 to 10 days before starting.

Studies regarding the best methodology for MAT continue, including exploring the administration of long-acting buprenorphine (Buprenex, Sublocade) to patients who have overdosed and are taken to an ED and the application of MAT programs among incarcerated populations. In 2016, the opportunity to undergo the required training for a prescribing waiver for buprenorphine (Buprenex, Sublocade) was extended to nurse practitioners (NPs) and physician assistants (PAs) nationally. The waiver requires 24 hours of training, and additional details for interested providers can be found on the SAMHSA website. Prescribers and the public can also search for state-authorized prescribers through the SAMHSA website. Currently, 484 authorized buprenorphine (Buprenex, Sublocade) prescribers are in WV (SAMHSA, 2021, 2024a, 2024c).

For patients with CNS depressant use disorder, great care must be taken to avoid sudden cessation of these medications. Detoxification of these medications should be done under medical supervision, as withdrawal symptoms can be severe and potentially life-threatening. Stimulant withdrawal can be uncomfortable, although less dangerous than CNS depressant withdrawal, and stimulant medications should be tapered to ease withdrawal symptoms. Treatment with the same behavioral therapies, including CBT, is effective for patients recovering from CNS depressant or stimulant use disorder. Unfortunately, while research continues, there are currently no FDA-approved medications for treating CNS depressant or stimulant use disorder (NIDA, 2025).

Naloxone (Narcan)

Naloxone (Narcan) is an opioid antagonist that blocks opioids from binding to and activating opioid receptors in the CNS. It is used as a reversal/rescue medication in the case of an opioid overdose. It can reverse the respiratory depression experienced by patients who have ingested large amounts of prescription opioids or heroin within 2 to 5 minutes. The initial dose can be repeated if no response is seen. First responders, emergency medical providers, and bystanders can administer it. Naloxone (Narcan) typically stays in a patient's system for 30 to 90 minutes, depending on the patient's body mass and metabolism, and may require more than one dose based on the half-life of the opioid ingested. It is administered as a nasal spray or intramuscular injection. Administration of naloxone (Narcan) typically causes symptoms of opioid withdrawal, including sweating/chills, nausea, vomiting, agitation/anxiety, fevers, runny nose, hypertension, shivering/shaking, and muscle aches. While naloxone (Narcan) is an effective opioid antagonist, it has no reversal effect on tramadol (Ultram), alcohol, CNS depressants, or stimulants. If this medication is ineffective after two doses, other explanations for the patient's symptoms should be explored and considered, including benzodiazepine overdose, and other treatments, such as flumazenil (Romazicon, a benzodiazepine antagonist), should be attempted (CDC, 2019; FDA, 2020, NIDA, 2022).

Prescribers should consider a naloxone (Narcan) prescription for patients who are currently taking a high dose of opioids (over 90 MME/day), chronic opioids (over 3 months), concurrent opioids and benzodiazepines, current ongoing treatment for a SUD, a history of opioid misuse or overdose, or immediate family members with a history of opioid misuse or overdose. A naloxone (Narcan) prescription should also be considered during periods of transition from one opioid to another in case of accidental overdose. Patients in secluded rural settings, those with chronic respiratory disease, current alcohol use, renal disease, hepatic disease, cardiac disease, HIV/AIDS, or those on depression/antidepressant medication are also considered good candidates for naloxone (Narcan) rescue prescriptions. Naloxone (Narcan) prescriptions should also be granted to caregivers who request them. Patients, as well as their family members and caregivers, must be educated on the signs/symptoms of an opioid overdose, such as snoring or choking sounds, shallow respirations, unresponsiveness, bradycardia, hypotension, and pale, clammy skin that may appear blue or gray. While naloxone (Narcan) does cross the placenta, no adverse effects have been noted in animal studies, and the benefits of overdose reversal are thought to outweigh the potential risks. Researchers have determined that naloxone (Narcan) is excreted in small amounts in breast milk (CDC, 2019; FDA, 2020; NIDA, 2022). In 2015, the WV Legislature passed Senate Bill 335, making naloxone (Narcan) available to first responders and relatives, friends, caregivers, or others in a position to assist someone at risk of experiencing an opiate-related overdose (OIG, 2019).

Specific Rules and Regulations for West Virginia

To mitigate the opioid epidemic, WV passed the Governor's Substance Abuse Prevention Bill (SB 437) in 2012, mandating that all healthcare providers who prescribe, dispense, or administer controlled substances must participate in continuing education related to prescription medication misuse and drug diversion. According to Rule WV 19 CSR 11, nurses licensed in the state must obtain the required contact hours to fulfill this legislative requirement (West Virginia RN Board, n.d.). West Virginia Code Chapter 60A governs the prescribing, dispensing, and consumption of controlled substances. This law establishes the standards for controlled substance prescribing, including reporting system requirements for prescribers and pharmacists in WV. The Rules and Regulations on Controlled Substances in West Virginia (Chapter 60A) specify the following (Dydyk, Sizemore, & Trachsel et al., 2023; OIG, 2019).

• Practitioners shall maintain a written record of all controlled substance prescriptions and a medical record for all patients receiving controlled substances. This record must include patient identification data, their chief concern, present illness, and physical examination as indicated (which must be completed prior to any prescriptions being issued but may have been performed by a consulting physician or hospital when records are available for review by the prescriber), diagnosis, data which support the diagnosis or treatment, and the treatment regimen (i.e., amount, strength, and directions for the use of any controlled substances).
• All practitioners who prescribe or dispense Schedule II, III, or IV controlled substances must register with the CSMP, and practitioners must document the information obtained from the CSMP search in the patient's medical record.
• All prescribers must check the CSMP database when issuing an initial prescription. If a prescriber continues to treat a patient with a controlled substance, the prescriber must continue to monitor the CSMP database at least annually. Physicians and other licensed pain management clinic practitioners must check the CSMP database when issuing an initial prescription and at least every 90 days.
• Before prescribing any medications in WV, all practitioners must perform a physical examination and establish a valid practitioner-patient relationship.
• All prescribers must follow the tamper-resistant (TR) forms law to prevent the use of fraudulent prescriptions to obtain controlled substances.
• According to the Opioid Reduction Act of 2018 (West Virginia Code § 16-54-1), prescribers must do the following.
  • Discuss the risks associated with opioid use and discuss alternatives to opioid therapy (i.e., physical therapy, massage).
  • Limit the number of opioids prescribed as follows.
    • Do not issue more than a 4-day opioid supply within an ED or an urgent care setting; prescribers in urgent care settings may issue an additional 7-day prescription with a documented medical rationale for exceeding the 4-day supply limit
    • Adults receiving an initial opioid prescription in an ED are limited to a 4-day supply of opioid medication.
    • Minors in the ED are limited to a 3-day supply, and the ED physician must explain the risks of addiction to the patient's parents.
    • Private practices are limited to prescribing a maximum 7-day supply at the lowest effective dose that, in the physician's best medical judgment, represents the best course of treatment.
    • Dentists and optometrists are limited to prescribing a 3-day supply of opioid pain medication.
• As of 2015, licensed healthcare providers may prescribe an opioid antagonist to first responders, individuals at risk of overdose, and relatives and friends of individuals at risk of overdose. Providers dispensing opioid antagonists must provide educational materials on overdose prevention, treatment programs, and the administration of opioid antagonists.

The WVBOP governs the prescribing of controlled substances and outlines the prescriptive authority of advanced practice registered nurses (APRNs). The following standards are required (American Medical Association, 2017; Dydyk, Sizemore, & Trachsel et al., 2023; West Virginia Legislature, 2022).

• APRNs will be granted prescriptive authority once they meet eligibility requirements, which include:
  • Successful completion of an advanced pharmacotherapy graduate-level course with at least 45 contact hours of pharmacology
  • Documentation of the use of pharmacotherapy in clinical practice during their educational program
  • Evidence of 15 graduate-level pharmacology contact hours within 2 years before the application for prescriptive authority
• When required, the APRN shall submit written verification of an agreement to a collaborative relationship with a licensed physician holding a WV license.
• Under West Virginia Code, § 30-7-15, and the West Virginia House Bill 214, passed in April 2022, APRNs are not authorized to hold Schedule I Controlled Substance prescriptive authority. An APRN may prescribe up to a 3-day supply of a Schedule II narcotic. There are no other limitations on prescriptive authority for APRNs in WV.
• Each prescription and subsequent refill given by the APRN shall be documented in the patient's chart.
• All prescriptions shall include the following information: name, title, address, and phone number of the prescriber; name and date of birth of the patient; date of the prescription; full name of the medication, the dosage, the route of administration, and directions for its use; the number of refills; DEA number of the prescriber (when required by federal law); and the prescriptive authority identification number issued by the board.
• An APRN shall, at the time of the initial prescription, record the plan for continued evaluation of the effectiveness of the controlled substances prescribed.
• An APRN shall prescribe refills of controlled substances according to current laws and standards.

References

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American Medical Association. (2017). State law chart: Nurse practitioner prescriptive authority. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/specialty%20group/arc/ama-chart-np-prescriptive-authority.pdf

American Nurses Association. (2018). The opioid epidemic: The evolving role of nursing. https://www.ncsbn.org/public-files/2018_ANA_Opioid_Epidemic.pdf

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

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Azadfard, M., Huecker, M. R., & Leaming, J. M. (2023). Opioid addiction. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK448203

Baker, D. W. (2017). History of the Joint Commission's pain standards. JAMA, 317(11), 1117-1118. http://doi.org/10.1001/jama.2017.0935

Centers for Disease Control and Prevention. (2016). Calculating total daily dose of opioids for safer dosage. https://stacks.cdc.gov/view/cdc/38481

Centers for Disease Control and Prevention. (2019). Life-saving naloxone from pharmacies. https://www.cdc.gov/vitalsigns/naloxone/index.html

Centers for Disease Control and Prevention. (2024a). Opioid dispensing rate maps. https://www.cdc.gov/overdose-prevention/data-research/facts-stats/opioid-dispensing-rate-maps.html

Centers for Disease Control and Prevention. (2024b). Overdose prevention: Commonly used terms. https://www.cdc.gov/overdose-prevention/glossary

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