Prescribing guideline for Narcotics/ Controlled drug:

It is crucial to have guidelines, in place when prescribing controlled drugs to ensure their
appropriate use as these medications carry a risk of abuse and harm. Here are some key
principles that prescribers should adhere to;

1. Prescribe controlled drugs for medical reasons following both national and international
guidelines.

2. Before initiating or continuing treatment with controlled drugs assess the patients history,
current condition and any potential risk factors.

3. Monitor the patients response to treatment carefully keeping an eye out for signs of
dependence, tolerance, diversion or adverse effects.

4. Thoroughly document the indication for prescribing the controlled drug along with details
such as dosage, duration of treatment and the date for review in the patients record.

5. Maintain effective communication with pharmacists and other healthcare professionals

involved in the patients care— during transitions of care.

6. Adhere to requirements when writing prescriptions for controlled drugs; this includes using
ink and specifying both the quantity (in words and figures) as well as providing your registration
number and address.

7. Take precautions to ensure storage and proper disposal of prescription pads as well as any
unused or expired controlled drugs. [1]

According to CDC guideline:

In 2022 the CDC Clinical Practice Guideline, for Prescribing Opioids for Pain was updated. It
provides recommendations on how to manage acute, subacute and chronic pain in patients who're
18 years or older. The guideline consists of 12 recommendations that can be summarized as
follows;
 1. Determining whether or not to initiate opioids for pain
2. Selecting opioids and determining opioid dosages
3. Deciding duration of initial opioid prescription and conducting follow-up
4. Assessing risk and addressing potential harms of opioid use
These guidelines aim to provide healthcare providers with insights on handling pain management
responsibly. [2]

According to NICE guideline:

 Recommendations for prescribers
1.When making decisions about prescribing controlled drugs take into account:
 the benefits of controlled drug treatment
 the risks of prescribing, including dependency, overdose and diversion
 all prescribed and non-prescribed medicines the person is taking (particularly any
centrally acting agents) and whether the person may be opioid naïve
 evidence-based sources, such as NICE and the British National Formulary (BNF), for
prescribing decisions when possible.
2. When prescribing controlled drugs:
 document clearly the indication and regimen for the controlled drug in the person’s care
record
 check the person’s current clinical needs and, if appropriate, adjust the dose until a good
balance is achieved between benefits and harms
 discuss with the person the arrangements for reviewing and monitoring treatment
 be prepared to discuss the prescribing decision with other health professionals if further
information is requested about the prescription.
3. Document and give information to the person taking the controlled drug or the carer
administering it, including:
 how long the person is expected to use the drug
 how long it will take to work
 what it has been prescribed for
  how to use controlled drugs when sustained-release and immediaterelease
formulations are prescribed together
 how it may affect the person’s ability to drive (see the advice from the Department of
Transport on drug driving and medicine: advice for healthcare professionals)
 that it is to be used only by the person it is prescribed for.
4. When prescribing ‘when required' controlled drugs:
 document clear instructions for when and how to take or use the drug in the person’s care
record
 include dosage instructions on the prescription (with the maximum daily amount or
frequency of doses) so that this can be included on the label when dispensed
 ask about and take into account any existing supplies the person has of ‘when required’
controlled drugs.
5. Prescribe enough of a controlled drug to meet the person’s clinical needs for no more than 30
days. If, under exceptional circumstances, a larger quantity is prescribed, the reasons for this
should be documented in the person’s care record.
6. Inform people who are starting controlled drugs that they or their representative may need to
show identification when they collect the controlled drugs.
7. When prescribing, reviewing or changing controlled drug prescriptions, prescribers should
follow local (where available) or national guidelines and take into account the:
 appropriate route
 dose (including when dose conversions or dose equivalence are needed)
 formulation (including changes to formulations).
If guidance on prescribing is not followed, document the reasons why in the person’s care
record. 8. Use a recognised opioid dose conversion guide when prescribing, reviewing or
changing opioid prescriptions to ensure that the total opioid load is considered.
9. When prescribing controlled drugs in primary care for use in the community, advise people
how to safely dispose of:
 unwanted controlled drugs at a community pharmacy
 used controlled drugs.
10. When prescribing a repeat prescription of a controlled drug for treating a longterm condition
in primary care, take into account the controlled drug and the person’s individual circumstances
to determine the frequency of review for further repeat prescriptions.
11. When prescribing controlled drugs outside general practice (for example in hospital or
out of hours), inform the person’s GP of all prescribing decisions and record this
information in the person’s care record so the GP has access to it. When sharing
information take into account the following 5 rules:
 Confidential information about service users or patients should be treated confidentially
and respectfully.
 Members of a care team should share confidential information when it is needed for the
safe and effective care of an individual.
 Information that is shared for the benefit of the community should be anonymised.
 An individual’s right to object to the sharing of confidential information about them
should be respected.
 Organisations should put policies, procedures and systems in place to ensure the
confidentiality rules are followed.
12. Follow locally agreed processes for reviewing anticipatory prescribing of controlled drugs in
primary care and palliative care services. Determine the type of review needed on a case-by-case
basis, including the ongoing clinical need and, where practicable, the expiry dates of any
controlled drugs already stored by the person.
13. When prescribing controlled drugs for inpatients (for example, on a medicines or inpatient
record) that are to be administered by different routes, prescribe each as a separate item and
clearly state when each should be used to avoid administration errors. [3]

According to WHO guideline:

Opoids are classified as controlled substances, and their misuse is a matter of concern. The
World Health Organization (WHO) has provided guidelines for the prescription of opoids.
Guideline 1: Governments should examine their drug control policies for the presence of overly
restrictive provisions that may impact their health care system in the delivery of pain relief, and
take corrective action as needed.
Guideline 2: National drug control policies should recognize that opioids are absolutely
necessary for medical care, in particular for relief of pain and suffering.
Guideline 3: National drug control policies should recognize the obligation of governments to
ensure adequate opioid availability for all medical and scientific needs.
Guideline 4: Governments should designate an authority for ensuring adequate availability of
opioids for medical care.
Guideline 5: Governments should develop, using information from relevant sources, a practical
method to estimate realistically the medical and scientific needs for opioids.
Guideline 6: Governments should furnish to the INCB annual estimates of the quantities of
narcotic drugs needed for medical and scientific purposes for the following year.
Guideline 7: Governments should furnish a supplementary estimate to the INCB if it appears
that the availability of narcotic drugs will fall short of medical needs, or to meet emergency
needs or exceptional medical demand.
Guideline 8: Governments should submit annual statistical reports to the INCB on the
production, manufacture, trade, use and stocks of narcotic drugs.
Guideline 9: Governments should establish a dialogue with health care professionals about the
legal requirements for prescribing and dispensing narcotic drugs.
Guideline 10: National drug control authorities and health care professionals should cooperate to
ensure the availability of opioid analgesics for medical and scientific purposes, including for the
relief of pain.
Guideline 11: Governments should ensure, in cooperation with licensees, that the procurement,
manufacture, and distribution of opioid medications are accomplished in a timely manner so that
there are no shortages of supply, and that such medications are always available to patients when
they are needed.
Guideline 12: Governments should permit and encourage the distribution and availability of
opioid medications throughout the country, in order to maximize physical access of patients to
pain relief medications while maintaining adequate controls to prevent diversion and abuse.
Guideline 13: Governments should establish and promote a national cancer control programme
that includes cancer pain relief and palliative care as a priority for health care resources,
including education about the WHO Analgesic Method and provision of pain relief and palliative
care.
Guideline 14: Terminology in national drug control policy should not have the potential to
confuse the medical use of opioids for pain with drug abuse or drug dependence.
Guideline 15: In their efforts to prevent diversion, governments should avoid undue restrictions
impacting on patient care decisions which are ordinarily medical in nature. Such decisions as the
amount of drug prescribed and duration of treatment should be made by the physician and be
based on individual patient needs.
Guideline 16: National drug control policy should avoid prescription requirements that may
unduly restrict physician and patient access to pain relief. [4]

References:
1. [Internet]. [cited 2023 Oct 28]. Available from:
https://www.cdc.gov/drugoverdose/pdf/Guidelines_At-A-Glance-508.pdf
2. [Internet]. [cited 2023 Oct 28]. Available from:
https://www.nice.org.uk/guidance/ng46/evidence/full-guideline-pdf-2427186353
3. Guideline recommendations and guiding principles [Internet]. Centers for Disease
Control and Prevention; 2023 [cited 2023 Oct 29]. Available from:
https://www.cdc.gov/opioids/healthcare-professionals/prescribing/guideline/
recommendations-principles.html#determining
4. Stepan JG, Lovecchio FC, Premkumar A, Kahlenberg CA, Albert TJ, Baurley JW,
Nwachukwu BU. Development of an institutional opioid prescriber education program and
opioid-prescribing guidelines: impact on prescribing practices. JBJS. 2019 Jan 2;101(1):5-
13.