Utah Controlled Substance Prescribing

Alexander Dydyk; Daniel Sizemore; Bhupendra Patel; Yasmyne Ronquillo; Burdett Porter

Utah Controlled Substance Prescribing

Author: Alexander M. Dydyk Author: Daniel C. Sizemore Author: Bhupendra C. Patel Author: Yasmyne Ronquillo Editor: Burdett R. Porter Updated: 4/10/2023 2:42:04 PM

Introduction

Chronic pain and opioid use and abuse is a significant problem in the United States.[1] Over one-quarter of United States citizens suffer from chronic pain.[2] It is among the most common complaints seen in an outpatient clinic and the emergency department. The failure to manage chronic pain and the possible complication of opioid dependence related to treatment can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence.[3] Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined.[4] How a patient's chronic pain gets managed can have profound and long-lasting effects on a patient's quality of life.

The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months.[5] There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy is in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical.[6]

Unfortunately, studies have revealed an inherent lack of education regarding pain management in most medical schools and training programs. The Association of American Medical Colleges recognized the problem and has encouraged schools to commit to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum.

Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, under prescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective.

The American Society of Addiction Medicine describes addiction as a treatable chronic disease that involves environmental pressures, genetics, an individual's life experiences, and interactions among brain circuits. Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, they identify five characteristics of addiction:

Craving for drug or positive reward
Dysfunctional emotional response
Failure to recognize significant problems affecting behavior and relationships
Inability to consistently abstain
Impairment in control of behavior

Unfortunately, most health providers' understanding regarding addiction is often confusing, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for effectively dealing with the challenges of addiction.

In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion contributed to the under-treatment of pain. Over time, the manual has eliminated these terms and now uses "substance use disorder," ranging from mild to severe.

Unfortunately, there are numerous challenges in pain management, such as both underprescribing and overprescribing opioids. The concerns are particularly prominent in patients with chronic pain. They have resulted in patients suffering from inadequately treated pain while at the same time developing concomitant opioid abuse, addiction, diversion, and overdose. As a result, providers are often negatively influenced and fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. To make the challenges even worse, chronic pain patients often develop opioid tolerance, significant psychological, behavioral, and emotional problems, including anxiety and depression related to under or overprescribing opioids.

Clinicians that prescribe opioids face challenges that involve medical negligence in either failure to provide adequate pain control or risk of licensure or even criminal charges if it is perceived they are involved in drug diversion or misuse. All providers that prescribe opioids need additional education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with over and under prescribing opioids.

Provider Opioid Knowledge Deficit

There are substantial knowledge gaps around appropriate and inappropriate opioid prescribing, including deficits in understanding current research, legislation, and appropriate prescribing practices. Providers often have knowledge deficits that include:

Understanding of addiction
At-risk opioid addiction populations
Prescription vs. non-prescription opioid addiction
The belief that addiction and dependence on opioids is synonymous
The belief that opioid addiction is a psychologic problem instead related to a chronic painful disease

With a long history of misunderstanding, poor society, provider education, and inconsistent laws, the prescription of opioids has resulted in significant societal challenges that will only resolve with significant education and training.

Etiology

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Etiology

Most patients who suffer from chronic pain complain of more than one type of pain.[7] For example, a patient with chronic back pain may also have fibromyalgia. A significant percentage of patients suffer from a major depressive and generalized anxiety disorder. Over 67% of patients with chronic pain suffer from a comorbid psychiatric disorder.[8]

There are multiple categories and etiologies of pain types, which include neuropathic, nociceptive, musculoskeletal, inflammatory, psychogenic, and mechanical.[6][9]

Neuropathic Pain

Peripheral neuropathic pain, as in the case of post-herpetic neuralgia or diabetic neuropathy
Central neuropathic pain - cerebral vascular accident sequella

Nociceptive Pain

Pain due to actual tissue injuries such as burns, bruises, sprains, or fractures.

Musculoskeletal Pain

Back pain
Myofascial pain

Inflammatory Pain

Autoimmune disorders (rheumatoid arthritis)
Infection

Psychogenic Pain

Pain caused by psychological factors such as headaches or abdominal pain caused by emotional, psychological, or behavioral factors

Mechanical Pain

Expanding malignancy

Opioid Manufacturer Role

Individuals and governments, including federal, state, and local municipalities, have successfully sued opioid manufacturers for their role in promoting the use of opioids. Purdue Pharma specifically has been found liable for the promotion of its sustained-release form of oxycodone.[10]

Epidemiology

Chronic Pain

There are over 100 million people in the United States who would meet the criteria for chronic pain syndrome.[2] Over 50 million Americans suffer from debilitating chronic pain, and over 20 million indicate that pain interferes with their daily lives. Chronic regional pain is reported in 11.1 percent of chronic pain patients, while chronic back pain accounts for 10.1 percent, leg and foot pain 7.1 percent, arm and hand pain 4.1 percent, and headache 3.5 percent. There are reports of widespread pain in 3.6% of patients with chronic pain.[8] Elderly patients have been shown to receive up to 25% fewer pain medications than the average population.[11]

Chronic pain is estimated to cost over $600 billion annually in lost productivity and medical treatment. Lifetime chronic pain is common, with over 50% of adults being affected at some point in their lives. Over 40% of chronic pain patients indicated their pain is not controlled, and over 10% suffer long-term disabling chronic pain.

Research has shown the lifetime prevalence for chronic pain patients attempting suicide between 5% and 14%; suicidal ideation was approximately 20%.[12] Of the chronic patient patients who commit suicide, 53.6% died of firearm-related injuries, while 16.2% by opioid overdose.[13]

The incidence of chronic pain is increasing due to the prevalence of obesity-related pain conditions, increased survival of trauma and surgical patients, an aging population, and heightened public awareness of pain as a treatable condition.

Opioids

Opioids are the most used therapeutic agent for chronic pain and are derived synthetically from generally unrelated compounds. Opiates are derived from the liquid of the opium poppy either by direct refinement or by relatively minor chemical modifications. Both opioids and opiates act on three major classes of opioid receptors: mu, kappa, delta, and several minor opioid receptors like nociceptin and zeta. Simplifying significantly, the mu receptors are thought to provide analgesia, respiratory suppression, bradycardia, physical dependence, gastrointestinal dysmotility, and euphoria. The kappa agonism can yield hallucinations, miosis, and dysphoria. The delta receptor likely has pain control and mood modulation effects, but some have suggested that mu agonism is necessary for the delta receptor to function strongly for analgesia.[14][15] The nociceptin receptor modulates brain dopamine levels and has clinical effects like analgesia and anxiolysis. The zeta receptor, also known as the opioid growth factor receptor, can modulate certain types of cell proliferation, such as skin growths, and are not thought to have many functions in modulating pain or emotion.[16][17]

In the past, providers in the United States rarely prescribed opioids for any condition except chronic cancer pain. This approach began to change in the 1990s. Dr. James Campbell addressed the American Pain Society (now bankrupt) in 1995 and urged healthcare providers to treat pain as the fifth vital sign.[18] The prescription of opioids for treating all chronic pain conditions has grown to the point that opioid sales have reached over 7 billion dollars. The United States currently consumes more than 80% of all opioids produced worldwide. With increased use, concomitant problems have developed, and the number of individuals abusing opioid analgesics has increased dramatically.[19][20]

West Virginia has been substantially affected by the diversion of prescription drugs, particularly hydrocodone and oxycodone. Hydrocodone and oxycodone are the most abused prescription drugs in West Virginia. With the education of providers on inappropriate prescribing of opioids and a slowing of diversion, individuals dependent on opioids have unfortunately shifted to the use of heroin and fentanyl. The death rate of overdose death due to prescription drugs has decreased while overdose deaths to non-prescription opioids have climbed rapidly. In fact, West Virginia has experienced the highest drug overdose rate in the country, with approximately 50 deaths per 100,000 population.[21]

Pathophysiology

The pathophysiology of acute and chronic pain is complex and not completely understood. Research is ongoing. In general, the following provides an overview of the current understanding of pain pathophysiology.[6][9]

Acute Pain

It is caused by the activation of peripheral pain receptors and specific A-delta and C-sensory nerve fibers (nociceptors). It is commonly a response to tissue injury.

Chronic Pain

Chronic pain is usually related to ongoing tissue injury is thought to be caused by persistent activation of these pain fibers. Chronic pain may also develop from ongoing damage to or dysfunction of the peripheral or central nervous system which causes neuropathic pain.

Nociceptive Pain

Nociceptive pain receptors may be somatic or visceral. Somatic pain receptors are located in the subcutaneous tissues, fascia, connective tissues, endosteum, periosteum, joint capsules, and skin. Stimulation results in burning, dull, or sharp pain.

Visceral pain receptors are located in the viscera and connective tissue. Visceral pain due is usually due to obstruction of a hollow organ. This pain is deep, cramping, poorly localized, and may be referred to a remote site. Visceral pain from injury of connective tissue or organ capsules may be more localized and sharp.

Psychologic Factors

Psychologic factors in the modulation of pain intensity are highly variable. Culture, emotions, and thoughts and emotions affect an individual's perception of pain. Patients who suffer from chronic pain may also have psychological stress, particularly anxiety and depression. As a result of some syndromes being characterized as psychiatric disorders such as somatic symptom disorders defined by self-reported pain, patients are often mischaracterized as having a psychiatric disorder and are deprived of appropriate care. Pain may interfere with cognitive attention, concentration, the content of thought, and memory.

Multifactorial Pain Syndromes

Many pain syndromes are multifactorial; for example, cancer and chronic low back pain syndromes have a nociceptive component but may also involve neuropathic pain as a result of nerve damage.

Pain Modulation and Transmission

Pain fibers enter the spinal cord at the posterior root ganglia and synapse in the posterior horn. Fibers then cross to the contralateral side and travel up the lateral columns reaching the thalamus and, finally, the cerebral cortex. Repetitive stimulation from prolonged pain can sensitize neurons in the posterior horn of the spinal cord so that a minimal peripheral stimulus results in pain.

Peripheral and nerves at other levels of the central nervous system are sensitized, resulting in long-term synaptic changes in cortical receptive fields that can result in exaggerated pain perception. This process of chronic afferent input causing increased sensitivity and lower pain thresholds, with the remodeling of the central nociceptive pathways and receptors termed central sensitization. The consequence may be:

Allodynia (exaggerated response to a nonpainful stimulus)
Hyperalgesia (excessive pain response to a normal pain stimulus)

Substances Released When Tissue is Injured

The inflammatory cascade can sensitize peripheral nociceptors. Substances released include vasoactive peptides such as calcitonin, gene-related protein, neurokinin A, substance P, and mediators such as bradykinin and epinephrine prostaglandin E2, and serotonin. The pain signal is modulated in both segmental and descending pathways by neurochemical mediators such as endorphins (enkephalin) and monoamines (norepinephrine, serotonin). These mediators are thought to increase, reduce, shorten sustain the perception and response to pain. They also mediate the benefits of CNS-active drugs such as antidepressants, antiseizure drugs, membrane stabilizers, and opioids that interact with neurochemicals and specific receptors that treat chronic pain.

Psychologic factors are important pain modulators. They affect how patients describe and react to pain; such as complaining, being irritable, grimacing, or being stoic. They may also generate neural output that modulates neurotransmission along pain pathways. The psychologic reaction to protracted pain interacts with central nervous system factors that may induce long-term changes in pain perception.

Pain Theories

Intensity Theory

The theory goes back to the Athenian philosopher Plato (c. 428 to 347 B.C.) who, in his work Timaeus, defined pain not as a unique experience, but as an 'emotion' that occurs when the stimulus is intense and lasting. Centuries later, we are aware that especially chronic pain represents a dynamic experience, profoundly changeable in a spatial-temporal manner. A series of experiments, conducted during the nineteenth century, sought to establish the scientific basis of the theory. Based on the tactile stimulation and impulses of other nature, such as electrical stimulations, these investigations provided important information concerning the threshold for tactile perceptions and on the role of the dorsal horn neurons in the transmission/processing of pain.[22]

Cartesian Dualistic Theory

The oldest explanation for why pain manifested in specific populations was rooted in religious beliefs. Throughout history, religious ideologies have had a substantial influence on people’s thoughts and actions. As a result, the majority of people believed that pain was the consequence of committing immoral acts. There was also a belief that the suffering they endured was the individual’s way to repent for these sins.[19] Although this belief remained popular up until the nineteenth century, this was not due to the lack of other available theories. One of the first alternative scientific pain theories was bravely introduced in 1644 by the French philosopher Renee Descartes (1596-1650). This theory has the name in current literature as the Cartesian dualism theory of pain.[23]

The dualism theory of pain hypothesized that pain was a mutually exclusive phenomenon. Pain could be a result of physical injury or psychological injury. However, the two types of injury did not influence each other. At no point were they to combine and create a synergistic effect on pain, hence making pain a mutually exclusive entity.[24] In an attempt to placate the church, Descartes also included in his theory the idea that pain has a connection to the soul. He claimed that his research uncovered that the soul of pain was in the pineal gland, consequentially designating the brain as the moderator of painful sensations.[25]

The dualistic approach to pain theory fails to account for many factors that are known to contribute to pain today. Furthermore, it lacks explanation as to why no two chronic pain patients have the same experience with pain even if they had similar injuries. Despite these shortcomings, it still provided future researchers with a solid foundation to continue expanding the scientific understanding of the intricate phenomenon of pain.

Specificity Theory

Many scientists continued to do research long after Descartes proposed the dualistic theory of pain. However, it wasn’t until 1811 that another well-known pain theory came onto the scene. This theory, initially presented by Charles Bell (1774–1842), is referred to as the specificity theory. This theory is similar to Descartes' dualistic approach to pain in the way that it delineates different types of sensations to different pathways. In addition to the identification of specific pathways for different sensory inputs, Bell also postulated that the brain was not the homogenous object that Descartes believed it was, but instead a complex structure with various components.[7]

Scientists and philosophers alike spent the next century and a half further developing the specificity theory. One of the many contributors to this theory was Johannes Muller. In the mid-1800s, Muller published in Manual of Physiology that individual sensations resulted from specific energy experienced at certain receptors. Furthermore, Muller believed that there was an infinite number of receptors in the skin. This surplus of receptors accounted for the ability of an individual to discriminate between different sensations.[8] In 1894, Maximillian von Frey made another critical addition to the specificity theory that served to advance the concept: four separate somatosensory modalities found throughout the body. These sensations include cold, pain, heat, and touch.[9]

This concept correlates well with previous research done regarding this theory of pain, which served to reiterate the presence of distinct pathways for different sensations. Although this theory and the research surrounding it provided significant advancement to understanding pain, it still fails to account for factors other than those of physical nature that results in the sensation of pain. Much like the dualistic approach to pain, this theory also lacks an explanation for why sometimes pain persists long after the healing of the initial injury. This incomplete nature of the specificity theory regarding pain etiology necessitated additional theories and continued research.

Pattern Theory

Following the specificity theory, there were a handful of other philosophies introduced regarding the sensation of pain. Of these philosophies, the pattern theory of pain has the greatest coverage in the scientific literature. The American psychologist John Paul Nafe (1888-1970) presented this theory in 1929. The ideas contained with the pattern theory were directly opposite of the ideas suggested in the Specificity theory in regards to sensation. Nafe indicated that there are not separate receptors for each of the four sensory modalities. Instead, he suggested that each sensation relays a specific pattern or sequence of signals to the brain. The brain then takes this pattern and deciphers it. Depending on which pattern the brain reads, correlates with the sensation felt.[10] At the time of its introduction, the pattern theory gained significant popularity among many researchers. However, through further research and the discovery of unique receptors for each type of sensation, it can be stated with certainty that this theory is an inaccurate explanation for how we feel pain.

Gate Control Theory

In 1965, Patrick David Wall (1925–2001) and Ronald Melzack announced the first theory that viewed pain through a mind-body perspective. This theory became known as the gate control theory.[11] Melzack and Wall’s new theory partially supported both of the two previous theories of pain but also presented more knowledge to advance the understanding of pain further. The gate control theory of pain states that when a stimulus gets sent to the brain, it must first travel to three locations within the spinal cord. These include the cells within the substantia gelatinosa in the dorsal horn, the fibers in the dorsal column, and the transmission cells located in the dorsal horn.[12] The substantia gelatinosa of the spinal cord's dorsal horn serves to modulate the signals that get through, acting similar to a “gate” for information traveling to the brain.[13]

The sensation of pain that an individual feels is the result of the complex interaction among these three components of the spinal cord. Simply stated, when the “gate” closes, the brain does not receive the information that is coming from the periphery to the spinal cord. However, when the signal traveling to the spinal cord reaches a certain level of intensity, the “gate” opens. Once the gate is open, the signal can travel to the brain where it is processed, and the individual proceeds to feel pain. The information mentioned above accounts for the physical component of pain. Still, as stated earlier, the Gate Control Theory was one of the first to acknowledge that psychological factors contributed to pain as well. In their original study, Melzack and Wall suggested that in addition to the control provided by the substantia gelatinosa, there was an additional control mechanism located in cortical regions of the brain.[14]

In more recent times, researchers have postulated that these cortical control centers are responsible for the effects of cognitive and emotional factors on the pain experienced. Current research has also suggested that a negative state-of-mind serves to amplify the intensity of the signals sent to the brain as well.[15] For example, somebody who is depressed has a “gate” that is open more often, allowing more signals to get through, increasing the probability that an individual will experience pain from an otherwise normal stimulus. Also, there are reports that certain unhealthy lifestyle choices will also result in an “open gate,” which in turn leads to pain that is disproportionate to the stimulus.[16]

The gate control theory has proven to be one of the most significant contributions to the study of pain throughout history. The concepts that Melzack and Wall introduced to the study of pain are still utilized by researchers today. Even though this theory initiated the idea that pain wasn’t solely a result of physical injury but rather a complex experience, influenced by cognitive and emotional factors, additional research was necessary to comprehend the mechanisms and etiology of pain completely. This need precipitated the introduction of the following two philosophies regarding pain.

Neuromatrix Model

Almost thirty years after introducing the gate control theory of pain, Ronald Melzack introduced another model that contributed to the explanation of how and why people feel pain. Until the mid-1900s, most pain theories implied that this experience was exclusively due to an injury that had occurred somewhere in the body. The thinking was that if an individual suffered an injury, whether it be through trauma, infection, or disease, a signal would transmit to the brain, which would, in turn, result in the sensation of pain. Although Melzack had contributed to these previous theories, his exposure to amputees experiencing phantom limb pain in well-healed areas prompted his inquiry into this more accurate philosophy of pain. The theory he proposed is known as the neuromatrix model of pain. This philosophy suggests that it is the central nervous system that is responsible for eliciting painful sensations rather than the periphery.[17]

The neuromatrix model denotes that there are four components within the central nervous system responsible for creating pain. The four components are the “body-self neuromatrix, the cyclic processing, and synthesis of signals, the sentinel neural hub, and the activation of the neuromatrix.”[18] According to Melzack, the neuromatrix consists of multiple areas within the central nervous system that contribute to the signal, which allows for the feeling of pain. These areas include the spinal cord, brain stem and thalamus, limbic system, insular cortex, somatosensory cortex, motor cortex, and prefrontal cortex.[20] The signal that these areas of the central nervous system work together to create is responsible for allowing an individual to feel pain, and he referred to as the “neurosignature.” Furthermore, this theory states that input coming in from the periphery can initiate or influence the neurosignature, but these peripheral signals cannot create a neurosignature of their own.[22]

This idea that peripheral signals can alter the neurosignature is an important concept when considering the effect of nonphysical factors on an individual’s experience with pain. Melzack’s theory claimed that not only are there specific neurosignatures that elicit certain sensations but when there is an alteration in a certain signal, this allows for memory formation of these particular experiences. If the same circumstances occur again in the future, this memory allows for the same sensation to be felt.[26] In addition to the hypothesis that pain was a product of different patterns of signals from the central nervous system, the neuromatrix model continued to elaborate on the idea that was initially brought forward in the gate control theory, that pain can be affected not only by physical factors but by cognitive and emotional factors. Melzack suggested that hyperactivity of the stress response has a direct effect on pain. Hyperactivity of the stress response is when an individual exposed to increased levels of stress experiences a higher level of pain.[27]

Taking all of these claims into consideration, it is evident that pain is a complex issue that cannot be accounted for by physical factors alone. Even though the neuromatrix model further established the idea that cognitive and emotional factors influence pain in addition to physical factors, it still fails to account for social constructs of pain. Therefore, a new theory of pain must be utilized to appropriately explain the mechanism behind pain and why each individual’s experience with pain is unique.

Biopsychosocial Model

The biopsychosocial model provides the most comprehensive explanation behind the etiology of pain. This specific theory of pain hypothesizes that pain is the result of complex interactions between biological, psychological, and sociological factors. Any theory that fails to include all of these three pain constructs fails to provide an accurate explanation for why an individual is experiencing pain.[28] Although the term biopsychosocial was not introduced until 1954 by Roy Grinker (1900-1993), a neurologist and psychologist, many physicians had considered the utility of using such a model to approach the management of a patient’s pain long before this.[29]

One of the most prominent physicians who utilized this more comprehensive approach to pain was John Joseph Bonica (1917-1994). This Sicilian American anesthesiologist at Madigan Army Hospital established himself as the founding father of the pain medicine discipline. In the 1940s, Bonica cared for many patients who had returned home from World War II and were now experiencing debilitating pain due to injuries they had suffered in the war. He had recognized that the pain these wounded soldiers were experiencing was rather complex and not easily managed. This situation led him to propose that to adequately manage these patients, physicians needed to create interprofessional pain clinics comprising multiple disciplines.[30] At this moment in history, there was little support for the idea that pain was more than just the result of an injury, and Bonica was relatively unsuccessful in establishing these clinics. It wasn’t until 1977 that the biopsychosocial model was scientifically suggested as an explanation for the etiology of some medical conditions. George Engle claimed that to treat disease adequately; one must consider multidimensional concepts and manage the whole patient instead of focusing on a single issue.[31]

This methodology takes into account that the human body cannot be divided into separate categories when considering treatment options. Instead, it is beneficial to acknowledge the fact that illness and disease are the results of complex interactions between biological, psychological, and sociological factors, and they all affect an individual’s physical and mental well-being.[32] Although Bonica had technically been the first physician to comprehend the importance of using a biopsychosocial approach to pain, John D. Loeser, another anesthesiologist, has been credited as the first person to use this model in association with pain.[33]

Loeser suggested that four elements need to be taken into consideration when evaluating a patient with pain. These elements include nociception, pain, suffering, and pain behaviors. Nociception is the signal that is sent to the brain from the periphery to alert the body that there is some degree of injury or tissue damage. On the other hand, pain is the subjective experience that occurs after the brain has processed the nociceptive input. The last two components of pain that merit consideration is suffering and pain behaviors. The thinking is that suffering is an individual’s emotional response to the nociceptive signals and that pain behaviors are the actions that people carry out in response to the experience of pain. Both of these can be either conscious or subconscious.[34]

Loeser’s four pain elements account for the biological, psychological, and sociological factors that can create or influence an individual’s experience with pain. Failing to consider any one of these four elements when determining the cause or establishing a management plan could be a consideration as inadequate assessment or care. With a better understanding of what is causing a patient to experience pain, the doctor is provided with a more accurate foundation to begin formulating a treatment plan. Loeser’s findings prove that the Biopsychosocial Model of pain offers the most comprehensive philosophy and provides the framework that is needed to start appropriate therapy to manage patients with chronic pain adequately.

Histopathology

Chronic pain and opioids generally do not cause any specific histopathology in and of themselves. However, there is a diversity of histopathologic changes that can occur in the presence of improper/recreational parenteral administration of opioids. There may be chronic tissue damage present due to the original assault.[6]

Toxicokinetics

Opioids have an extensive diversity of durations and intensities of effect. For example, alfentanil has a half-life of around 1.5 hours; whereas, methadone has a half-life of between 8 to 60 hours. Opioid uptake and effect can also vary by administration route, some examples being fentanyl patches or long-acting oral formulations of oxycodone and morphine. Some, such as diphenoxylate and loperamide, have almost no effect other than suppression of bowel motility. Opioids such as methadone can significantly prolong the QT interval.

Opioids can sometimes precipitate serotonin syndrome, especially when given to patients already taking various psychoactive medications (antidepressant medications like SSRI). There is an evolving body of knowledge that the intensity and quality of response to opioids can vary significantly between patients, which can be unrelated to tolerance; this is likely related to genetics, but this is not well characterized at this time.[26][20]

History and Physical

History

History should include the onset of pain, description, mechanism of injury if applicable, location, radiation of pain, quality, severity, factors contributing to relief or worsening of the pain, frequency of the pain, and any breakthrough pain. A verbal numeric rating scale (VNRS) or number scale for pain is a common measure to determine the severity of pain, numbered from 0 to 10. This tool is commonly used for pain intensity. Furthermore, associated symptoms should be assessed, such as muscle spasms or aches, temperature changes, restrictions to range of motion, morning stiffness, weakness, muscle strength changes, changes in sensation, hair, skin, or nail changes.

In addition to the patient's symptoms, the significance of the impact of the pain in day-to-day function should be discussed, and a review of daily living activities. It is important to understand how chronic pain affects the patient’s quality of life. Is pain impacting relationships or hobbies? Does the patient find themselves becoming depressed? Is the patient able to sleep throughout the night or exercise regularly? Can the patient go to work without limitations? Are activities of daily living affected, such as toileting, dressing, bathing, walking, or eating limited or restricted?

Older adults are a specific population that often identifies as suffering from chronic pain. The self-reporting of pain can be difficult in this population. Self-reporting of pain is essential for the identification and treatment of pain, while the inability to describe or communicate pain leads to undertreatment. Often elderly patients describe pain differently than the average population complicating diagnosis.[27][11] Instead of pain, an elderly patient may complain of soreness or discomfort.[28]

There are multiple acronyms used to obtain the history of a patient's pain. Some of the most commonly used abbreviations are "COLDERAS" and "OLDCARTS. These acronyms summarize the character, onset, location, duration exacerbating symptoms, relieving symptoms, radiation of pain, associated symptoms, and severity of illness. "PQRST" stands for provocation or palliation, quality, radiation or region, severity, and timing.[29]

A multidimensional assessment of a patient's pain and the severity of their pain can be completed. A pain, enjoyment, general Activity (PEG) tool can aid the multidimensional assessment of patients in pain.[30] The PEG score focuses on function and quality of life. A chronic pain patient who experiences daily 7/10 pain is treated with both pharmacological and nonpharmacological therapies. Following treatment, their pain is 5/10. A few points might not seem like a significant difference, but if their enjoyment and quality of life and function are improving, treatment may have had a profound impact on the patient's life. The PEG tool is scored 0 to 10 for each category. The higher the score, the worse the function and uncontrolled pain.

The Four-item Patient Health Questionnaire or PHQ-4 is a combination of the PHQ9 and GAD7 assessment tools used to evaluate depression and anxiety, respectively.[31] The PHQ-4 should be used as a screening tool for all cases of chronic pain. If the score of the PHQ-4 is more significant than five, then a full GAD-7, PHQ-9, and the Primary Care PTSD screening tools are recommended.[32]

The Defense and Veterans Pain Rating Scale (DVRPS) is a five-item tool with a 0 to 10 out pain scale, as well as an assessment of the impact of pain on sleep, mood, stress, and activity levels.[33]

In children's self-reporting, behavioral observation scales are used to assess pain.[34] Age-based rating scales of pain can be used. Visual analogs are also often implemented. Typically visual analogs are done with pictures of faces in various degrees of distress. By adolescence, children usually can rate their pain on a numerical scale, similar to adults.[35]

The Pediatric Pain Questionnaire and the Adolescent and Pediatric Pain Tool are used to assess the location of a patient's pain as well. The patient is asked to draw on the body map where they feel pain.[36] The ideal age for these tools is age 10 years.

Observational pain assessment tools are used in populations who cannot self-report. The facial expression, fussiness, distractibility, ability to be consoled, verbal responsiveness, and motor control are observational findings used in such an assessment tool. Observational pain assessment in infants or young children can use the (r-FLACC) tool.[34][37] The tool is an acronym for Revised Face, Legs, Activity, Cry, Consolability.[38][39] Multiple other validated tools can be used. The one that is better than another is the NAPI tool. However, multiple tools have been used and are validated.[40][41][42]

Nonverbal children with neurologic impairment (NI) is a challenging population to assess pain. Caregivers are often needed to help determine changes in the patient's behavior. Grimacing, moaning, increased muscle tone, crying, arching, atypical behavior such as aggressive behavior are a few symptoms to monitor in this population. Nonverbal children with NI include the Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) scale, and the Individualized Numeric Rating Scale (INRS). The assessment adds specific behavior for atypical presentations.[38][41]

The Brief Pain Inventory (BPI) can be used to assess patients' beliefs on pain and the impact of pain on their lives.[43][44] Separately, the McGill Pain Questionnaire (SF-MPQ-2) includes a drawing for the location of pain on the human body, a questionnaire regarding previous pain medication use, and past experiences with pain.[45] Neuropathic pain is assessable using the Neuropathic Pain Scale to follow responses to therapy.

Physical

A detailed physical, including musculoskeletal, neurologic, and psychiatric exam, should be completed, as well as a focused examination of the area of pain.

Evaluation

Chronic Pain Assessment

Standard blood work and imaging are not indicated for chronic pain, but the clinician can order it when specific causes of pain are suspected. This can be on a case-by-case basis. In some cases, urine toxicology is ordered to monitor compliance and exclude nonprescription drugs.

Psychiatric disorders can amplify pain signaling making symptoms of pain worse.[46] Furthermore, comorbid psychiatric disorders, such as major depressive disorder, can significantly delay the diagnosis of pain disorders.[47] Major depressive disorder and generalized anxiety disorder are the most common comorbid conditions related to chronic pain. There are twice as many prescriptions for opioids prescribed each year to patients with underlying pain and a comorbid psychiatric disorder compared to patients without such comorbidity.[28] Intuitively, this makes sense. For example, a patient suffering from depression often complain of fatigue, sleep changes, loss of appetite, and decreased activity. These symptoms can make their pain worse over time. It is also crucial to realize patients with chronic pain are at an increased risk for suicide and suicidal ideation.[12][13]

Simultaneously screening for depression is recommended for patients with chronic pain. The Minnesota Multiphasic Personality Inventory-II (MMPI-2) or Beck's Depression Scale are the two most commonly used tools. The MMPI-2 has been used more frequently for patients with chronic pain.[48][49]

Addiction Risk Assessment[19][50][51]

The clinician should consider information from the history and physical, family members, the state prescription monitoring program, and screening tools to assess the risk of developing an untoward behavioral response to opioids. Patients can be stratified to three risk levels:

Low-risk: standard monitoring, vigilance, and care
- Objective signs and symptoms, localizable physical pathology
- Confirmatory testing such as physical exam findings, CT, MRI, etc.
- No individual or family history of substance abuse
- At most, mild medical or psychologic comorbidity
- Age < 45
- High pain tolerance
- Active coping strategies
- Willingness to participate in multimodal therapy
- Attempting to function at normal levels
Moderate-risk: additional level of monitoring and more frequent provider contact
- Significant pain
- Defined pathology with objective signs and symptoms
- Confirmatory testing such as physical exam findings, CT, MRI, etc.
- Moderate psychologic problems controlled by therapy
- Moderate comorbidities are well controlled by medical therapy and are not affected by opioids.
- Mild opioid tolerance but not hyperalgesia without addiction or physical dependence
- Individual or family history of substance abuse
- Pain involving more than three regions of the body
- Moderate levels of pain acceptance
- Active coping strategies
- Willing to participate in multimodal therapy
- Attempting to function at normal levels
High-risk: intensive and structured monitoring, frequent follow-up contact, consultation with addiction psychiatrist, and limited monthly prescription of short-acting opioids
- Significant widespread pain
- No objective signs and symptoms
- Pain involves more than 3 body regions.
- Divergent drug-related behavior
- Individual or family history of addiction, dependency, diversion, hyperalgesia, substance abuse, or tolerance
- Major psychologic problems
- Age >45
- HIV-related pain
- High levels of pain exacerbation
- Poor coping strategies
- Unwilling to participate in multimodal therapy
- Not functioning at a normal lifestyle.

Prescribing Opioids

Before prescribing opioids, complete a detailed patient history that includes:

Indication requested for pain relief.
Location, nature, and intensity of pain
Prior pain treatments and response
Comorbid conditions
Potential physical and psychologic pain impact on the function
Family support, employment, and housing
Leisure activities, mood, sleep, substance use, and work
Emotional, physical, or sexual abuse

When considering opioids, weigh the risks of abuse, addiction, adverse drug reactions, overdose, and physical dependence. If there are any special concerns, such as a history of substance abuse, consult a psychiatrist or addiction specialist. If current substance abuse, withhold prescribing until the patient is involved in an addiction treatment and monitoring program.

Assessment Tools[51]

Screening tools assist in determining the risk level and degree of monitoring and structure required for a treatment plan; however, their validity is not yet supported in the literature. Some examples of opioid tools include:

Brief Intervention Tool

Brief Intervention Tool is a 26-item "yes-no" questionnaire used to identify signs of opioid addiction or abuse. The items assess for problems related to drug use-related functional impairment.

CAGE, CAGE-AID, and CAGE-Opioid

CAGE (Cut down, Annoyed, Guilty, and Eye-opener) Questionnaire consists of four questions designed to assess alcohol abuse. CAGE-AID and CAGE-OPIOID are revised versions to assess the likelihood of current substance abuse.[52]

Current Opioid Misuse Measure (COMM)

The Current Opioid Misuse Measure is a 17-item patient self-report assessment designed to identify abuse in chronic pain patients. It identifies aberrant behaviors associated with opioid misuse in patients already receiving long-term opioid therapy.

Diagnosis, Intractability, Risk, and Efficacy (DIRE) Tool

The Diagnosis, Intractability, Risk, and Efficacy is a clinician-rated questionnaire used to predict patient compliance with long-term opioid therapy. Patients scoring low are poor candidates for long-term opioids.

Mental Health Screening Tool

The Mental Health Screening Tool is a five-item screen that evaluates feelings of calmness, depression, happiness, peacefulness, and nervousness in the past month. A low is an indicator that the patient should be referred to a pain management specialist.

Opioid Risk Tool

The Opioid Risk Tool is a five-item assessment to evaluate for aberrant drug-related behavior. It categorizes the patient into low, medium, or high levels of risk for aberrant drug-related behaviors based on question responses concerning previous alcohol, drug abuse, psychologic disorders, and other risk factors.

Pain Assessment and Documentation Tool (PADT)

Guidelines by the CDC, the Federation of State Medical Boards, and Joint Commission stress documentation from both a quality and medicolegal perspective. The Pain Assessment and Documentation Tool (PADT) was designed to help the clinician document appropriate information.

Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)

The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a screen with questions addressing the history of alcohol or substance use, cravings, mood psychologic status, and stress. The SOAPP-R helps assess the risk level of aberrant drug-related behaviors and the monitoring level needed.

VIGIL

Verification: Is this a responsible opioid user?
Identification: Is the identity of this patient verifiable?
Generalization: Do we agree on mutual responsibilities and expectations?
Interpretation: Do I feel comfortable allowing this person to have controlled substances?
Legalization: Am I acting legally and responsibly?

Urine Drug Tests (UDT)

Urine drug tests evaluate the use of the medication prescribed and detect unsanctioned drug use. The CDC recommends drug testing before starting opioid therapy and at least annually.

One study suggests monitoring frequency based on risk level.[53]

Low-Risk Level	UDT every 1-2 years	State drug monitoring program - 2x per year
Medium-Risk Level	UDT every 6-12 months	State drug monitoring program - 3x per year
High-Risk Level	UDT every 3 months	State drug monitoring program - 4x per year

Testing is usually done with class-specific immunoassay drug panels; however, this may be followed with gas chromatography/mass spectrometry for specific metabolite detection. The test should identify the specific drug. If urine test results suggest aberrant opioid use, discuss the issue in a positive, supportive approach, and document the discussion.

Treatment / Management

Healthcare professionals who treat patients with chronic pain should understand best practices in opioid prescribing, approaches to pain assessment, pain management modalities, and appropriate use of opioids for pain control. Pharmacologic and nonpharmacologic approaches should be evaluated. Patients with moderate-to-severe chronic pain who have been assessed and treated with non-opioid therapy without adequate pain relief are candidates for opioid therapy. Initial treatment should be a trial of therapy, not a definitive course of treatment. The CDC has issued updated guidance on the prescription of opioids for chronic pain. These guidelines address when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assess risk and address opioid use harm.

Recommendations are to refer a patient to pain management in the case of debilitating pain, which is unresponsive to initial therapy. The pain may be located at multiple locations, requiring multimodal treatment or increases in dosages for adequate pain control or invasive procedures to control pain. Treatment of both pain and a comorbid psychiatric disorder leads to a more significant reduction of both pain and symptoms of the psychiatric disorder.[54] Pain may also worsen concurrent depression; thus, the treatment of pain has been demonstrated to improve the responses to the treatments for depression.[55] There are multiple pharmacological, adjunct, nonpharmacological, and interventional treatments for chronic, severe, and persistent pain. (B2)

The list of pharmacological options for chronic pain is extensive. This list includes nonopioid analgesics such as nonsteroidal anti-inflammatories (NSAIDs), acetaminophen, and aspirin. Additionally, medications such as tramadol, opioids, antiepileptic drugs (gabapentin or pregabalin) can be useful. Furthermore, antidepressants such as tricyclic antidepressants and SNRI’s, topical analgesics, muscle relaxers, N-methyl-d-aspartate (NMDA) receptor antagonists, and alpha 2 adrenergic agonists are also possible pharmacological therapies.

Treatment response can differ between individuals, but treatment is typically done in a stepwise fashion to reduce the duration and dosage of opioid analgesics. However, there is no singular approach appropriate for the treatment of pain in all patients.[56]

Chronic musculoskeletal pain is nociceptive pain. The treatment of such pain is in a stepwise approach but includes a combination of nonopioid analgesics, opioids, and nonpharmacological therapies. First-line therapy would be acetaminophen or NSAIDs. Both are effective for osteoarthritis and chronic back pain.[57][58][59] However, NSAIDs are relatively contraindicated in patients with a history of heart disease or myocardial infarction, renal disease, or patients on anticoagulation or with a history of ulcers.[60][61] There is limited evidence of which NSAID to use over another. One nonsteroidal antiinflammatory pharmacological agent may have a limited effect on a patient's pain, while another may provide adequate pain relief. The recommendations are to try different agents before moving on to opioid analgesics.[62] Failure to achieve appropriate pain relief with either acetaminophen or NSAIDs can lead to considering opioid analgesic treatment. (A1)

Opioids are considered a second-line option; however, they may be warranted for pain management for patients with severe persistent pain or neuropathic pain secondary to malignancy.[63] There have been conflicting results on the use of opioids in neuropathic pain. However, for both short term and intermediate use, opioids are often used to treat neuropathic pain.[64] Opioid therapy should only start with extreme caution for patients with chronic musculoskeletal pain.[65] Side effects of opioids are significant and frequent and may include opioid-induced hyperalgesia, constipation, dependence, and sedation. For chronic musculoskeletal pain, they are not superior to nonopioid analgesics.[66][67](A1)

Administration of opioid analgesics should be reserved for when alternative pain medications have not provided adequate pain relief or contraindicated and when pain is impacting the patient's quality of life. The potential benefits outweigh the short and long-term effects of opioid therapy. The patient must make an informed choice before starting opioid treatment after discussing the risks, benefits, and alternatives to opioids.[66][68][69] Patients taking opioids at greater than 100 morphine milligram equivalents per day are at significantly increased risk of side effects. Side effects of opioids such as respiratory compromise will increase as the dosages increase. Patients with chronic pain could benefit from a therapy program designed to wean them from opioid analgesics to a safer dosage.[70][71] Long-acting opioids should only be used over short-acting opioids in the setting of disabling pain, causing severe impairment to quality of life.[72](A1)

There is an estimated 78 percent risk of an adverse reaction to opioids such as constipation or nausea. In comparison, there is a 7.5 percent risk of developing a severe adverse reaction ranging from immunosuppression to respiratory depression.[73] Patients with chronic pain who meet the criteria for the diagnosis of opioid use disorder should receive the option of buprenorphine to treat their chronic pain. Buprenorphine is a considerably better alternative for patients with very high daily morphine equivalents who have failed to achieve adequate analgesia.(B3)

Different types of pain also warrant different treatments. For example, chronic musculoskeletal back pain would be treated differently from severe diabetic neuropathy. A combination of multiple pharmacological therapies is often necessary to treat neuropathic pain. Less than 50% of patients with neuropathic pain will achieve adequate pain relief with a single agent.[74] Adjunctive topical therapy, such as lidocaine or capsaicin cream, can be utilized as well.[75][76](A1)

The initial treatment of neuropathic is often with gabapentin or pregabalin. These are calcium channel alpha 2-delta ligands. They are indicated for postherpetic neuralgia, diabetic neuropathy, and mixed neuropathy.[77] There is limited evidence in the use of other antiepileptic medications to treat chronic pain, where many of these, such as lamotrigine, have a more significant side effect profile. The exception is carbamazepine in the treatment of trigeminal neuralgia and other types of chronic neuropathic pain.[78][79](A1)

Alternatively, antidepressants such as dual reuptake inhibitors of serotonin and norepinephrine (SNRI) or tricyclic antidepressants (TCA) can is an option. Antidepressants are beneficial in the treatment of neuropathic pain, central pain syndromes, and chronic musculoskeletal pain. For neuropathic pain, antidepressants have demonstrated a 50 percent reduction of pain. Fifty percent is a significant reduction, considering the average decrease in pain from various pain treatments is 30%.[80][81](A1)

The serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine is a useful treatment for treating chronic pain, osteoarthritis, and the treatment of fibromyalgia.[82] Furthermore, the efficacy of duloxetine in the treatment of comorbid depression is comparable to other antidepressants.[83][80] Venlafaxine is an effective treatment for neuropathic pain, as well.[84] A TCA can also be utilized, such as nortriptyline. TCA medications may require six to eight weeks to achieve their desired effect.[63](A1)

Adjunctive topical agents such as topical lidocaine are a useful treatment for neuropathic pain and allodynia as in postherpetic neuralgia.[85][86] Topical NSAIDs have been shown to improve acute musculoskeletal pain, such as a strain, but are less effective in chronic pain. Yet, topical NSAIDs are more effective than controls in the treatment of pain related to knee osteoarthritis.[87][88] Separately, topical capsaicin cream is an option for chronic neuropathic or musculoskeletal pain unresponsive to other treatments.[89] Botulinum toxin has also demonstrated effectiveness in the treatment of postherpetic neuralgia.[90] The use of cannabis is also an area of interest in pain research. There is some evidence that medical marijuana can be an effective treatment of neuropathic pain, while the evidence is currently limited in treating other types of chronic pain.[91](A1)

The list of nonpharmacological therapies for chronic pain is extensive. Nonpharmacological options include heat and cold therapy, cognitive behavioral therapy, relaxation therapy, biofeedback, group counseling, ultrasound stimulation, acupuncture, aerobic exercise, chiropractic, physical therapy, osteopathic manipulative medicine, occupational therapy, and TENS units. Interventional techniques can also be utilized in the treatment of chronic pain. Spinal cord stimulation, epidural steroid injections, radiofrequency nerve ablations, botulinum toxin injections, nerve blocks, trigger point injections, and intrathecal pain pumps are some of the procedures and techniques commonly used to combat chronic pain. TENS units' efficacy has been variable, and the results of TENS units for chronic pain management are inconclusive.[92] (A1)

Deep brain stimulation is for post-stroke and facial pain as well as severe, intractable pain where other treatments have failed.[93] There is limited evidence of interventional approaches to pain management. For refractory pain, implantable intrathecal delivery systems are an option for patients who have exhausted all other options.(A1)

Spinal cord stimulators are an option for patients with chronic pain who have failed other conservative approaches. Most commonly, spinal cord stimulators are placed following failed back surgery but can also be an option for other causes of chronic pain such as complex regional pain syndrome, painful peripheral vascular disease, intractable angina, painful diabetic neuropathy, and visceral abdominal and perineal pain.[94][95][96][97][98] Spinal cord stimulators have shown a 50% reduction of pain compared to continued medical therapy.[99](A1)

Differential Diagnosis

Pain is a symptom, not a diagnosis. Developing a differential diagnosis for a patient's chronic pain is based on assessing the possible underlying etiologies of the patient's pain. It is essential to determine what underlying injury or disease processes are responsible for the patient's pain since this requires the identification of effective treatment. For instance, it is crucial to determine if a patient's neuropathic pain is peripheral or central. In another example, if a patient suffers from severe knee pain, it is essential to consider whether or not the knee pain is secondary to severe osteoarthritis since the patient may benefit from an injection or a knee replacement. In contrast, if the knee pain were instead related to a different condition such as rheumatoid arthritis, infection, gout, pseudogout, or meniscal injury, very different treatments would be necessary.

The differential diagnosis for generalized chronic pain would include patients who develop allodynia from chronic opioids and patients suffering from a major depressive disorder and other psychiatric or sleep disorders, including insomnia. Furthermore, autoimmune diseases such as lupus or psoriatic arthritis, fibromyalgia, and central pain syndromes should be considered in states involving wide-spread, generalized chronic pain states. The four main categories of pain are neuropathic, musculoskeletal, mechanical, and inflammatory. Persistent and under-treated painful conditions can lead to chronic pain. Thus chronic pain is often a symptom of one or multiple diagnoses and can become its diagnosis as it becomes persistent and the body's neurochemistry changes. It is critical to treat acute and subacute pain before chronic pain develops.

Treatment Planning

Opioid therapy should begin as a trial for a pre-defined period, usually less than 30 days. Treatment goals should be established before the initiation of opioid therapy. These include the level of relief of pain, anxiety, depression, the return of function while avoiding unnecessary opioid use. The plan should include therapy selection, progress measures, and additional consultations, evaluations, referrals, and therapies. The provider should:

Start at the lowest possible dose and then titrate to effect.
Start with short-acting opioid formulations.
Discuss the need for frequent risk/benefit assessments
Be instructed in the signs and symptoms of respiratory depression.
Reassess risk/benefit with each dose increase
Decisions to titrate dose to 90 mg or more morphine equivalent dose should be justified.
Be knowledgeable of federal and state opioid prescribing regulations.
Be knowledgeable of patient monitoring, equianalgesic dosing, and cross-tolerance with the opioid conversion.
Augment treatment with nonopioid or, if necessary immediate-release opioids over long-acting opioids.
Taper opioid dose whenever possible

Consent and Treatment[19]

The opioid prescription should include documented informed consent and a treatment agreement addressing:

Drug interactions
Physical dependence
Side effects
Tolerance
Physical dependence
Driving and motor skill impairment
Limited evidence of long-term benefit
Addiction, dependence, misuse
Risk/benefit profile of the drug prescribed
Signs/symptoms of overdose

Prescribing policies should be clearly described, including policies regarding the number and frequency of refills and procedures for lost or stolen medications.

Patient and Physician treatment Agreement

The patient should agree to use medications safely, avoid "doctor shopping," and consent to urine drug testing.
The prescriber should agree to address problems, follow-up visits, and scheduled refills.

Reasons for opioid therapy change or discontinuation should be listed. Agreements can also include follow-up visits, monitoring, and safe storage and disposal of unused drugs. If the patient does not speak English, an interpreter should be used.

Discontinuing Opioid Therapy

Discontinuing opioid therapy should be based on a physician-patient discussion. Opioids should be discontinued when the pain has resolved, side effects develop, analgesia is inadequate, or quality of life is not improved, deteriorating function, or there is evidence of aberrant medication use. Opioids should be tapered slowly, and an addiction specialist should manage withdrawal.

Toxicity and Adverse Effect Management

The American Society of Interventional Pain Physicians guidelines recommends monitoring opioid adherence, abuse, and noncompliance through urine drug tests and monitoring programs.

The treatment plan for opioid use in chronic pain should include frequent assessment of pain level, origin, and function. If there is a change of dosage or agent, the frequency of patient visits should be increased. Chronic response to opioids should be monitored by evaluating the 5 A's.

Affect
Aberrant drug-related behaviors
Activities of daily living
Adverse or side effects
Analgesia

Signs and symptoms, if present, that suggests treatment goals are not being achieved include:

Decreased appetite
Excessive sleeping or day/night reversal
Impaired function
Inability to concentrate
Mood volatility
Lack of involvement with others
Lack of re-engaging in life
Lack of hygiene

The decision to change, continue, or terminate opioid therapy is based on achieving treatment objectives without adverse effects. Physicians, wherever possible, should work with pharmacists.

Acute Overdose Management[20]

Accidental or deliberate overdose is always a risk factor in patients taking opioids. The patient and family should be instructed in the signs and symptoms of an overdose and basic emergency management until paramedics' arrival.

The immediate response to overdose management is to secure the airway and breathing; however, survival is heavily dependent upon the rapid administration of an opioid antagonist. Many states, including West Virginia, allow naloxone distribution to the public. Licensed healthcare providers may prescribe opioid antagonists for at-risk individuals, relatives, or caregivers. Emergency medical service personnel, peace officers, and firefighters also have the drug available.

While opioid antagonists such as naloxone, naltrexone, and nalmefene are available, acute overdoses are usually treated with naloxone as it quickly reverses opioid-related respiratory depression. Naloxone competes with opioids at receptor sites in the brain stem, reversing desensitization to carbon dioxide and preventing respiratory failure.

The naloxone dose is 0.4 to 2 mg administered intravenously, intramuscularly, or subcutaneously. The dose may be repeated every 2 to 3 minutes. Naloxone is available in pre-filled auto-injection devices. Advanced Cardiac Life Support protocols should be continued while naloxone is being administered.

In West Virginia, pharmacists and pharmacy interns may dispense naloxone without a provider prescription. The pharmacist or intern is required to screen the potential recipient by asking if they have a known hypersensitivity to naloxone; provide appropriate counseling and information on the product, including dosing, effectiveness, adverse effects, storage, shelf-life, safety, and contact information (1-844-HELP-4-WV) for access to substance abuse treatment and recovery services if the recipient indicates interest in such services. Patients receiving opioid treatment for chronic pain may benefit from education and naloxone being available at home to treat an overdose.[100]

Prognosis

Current chronic pain treatments can result in an estimated 30% decrease in a patient's pain scores.[56] A thirty percent reduction in a patient's pain can significantly improve patients' function and quality of life.[101] However, the long-term prognosis for patients with chronic pain demonstrates reduced function and quality of life. Improved outcomes are possible in patients with chronic pain improves with the treatment of comorbid psychiatric illness. Chronic pain increases patient morbidity and mortality, as well as increases rates of chronic disease and obesity. Patients with chronic pain are also at a significantly increased risk for suicide compared to the regular population.

Spinal cord stimulation results in inadequate pain relief in about 50% of patients. Tolerance can also occur in up to 20 to 40 percent of patients. The effectiveness of spinal cord stimulation decreases over time.[102] Similarly, patients who develop chronic pain and are dependent on opioids often build tolerance over time. As the amount of morphine milligram equivalents increases, the patient's morbidity and mortality also increase.

Ultimately, prevention is critical in the treatment of chronic pain. If acute and subacute pain receives appropriate treatment, and chronic pain can be avoided, the patient will have limited impacts on their quality of life.

Complications

Chronic pain leads to significantly decreased quality of life, reduced productivity, lost wages, worsening of chronic disease, and psychiatric disorders such as depression, anxiety, and substance abuse disorders. Patients with chronic pain are also at a significantly increased risk for suicide and suicidal ideation.

Many medications often used to treat chronic pain have potential risks and side effects and possible complications associated with their use.

Acetaminophen is a standard pharmacological therapy for patients with chronic pain. It is taken either as a single agent or in combination with an opioid. The hepatotoxicity occurs with acetaminophen when exceeding four grams per day.[103] It is the most common cause of acute liver failure in the United States.[104] Furthermore, hepatotoxicity can occur at therapeutic doses for patients with chronic liver disease.[105]

Frequently used adjunct medications such as gabapentin or pregabalin can cause sedation, swelling, mood changes, confusion, and respiratory depression in older patients who require additional analgesics.[106] These agents require caution in elderly patients with painful diabetic neuropathy. Also, gabapentin or pregabalin, combined with opioid analgesics, has been shown to increase the rate of patient mortality.[107]

Duloxetine can cause mood changes, headaches, nausea, and other possible side effects and should be avoided in patients with a history of kidney or liver disease.

Feared complications of opioid therapy include addiction as well as overdose resulting in respiratory compromise. However, opioid-induced hyperalgesia is also a significant concern. Patients become more sensitive to painful stimuli while on chronic opioids.[108] The long-term risks and side effects of opioids include constipation, tolerance, dependence, nausea, dyspepsia, arrhythmia (methadone treatment QT prolongation), and opioid-induced endocrine dysfunction, which can result in amenorrhea, impotence, gynecomastia, and decreased energy and libido. Also, there appears to be a dose-dependent risk of opioid overdose with increasing daily milligram morphine equivalents.

Complication rates for spinal could stimulators are high, ranging from five up to 40%.[109][110] Most commonly, lead migration occurs, causing inadequate pain relief, often requiring revision and anchoring.[111][112] Lead movement often occurs in the cervical region of the spinal cord, given an increased range of motion of the cervical vertebra.[113][114] Spinal cord stimulator lead fracture can occur in up to 9% of placements [115][116]. Seromas are also very common and may require surgical incision and drainage.[117][109] The risk of infection following a spinal cord stimulator placement is between 2.5 and 12 percent.[118][119] Lastly, direct spinal cord trauma could occur. The most significant infectious complication would be a spinal cord abscess. A dural puncture can cause a post-dural headache in up to 70% of patients.[120][121][117] The most significant adverse to spinal cord stimulator placement would be a spinal epidural hematoma. This emergency would require immediate neurosurgical decompression of the hematoma. The incidence of a spinal epidural hematoma is 0.71%.[122]

Drug Diversion and Drug Seeking[50]

Unfortunately, due to addiction or financial gain, some individuals seek prescribed opioids for illicit purposes. Prescription opioids may be obtained from a friend or relative, purchased from a black market drug dealer, obtained by doctor shopping and acquiring drugs from multiple prescribers, and theft from clinics, hospitals, or pharmacies.

Aggressive demands for more opioids
Asking for opioids by name
Behaviors suggesting opioid use disorder
Forged prescriptions
Increased alcohol use
Increasing medication dose without provider permission
Injecting oral medications
Obtaining medications from nonmedical sources
Obtaining opioids from multiple providers
Prescription loss or theft
Reluctance to decrease opioid dosing
Resisting medication change
Requesting early refills
Selling prescriptions
Sharing or borrowing similar medications
Stockpiling medications
Unsanctioned dose escalation
Using illegal drugs
Using pain medications to treat other symptoms

Drug Diversion Interventions

Prescribers and dispensers can take several precautions to avoid drug diversion. Some approaches include:

Communication among providers and pharmacies to avoid "doctor shopping."
Educate patients on the dangers of sharing opioids
Encourage patients to keep opioid medications in a private place.
Encourage patients to refrain from public disclosure of opioid use.
Report patient prescribing to state central database if available

If a patient is suspected of drug-seeking or diversion, consider the following actions:

Inquire about prescription and illicit drug use

Obtain a urine drug screen
Perform a thorough examination
Perform pill counting
Prescribe smaller quantities of the opioid

If a patient is abusing prescribed opioids, this is a violation of the treatment agreement. The provider may then chose to discharge the patient from their practice. If the relationship is terminated, the provider must do it legally. The provider should avoid patient abandonment, ending a relationship with a patient without consideration of continuity of care, and without providing notice to the patient. To avoid abandonment charges, the patient must be given enough advanced warning to allow them to secure another physician and facilitate the transfer of care.

Patients with a substance abuse problem or addiction should be referred to a pain specialist. Theft or loss of controlled substances should be reported to the Drug Enforcement Administration. If drug diversion has occurred, the activity should be documented and reported to law enforcement.

Consultations

Seek consultation or patient referral when input from a pain specialist, addiction specialist, or psychiatrist is needed, particularly for long-term chronic pain management. Clinicians who prescribe opioids should be aware of opioid addiction treatment options.

Deterrence and Patient Education

Involvement of Patient and Family

The patient and family can assist in making informed decision-making regarding continuing or discontinuing opioid therapy. Family members are often aware of when a patient is depressed and less functional. Questions to ask the family include:

Is the patient's day focused on taking opioid pain medication?
What is the frequency of pain medication?
Does the patient have any other alcohol or drug problems?
Does the patient avoid activity?
Is the patient depressed?
Is the patient able to function?

What To Teach A Patient Taking Opioids

Avoid driving or operating power equipment.
Avoid stoping opioids suddenly.
Avoid taking other drugs that depress the respiratory system as alcohol, sedatives, and anxiolytics.
Contact prescribing if pain medication is not adequate for relief.
Destroy opioids based on product-specific disposal information (usually flushing down the toilet or mixing with cat litter or coffee grounds)
Do not chew tables
Do not share opioids with friends or family.
Follow the dosing regimen as prescribed.
Provide product-specific information
Take opioids only as prescribed.

Pearls and Other Issues

Maintain Accurate Medical Records Regarding Opiate Prescriptions

All clinicians should maintain accurate, complete, and current medical records, including:

Records of prescriptions for controlled substances
Record instructions provided
Detailed history, physical, monitoring, and reasons prescribed.

Federal and State Laws[123]

Several regulations and programs at the federal and state level to reduce prescription opioid abuse, diversion, and overdose. These laws require:

Immunity from prosecution for individuals seeking assistance during an overdose
Pain clinic oversight
Patient identification prior to dispencing
Physical examination prior to prescribing opioids
Prescription limits
Prohibition from obtaining controlled substance prescriptions
Tamper-resistant prescriptions

Federal Laws

The U.S. Drug Enforcement Administration (DEA) sets national standards for controlled substances. Drug scheduling was mandated under The Federal Comprehensive Drug Abuse Prevention and Control Act of 1970. The law addresses controlled substances within Title II. The DEA maintains a list of controlled medications and illicit substances that are categorized from scheduled I to V. The five categories have their basis on the medication’s proper and beneficial medical use and the medication’s potential for dependency and abuse. The purpose of the law is to provide government oversight over the manufacturing and distribution of these types of substances. Prescribers and dispensers are required to have a DEA license to supply these drugs. The licensing provides links to users, prescribers, and distributors.[124][125][126]

The schedules range from Schedule I to V. Schedule I drugs are considered to have the highest risk of abuse, while Schedule V drugs have the lowest potential for abuse. Other factors considered by the DEA include pharmacological effect, evidenced-based knowledge of the drug, risk to public health, trends in the use of the drug, and whether or not the drug has the potential to be made more dangerous with minor chemical modifications.

Schedule
I	"High abuse potential with no accepted medical use; medications within this schedule may not be prescribed, dispensed, or administered"[124] Examples include marijuana (cannabis), heroin, mescaline (peyote), lysergic acid diethylamide (LSD), methylenedioxymethamphetamine (MDMA), and methaqualone.
II	"High abuse potential with severe psychological or physical dependence; however, these medications have an accepted medical use and may be prescribed, dispensed, or administered"[124] Examples include fentanyl, oxycodone, morphine, methylphenidate, hydromorphone, amphetamine, methamphetamine (meth), pentobarbital, and secobarbital. Schedule II drugs may not receive a refill.
III	"Intermediate abuse potential (i.e., less than Schedule II but more than Schedule IV medications)"[124] Examples include anabolic steroids, testosterone, and ketamine.
IV	"Abuse potential less than Schedule II but more than Schedule V medications"[124] Examples include diazepam, alprazolam, and tramadol.
V	"Medications with the least potential for abuse among the controlled substances." [124] Examples include pregabalin, Diphenoxylate/atropine, dextromethorphan.

It is essential to understand the DEA controlled-substance scheduling both to ensure adequate caution when prescribing medications with high abuse potential and also to ensure against prescribing outside of one's authority.[127][128]

The Controlled Substances Act has great potential to improve patient safety by providing federal oversight for drugs with a high potential for abuse. Providers of scheduled substances (physicians, dentists, podiatrists, advanced practitioners) may have links to the distribution of these substances. They are required to have a DEA license and record prescription of scheduled drugs. This licensing prevents overprescribing and obligates providers to be wary of potential drug-seeking patients. The dispenser must also be aware of a patient's medication history and be mindful of the potential for polypharmacy if a patient seeks multiple providers. The current opioid epidemic is a time where federal oversight and interdisciplinary coordination have the potential to reduce harm to patients prescribed scheduled drugs drastically. It will, however, take further time and evaluation to know if drug scheduling actually reduces abuse, addiction, and overdose.[129][130][131][132][133]

See Table 1 for information regarding registration, records, prescriptions, refills, distribution, security, and theft or significant loss of controlled substances.

See Table 2 for information regarding DEA forms 106, 222, 224, and 224a.

Utah State Laws

Utah Controlled Substances Act58-37-2 Definitions.(1) As used in this chapter:(a) "Administer" means the direct application of a controlled substance, whether by injection, inhalation, ingestion, or any other means to the body of a patient or research subject by:(i) a practitioner or, in the practitioner's presence, by the practitioner's authorized agent; or(ii) the patient or research subject at the direction and in the presence of the practitioner.(b) "Agent" means an authorized person who acts on behalf of or at the direction of a manufacturer, distributor, or practitioner but does not include a motor carrier, public warehouseman, or employee of any of them.(c) "Consumption" means ingesting or having any measurable amount of a controlled substance in a person's body, but this Subsection (1)(c) does not include the metabolite of a controlled substance.(d) "Continuing criminal enterprise" means any individual, sole proprietorship, partnership, corporation, business trust, association, or other legal entity, and any union or groups of individuals associated in fact, although not a legal entity, and includes illicit as well as licit entities created or maintained for the purpose of engaging in conduct which constitutes the commission of episodes of activity made unlawful by Title 58, Chapter 37, Utah Controlled Substances Act, Chapter 37a, Utah Drug Paraphernalia Act, Chapter 37b, Imitation Controlled Substances Act, Chapter 37c, Utah Controlled Substance Precursor Act, orChapter 37d, Clandestine Drug Lab Act, which episodes are not isolated, but have the same or similar purposes, results, participants, victims, methods of commission, or otherwise are interrelated by distinguishing characteristics. Taken together, the episodes shall demonstrate continuing unlawful conduct and be related either to each other or to the enterprise.(e) "Control" means to add, remove, or change the placement of a drug, substance, or immediate precursor under Section 58-37-3.

(f) "Controlled substance" means a drug or substance:

(A) included in Schedules I, II, III, IV, or V of Section 58-37-4;(B) included in Schedules I, II, III, IV, or V of the federal Controlled Substances Act, Title II,P.L. 91-513;(C) that is a controlled substance analog; or(D) listed in Section 58-37-4.2.(ii) "Controlled substance" does not include:(A) distilled spirits, wine, or malt beverages, as those terms are defined in Title 32B, AlcoholicBeverage Control Act;(B) any drug intended for lawful use in the diagnosis, cure, mitigation, treatment, or preventionof disease in human or other animals, which contains ephedrine, pseudoephedrine,norpseudoephedrine, or phenylpropanolamine if the drug is lawfully purchased, sold,transferred, or furnished as an over-the-counter medication without prescription; orUtah Code(C) dietary supplements, vitamins, minerals, herbs, or other similar substances including concentrates or extracts, which:(I) are not otherwise regulated by law; and(II) may contain naturally occurring amounts of chemical or substances listed in this chapter,or in rules adopted pursuant to Title 63G, Chapter 3, Utah Administrative RulemakingAct.(g)(i) "Controlled substance analog" means:(A) a substance the chemical structure of which is substantially similar to the chemicalstructure of a controlled substance listed in Schedules I and II of Section 58-37-4, a substance listed in Section 58-37-4.2, or in Schedules I and II of the federal Controlled Substances Act, Title II, P.L. 91-513;(B) a substance that has a stimulant, depressant, or hallucinogenic effect on the central nervous system substantially similar to the stimulant, depressant, or hallucinogenic effect on the central nervous system of controlled substances listed in Schedules I and II of Section 58-37-4, substances listed in Section 58-37-4.2, or substances listed in Schedules I and II of the federal Controlled Substances Act, Title II, P.L. 91-513; or(C) A substance which, with respect to a particular individual, is represented or intended to have a stimulant, depressant, or hallucinogenic effect on the central nervous system substantially similar to the stimulant, depressant, or hallucinogenic effect on the central nervous system of controlled substances listed in Schedules I and II of Section 58-37-4,substances listed in Section 58-37-4.2, or substances listed in Schedules I and II of the federal Controlled Substances Act, Title II, P.L. 91-513.(ii) "Controlled substance analog" does not include:(A) a controlled substance currently scheduled in Schedules I through V of Section 58-37-4;(B) a substance for which there is an approved new drug application;(C) a substance with respect to which an exemption is in effect for investigational use by a particular person under Section 505 of the Food, Drug, and Cosmetic Act, 21 U.S.C. 355,to the extent the conduct with respect to the substance is permitted by the exemption;(D) any substance to the extent not intended for human consumption before an exemption takes effect with respect to the substance;(E) any drug intended for lawful use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals, which contains ephedrine, pseudoephedrine,norpseudoephedrine, or phenylpropanolamine if the drug is lawfully purchased, sold, transferred, or furnished as an over-the-counter medication without prescription; or(F) dietary supplements, vitamins, minerals, herbs, or other similar substances, including concentrates or extracts, which are not otherwise regulated by law, which may contain naturally occurring amounts of chemical or substances listed in this chapter, or in rules adopted pursuant to Title 63G, Chapter 3, Utah Administrative Rulemaking Act.(h)(i) "Conviction" means a determination of guilt by the verdict, whether the jury or bench or plea, whether guilty or no contest, for any offense proscribed by:(A)Chapter 37, Utah Controlled Substances Act;(B)Chapter 37a, Utah Drug Paraphernalia Act;(C)Chapter 37b, Imitation Controlled Substances Act;(D)Chapter 37c, Utah Controlled Substance Precursor Act; or(E)Chapter 37d, Clandestine Drug Lab Act; orUtah CodePage 3(ii) for any offense under the laws of the United States and any other state which, if committedin this state, it would be an offense under:(A)Chapter 37, Utah Controlled Substances Act;(B)Chapter 37a, Utah Drug Paraphernalia Act;(C)Chapter 37b, Imitation Controlled Substances Act;(D)Chapter 37c, Utah Controlled Substance Precursor Act; or(E)Chapter 37d, Clandestine Drug Lab Act.(i) "Counterfeit substance" means:(i) any controlled substance or container or labeling of any controlled substance that:(A) without authorization bears the trademark, trade name, or other identifying marks, imprint, number, device, or any likeness of them, of a manufacturer, distributor, or dispenser other than the person or persons who in fact manufactured, distributed, or dispensed the substance which falsely purports to be a controlled substance distributed by any other manufacturer, distributor, or dispenser; and(B) a reasonable person would believe to be a controlled substance distributed by an authorized manufacturer, distributor, or dispenser based on the appearance of the substance as described under Subsection (1)(i)(i)(A) or the appearance of the container of that controlled substance; or(ii) any substance other than under Subsection (1)(i)(i) that:(A) is falsely represented to be any legally or illegally manufactured controlled substance; and(B) a reasonable person would believe to be a legal or illegal controlled substance.(j) "Deliver" or "delivery" means the actual, constructive, or attempted transfer of a controlledsubstance or a listed chemical, whether or not an agency relationship exists.(k) "Department" means the Department of Commerce.(l) "Depressant or stimulant substance" means:(i) a drug which contains any quantity of barbituric acid or any of the salts of barbituric acid;(ii) a drug which contains any quantity of:(A) amphetamine or any of its optical isomers;(B) any salt of amphetamine or any salt of an optical isomer of amphetamine; or(C) any substance which the Secretary of Health and Human Services or the AttorneyGeneral of the United States after the investigation has found and by regulation designated habit-forming because of its stimulant effect on the central nervous system;(iii) lysergic acid diethylamide; or(iv) any drug which contains any quantity of a substance which the Secretary of Health andHuman Services or the Attorney General of the United States after the investigation has found to have, and by regulation designated as having, a potential for abuse because of its depressant or stimulant effect on the central nervous system or its hallucinogenic effect.(m) "Dispense" means the delivery of a controlled substance by a pharmacist to an ultimate user pursuant to the lawful order or prescription of a practitioner, and includes distributing to, leaving with, giving away, or disposing of that substance as well as the packaging, labeling, or compounding necessary to prepare the substance for delivery.(n) "Dispenser" means a pharmacist who dispenses a controlled substance.(o) "Distribute" means to deliver other than by administering or dispensing a controlled substanceor a listed chemical.(p) "Distributor" means a person who distributes controlled substances.(q) "Division" means the Division of Occupational and Professional Licensing created in Section58-1-103.(r)Utah Code(i) "Drug" means:(A) a substance recognized in the official United States Pharmacopoeia, Official Homeopathic Pharmacopoeia of the United States, or Official National Formulary, or any supplement to any of them, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans or animals;(B) a substance that is required by any applicable federal or state law or rule to be dispensed by prescription only or is restricted to administration by practitioners only;(C) a substance other than food intended to affect the structure or any function of the body of humans or other animals; and(D) substances intended for use as a component of any substance specified in Subsections(1)(r)(i)(A), (B), and (C).(ii) "Drug" does not include dietary supplements.(s) "Drug dependent person" means any individual who unlawfully and habitually uses any controlled substance to endanger the public morals, health, safety, or welfare, or who is so dependent upon the use of controlled substances as to have lost the power of self-control with reference to the individual's dependency.(t) "Food" means:(i) any nutrient or substance of plant, mineral, or animal origin other than a drug as specified in this chapter, and normally ingested by human beings; and(ii) foods for special dietary uses as exist by reason of a physical, physiological, pathological, or other condition including but not limited to the conditions of disease, convalescence, pregnancy, lactation, allergy, hypersensitivity to food, underweight, and overweight; uses for supplying a particular dietary need which exists by reason of age including but not limited to the ages of infancy and childbirth, and also uses for supplementing and for fortifying the ordinary or unusual diet with any vitamin, mineral, or other dietary property for the use of food.Any particular use of food is a special dietary use regardless of nutritional purposes.(u) "Immediate precursor" means a substance which the Attorney General of the United States has found to be, and by regulation designated as being, the principal compound used or produced primarily for use in the manufacture of a controlled substance, or which is an immediate chemical intermediary used or likely to be used in the manufacture of a controlledsubstance, the control of which is necessary to prevent, curtail, or limit the manufacture of the controlled substance.(v) "Indian" means a member of an Indian tribe.(w) "Indian religion" means any religion:(i) the origin and interpretation of which is from within a traditional Indian culture or community; and(ii) which is practiced by Indians.(x) "Indian tribe" means any tribe, band, nation, pueblo, or other organized group or community of Indians, including any Alaska Native village, which is legally recognized as eligible for andis consistent with the special programs, services, and entitlements provided by the United States to Indians because of their status as Indians.(y) "Manufacture" means the production, preparation, propagation, compounding, or processing of a controlled substance, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis or by a combination of extraction and chemical synthesis.(z) "Manufacturer" includes any person who packages, repackages, or labels any container of any controlled substance, except pharmacists who dispense or compound prescription orders for delivery to the ultimate consumer.Utah CodePage 5(aa)(i) "Marijuana" means all species of the genus cannabis and all parts of the genus, whethergrowing or not, including:(A) seeds;(B) resin extracted from any part of the plant, including the resin extracted from the maturestalks;(C) every compound, manufacture, salt, derivative, mixture, or preparation of the plant, seeds,or resin; and(D) any synthetic equivalents of the substances contained in the plant cannabis sativa or any other species of the genus cannabis which are chemically indistinguishable and pharmacologically active.(ii) "Marijuana" does not include:(A) the mature stalks of the plant;(B) fiber produced from the stalks;(C) oil or cake made from the seeds of the plant;(D) except as provided in Subsection (1)(aa)(i), any other compound, manufacture, salt, derivative, mixture, or preparation of the mature stalks, fiber, oil, or cake;(E) the sterilized seed of the plant which is incapable of germination; or(F) any compound, mixture, or preparation approved by the federal Food and DrugAdministration under the federal Food, Drug, and Cosmetic Act, 21 U.S.C. Sec. 301 et seq. that is not listed in a schedule of controlled substances in Section 58-27-4 or in the federal Controlled Substances Act, Title II, P.L. 91-513.(bb) "Money" means officially issued coin and currency of the United States or any foreign country.(cc) "Narcotic drug" means any of the following, whether produced directly or indirectly by extraction from substances of vegetable origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis:(i) opium, coca leaves, and opiates;(ii) a compound, manufacture, salt, derivative, or preparation of opium, coca leaves, or opiates;(iii) opium poppy and poppy straw; or(iv) a substance, and any compound, manufacture, salt, derivative, or preparation of the substance, which is chemically identical with any of the substances referred to in Subsection(1)(cc)(i), (ii), or (iii), except narcotic drug does not include decocainized coca leaves or extracts of coca leaves which do not contain cocaine or ecgonine.(dd) "Negotiable instrument" means documents containing an unconditional promise to pay a sum of money, which are legally transferable to another party by endorsement or delivery.(ee) "Opiate" means any drug or other substance having an addiction-forming or addiction sustaining liability similar to morphine or being capable of conversion into a drug havingaddiction-forming or addiction-sustaining liability.(ff) "Opium poppy" means the plant of the species papaver somniferum L., except the seeds of the plant.(gg) "Person" means any corporation, association, partnership, trust, other institution or entity or one or more individuals.(hh) "Poppy straw" means all parts, except the seeds, of the opium poppy, after mowing.(ii) "Possession" or "use" means the joint or individual ownership, control, occupancy, holding, retaining, belonging, maintaining, or the application, inhalation, swallowing, injection, or consumption, as distinguished from distribution, of controlled substances and includes individual, joint, or group possession or use of controlled substances. For a person to be aUtah CodePage 6possessor or user of a controlled substance, it is not required that the person be shown to have individually possessed, used, or controlled the substance, but it is sufficient if it is shown that the person jointly participated with one or more persons in the use, possession, or control of any substances with the knowledge that the activity was occurring, or the controlled substance is found in a place or under the circumstances indicating that the person had the ability and theintent to exercise dominion and control over it.(jj) "Practitioner" means a physician, dentist, naturopathic physician, veterinarian, pharmacist, scientific investigator, pharmacy, hospital, or other person licensed, registered, or otherwise permitted to distribute, dispense, conduct research with respect to, administer, or use in teaching or chemical analysis a controlled substance in the course of professional practice or research in this state.(kk) "Prescribe" means to issue a prescription:(i) orally or in writing; or(ii) by telephone, facsimile transmission, computer, or other electronic means of communication as defined by division rule.(ll) "Prescription" means an order issued:(i) by a licensed practitioner, in the course of that practitioner's professional practice or by collaborative pharmacy practice agreement; and(ii) for a controlled substance or other prescription drug or device for use by a patient or an animal.(mm) "Production" means the manufacture, planting, cultivation, growing, or harvesting of a controlled substance.(nn) "Securities" means any stocks, bonds, notes, or other evidence of debt or of property.(oo) "State" means the state of Utah.(pp) "Ultimate user" means any person who lawfully possesses a controlled substance for the person's own use, for the use of a member of the person's household, or for administration to an animal owned by the person or a member of the person's household.(2) If a term used in this chapter is not defined, the definition and terms of Title 76, Utah Criminal Code, shall apply.Amended by Chapter 12, 2020 General Session58-37-2.5 Restricted applicability. This chapter does not restrict the sale and use of herbs, herbal products, or food supplements that are not scheduled in this chapter as controlled substances.Amended by Chapter 101, 1990 General Session58-37-3 Controlled substances.(1) All substances listed in Section 58-37-4 or 58-37-4.2 are controlled.(2) All substances listed in the federal Controlled Substances Act, Title II, P.L. 91-513, are controlled.Amended by Chapter 12, 2011 General Session58-37-3.6 Exemption for possession or distribution of a cannabinoid product or expanded cannabinoid product pursuant to an approved study.(1) As used in this section:Utah CodePage 7(a) "Cannabinoid product" means a product intended for human ingestion that:(i) contains an extract or concentrate that is obtained from cannabis;(ii) is prepared in a medicinal dosage form; and(iii) contains at least 10 units of cannabidiol for every one unit of tetrahydrocannabinol.(b) "Cannabis" means any part of the plant cannabis sativa, whether growing or not.(c) "Drug paraphernalia" means the same as that term is defined in Section 58-37a-3.(d) "Expanded cannabinoid product" means a product intended for human ingestion that:(i) contains an extract or concentrate that is obtained from cannabis;(ii) is prepared in a medicinal dosage form; and(iii) contains less than 10 units of cannabidiol for every one unit of tetrahydrocannabinol.(e) "Medicinal dosage form" means:(i) a tablet;(ii) a capsule;(iii) a concentrated oil;(iv) a liquid suspension;(v) a transdermal preparation; or(vi) a sublingual preparation.(f) "Tetrahydrocannabinol" means a substance derived from cannabis that meets the descriptionin Subsection 58-37-4(2)(a)(iii)(AA).(2) Notwithstanding any other provision of this chapter an individual who possesses or distributes a cannabinoid product or an expanded cannabinoid product is not subject to the penalties described in this title for the possession or distribution of marijuana or tetrahydrocannabinol to the extent that the individual's possession or distribution of the cannabinoid product or expanded cannabinoid product complies with Title 26, Chapter 61, Cannabinoid Research Act.Amended by Chapter 1, 2018 Special Session 358-37-3.7 Medical cannabis decriminalization.(1) As used in this section:(a) "Cannabis" means the same as that term is defined in Section 26-61a-102.(b) "Cannabis product" means the same as that term is defined in Section 26-61a-102.(c) "Legal dosage limit" means the same as that term is defined in Section 26-61a-102.(d) "Medical cannabis card" means the same as that term is defined in Section 26-61a-102.(e) "Medical cannabis device" means the same as that term is defined in Section 26-61a-102.(f) "Medicinal dosage form" means the same as that term is defined in Section 26-61a-102.(g) "Nonresident patient" means the same as that term is defined in Section 26-61a-102.(h) "Qualifying condition" means the same as that term is defined in Section 26-61a-102.(i) "Tetrahydrocannabinol" means the same as that term is defined in Section 58-37-3.9.(2) Before January 1, 2021, an individual is not guilty under this chapter for the use or possessionof marijuana, tetrahydrocannabinol, or marijuana drug paraphernalia if:(a) at the time of the arrest or citation, the individual:(i)(A) had been diagnosed with a qualifying condition; and(B) had a pre-existing provider-patient relationship with an advanced practice registered nurselicensed under Title 58, Chapter 31b, Nurse Practice Act, a physician licensed under Title58, Chapter 67, Utah Medical Practice Act, a physician licensed under Title 58, Chapter68, Utah Osteopathic Medical Practice Act, or a physician assistant licensed under TitleUtah CodePage 858, Chapter 70a, Utah Physician Assistant Act, who believed that the individual's illnessdescribed in Subsection (2)(a)(i)(A) could benefit from the use in question;(ii) for possession, was:(A) the parent or legal guardian of an individual described in Subsection (2)(a)(i) who is a minor; or(B) the spouse of an individual described in Subsection (2)(a)(i); or(iii)(A) for possession, was a medical cannabis cardholder; or(B) for use, was a medical cannabis patient cardholder or a minor with a qualifying condition under the supervision of a medical cannabis guardian cardholder; and(b)(i) for use or possession of marijuana or tetrahydrocannabinol, the marijuana ortetrahydrocannabinol is one of the following in an amount that does not exceed the legal dosage limit:(A) unprocessed cannabis in a medicinal dosage form; or(B) a cannabis product in a medicinal dosage form; and(ii) for use or possession of marijuana drug paraphernalia, the paraphernalia is a medical cannabis device.(3) A nonresident patient is not guilty under this chapter for the use or possession of marijuana, tetrahydrocannabinol, or marijuana drug paraphernalia under this chapter if:(a) for use or possession of marijuana or tetrahydrocannabinol, the marijuana ortetrahydrocannabinol is one of the following in an amount that does not exceed the legal dosage limit:(i) unprocessed cannabis in a medicinal dosage form; or(ii) a cannabis product in a medicinal dosage form; and(b) for use or possession of marijuana drug paraphernalia, the paraphernalia is a medical cannabis device.(4)(a) There is a rebuttable presumption against an allegation of use or possession of marijuana or tetrahydrocannabinol if:(i) an individual fails a drug test based on the presence of tetrahydrocannabinol in the sample; and(ii) the individual provides evidence that the individual possessed or used cannabidiol or a cannabidiol product.(b) The presumption described in Subsection (4)(a) may be rebutted with evidence that the individual purchased or possessed marijuana or tetrahydrocannabinol that is not authorized under:(i) Section 4-41-402; or(ii)Title 26, Chapter 61a, Utah Medical Cannabis Act.Amended by Chapter 12, 2020 General Session58-37-3.8 Enforcement.(1) A law enforcement officer, as that term is defined in Section 53-13-103, except for an officially designated drug enforcement task force regarding conduct that is not in accordance with Title 26, Chapter 61a, Utah Medical Cannabis Act, may not expend any state or local resources, including the officer's time, to:Utah CodePage 9(a) effect any arrest or seizure of cannabis, as that term is defined in Section 26-61a-102, orconduct any investigation, on the sole basis of activity the officer believes to constitute a violation of federal law if the officer has reason to believe that the activity is in compliance with the state medical cannabis laws;(b) enforce a law that restricts an individual's right to acquire, own, or possess a firearm based solely on the individual's possession or use of cannabis in accordance with state medical cannabis laws; or(c) provide any information or logistical support related to an activity described in Subsection (1)(a) to any federal law enforcement authority or prosecuting entity.(2) An agency or political subdivision of the state may not take adverse action against a person for providing a professional service to a medical cannabis pharmacy, as that term is defined in Section 26-61a-102, the state central patient portal, as that term is defined in Section 26-61a-102, or a cannabis production establishment, as that term is defined in Section 4-41a-102, on the sole basis that the service is a violation of federal law.Amended by Chapter 5, 2019 Special Session 158-37-3.9

Exemption for possession or use of cannabis to treat a qualifying illness.

(1) As used in this section:(a) "Cannabis" means marijuana.(b) "Cannabis product" means the same as that term is defined in Section 26-61a-102.(c) "Drug paraphernalia" means the same as that term is defined in Section 58-37a-3.(d) "Medical cannabis cardholder" means the same as that term is defined in Section26-61a-102.(e) "Medical cannabis device" means the same as that term is defined in Section 26-61a-102.(f) " Medicinal dosage form" means the same as that term is defined in Section 26-61a-102.(g) "Tetrahydrocannabinol" means a substance derived from cannabis or a synthetic description as described in Subsection 58-37-4(2)(a)(iii)(AA).(2) Notwithstanding any other provision of law, except as otherwise provided in this section:(a) an individual is not guilty of a violation of this title for the following conduct if the individual engages in the conduct in accordance with Title 4, Chapter 41a, Cannabis Production Establishments, or Title 26, Chapter 61a, Utah Medical Cannabis Act:(i) possessing, ingesting, inhaling, producing, manufacturing, dispensing, distributing, selling, or offering to sell cannabis or a cannabis product; or(ii) possessing cannabis or a cannabis product with the intent to engage in the conduct described in Subsection (2)(a)(i); and(b) an individual is not guilty of a violation of this title regarding drug paraphernalia if the individual, in accordance with Title 4, Chapter 41a, Cannabis Production Establishments, andTitle 26, Chapter 61a, Utah Medical Cannabis Act:(i) possesses, manufactures, distributes, sells, or offers to sell a medical cannabis device; or(ii) possesses a medical cannabis device with the intent to engage in any of the conduct described in Subsection (2)(b)(i).(3)(a) As used in this Subsection (3), "smoking" does not include the vaporization or heating of medical cannabis.(b)Title 26, Chapter 61a, Utah Medical Cannabis Act, does not authorize a medical cannabis cardholder to smoke or combust cannabis or to use a device to facilitate the smoking or combustion of cannabis.Utah CodePage 10(c) A medical cannabis cardholder or a nonresident patient who smokes cannabis or engages in any other conduct described in Subsection (3)(b):(i) does not possess the cannabis in accordance with Title 26, Chapter 61a, Utah Medical Cannabis Act; and(ii) is, for the use or possession of marijuana, tetrahydrocannabinol, or marijuana drug paraphernalia for the conduct described in Subsection (3)(b):(A) for the first offense, guilty of an infraction and subject to a fine of up to $100; and(B) for a second or subsequent offense, subject to charges under this chapter.(4) An individual who is assessed for a penalty or convicted of a crime under Title 4, Chapter 41a,Cannabis Production Establishments, or Title 26, Chapter 61a, Utah Medical Cannabis Act, is not, based on the conduct underlying that penalty or conviction, subject to a penalty described in this chapter for:(a) the possession, manufacture, sale, or offer for sale of cannabis or a cannabis product; or(b) the possession, manufacture, sale, or offer for sale of drug paraphernalia.Amended by Chapter 12, 2020 General Session58-37-4 Schedules of controlled substances -- Schedules I through V -- Findings required --Specific substances included in schedules.(1) There are established five schedules of controlled substances known as Schedules I, II, III, IV,and V, which consist of substances listed in this section.(2) Schedules I, II, III, IV, and V consist of the following drugs or other substances by the official name, common or usual name, chemical name, or brand name designated:(a) Schedule I:(i) Unless specifically excepted or unless listed in another schedule, any of the followingopiates, including their isomers, esters, ethers, salts, and salts of isomers, esters, and ethers, when the existence of the isomers, esters, ethers, and salts is possible within the specific chemical designation:(A) Acetyl-alpha-methylfentanyl (N-[1-(1-methyl-2-phenethyl)-4-piperidinyl]-Nphenylacetamide);(B) Acetyl fentanyl: (N-(1-phenethylpiperidin-4-yl)-N-phenylacetamide);(C) Acetylmethadol;(D) Acryl fentanyl (N-(1-Phenethylpiperidin-4-yl)-N-phenylacrylamide);(E) Allylprodine;(F) Alphacetylmethadol, except levo-alphacetylmethadol also known as levo-alphaacetylmethadol, levomethadyl acetate, or LAAM;(G) Alphameprodine;(H) Alphamethadol;(I) Alpha-methylfentanyl (N-[1-(alpha-methyl-beta-phenyl)ethyl-4-piperidyl] propionanilide; 1-(1-methyl-2-phenylethyl)-4-(N-propanilido) piperidine);(J) Alpha-methylthiofentanyl (N-[1-methyl-2-(2-thienyl)ethyl-4- piperidinyl]-Nphenylpropanamide);(K) Benzylpiperazine;(L) Benzethidine;(M) Betacetylmethadol;(N) Beta-hydroxyfentanyl (N-[1-(2-hydroxy-2-phenethyl)-4- piperidinyl]-Nphenylpropanamide);Utah CodePage 11(O) Beta-hydroxy-3-methylfentanyl, other name: N-[1-(2-hydroxy-2- phenethyl)-3-methyl-4-piperidinyl]-N-phenylpropanamide;(P) Betameprodine;(Q) Betamethadol;(R) Betaprodine;(S) Butyryl fentanyl (N-(1-(2-phenylethyl)-4-piperidinyl)-N-phenylbutyramide);(T) Clonitazene;(U) Cyclopropyl fentanyl (N-(1-Phenethylpiperidin-4-yl)-N-phenylcyclopropanecarboxamide);(V) Dextromoramide;(W) Diampromide;(X) Diethylthiambutene;(Y) Difenoxin;(Z) Dimenoxadol;(AA) Dimepheptanol;(BB) Dimethylthiambutene;(CC) Dioxaphetyl butyrate;(DD) Dipipanone;(EE) Ethylmethylthiambutene;(FF) Etizolam (1-Methyl-6-o-chlorophenyl-8-ethyl-4H-s-triazolo[3,4-c]thieno[2,3-e]1,4-diazepine);(GG) Etonitazene;(HH) Etoxeridine;(II) Furanyl fentanyl (N-phenyl-N-[1-(2-phenylethyl)piperidin-4-yl] furan-2-carboxamide);(JJ) Furethidine;(KK) Hydroxypethidine;(LL) Ketobemidone;(MM) Levomoramide;(NN) Levophenacylmorphan;(OO) Methoxyacetyl fentanyl (2-Methoxy-N-(1-phenylethylpiperidinyl-4-yl)-N-acetamide);(PP) Morpheridine;(QQ) MPPP (1-methyl-4-phenyl-4-propionoxypiperidine);(RR) Noracymethadol;(SS) Norlevorphanol;(TT) Normethadone;(UU) Norpipanone;(VV) Para-fluorofentanyl (N-(4-fluorophenyl)-N-[1-(2-phenethyl)-4- piperidinyl] propanamide);(WW) Para-fluoroisobutyryl fentanyl (N-(4-Fluorophenyl)-N-(1-phenethylpiperidin-4-yl)isobutyramide);(XX) PEPAP (1-(-2-phenethyl)-4-phenyl-4-acetoxypiperidine);(YY) Phenadoxone;(ZZ) Phenampromide;(AAA) Phenomorphan;(BBB) Phenoperidine;(CCC) Piritramide;(DDD) Proheptazine;(EEE) Properidine;(FFF) Propiram;(GGG) Racemoramide;Utah CodePage 12(HHH) Tetrahydrofuran fentanyl (N-(1-Phenethylpiperidin-4-yl)-N-phenyltetrahydrofuran-2-carboxamide);(III) Thiofentanyl (N-phenyl-N-[1-(2-thienyl)ethyl-4-piperidinyl]- propanamide;(JJJ) Tilidine;(KKK) Trimeperidine;(LLL) 3-methylfentanyl, including the optical and geometric isomers (N-[3-methyl-1-(2-phenylethyl)-4-piperidyl]- N-phenylpropanamide);(MMM) 3-methylthiofentanyl (N-[(3-methyl-1-(2-thienyl)ethyl-4-piperidinyl]-Nphenylpropanamide);(NNN) 3,4-dichloro-N-[2-(dimethylamino)cyclohexyl]-N-methylbenzamide also known as U-47700; and(OOO) 4-cyano CUMYL-BUTINACA.(ii) Unless specifically excepted or unless listed in another schedule, any of the following opium derivatives, their salts, isomers, and salts of isomers when the existence of the salts, isomers, and salts of isomers is possible within the specific chemical designation:(A) Acetorphine;(B) Acetyldihydrocodeine;(C) Benzylmorphine;(D) Codeine methylbromide;(E) Codeine-N-Oxide;(F) Cyprenorphine;(G) Desomorphine;(H) Dihydromorphine;(I) Drotebanol;(J) Etorphine (except hydrochloride salt);(K) Heroin;(L) Hydromorphinol;(M) Methyldesorphine;(N) Methylhydromorphine;(O) Morphine methylbromide;(P) Morphine methylsulfonate;(Q) Morphine-N-Oxide;(R) Myrophine;(S) Nicocodeine;(T) Nicomorphine;(U) Normorphine;(V) Pholcodine; and(W) Thebacon.(iii) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of the following hallucinogenic substances, or which contains any of their salts, isomers, and salts of isomers when the existence of the salts, isomers, and salts of isomers is possible within the specific chemical designation; as used in this Subsection (2)(a)(iii) only, "isomer" includes the optical, position, and geometric isomers:(A) Alpha-ethyltryptamine, some trade or other names: etryptamine; Monase; α-ethyl-1Hindole-3-ethanamine; 3-(2-aminobutyl) indole; α-ET; and AET;Utah CodePage 13(B) 4-bromo-2,5-dimethoxy-amphetamine, some trade or other names: 4-bromo-2,5-dimethoxy-α-methylphenethylamine; 4-bromo-2,5-DMA;(C) 4-bromo-2,5-dimethoxyphenethylamine, some trade or other names: 2-(4-bromo-2,5-dimethoxyphenyl)-1-aminoethane; alpha-desmethyl DOB; 2C-B, Nexus;(D) 2,5-dimethoxyamphetamine, some trade or other names: 2,5-dimethoxy-αmethylphenethylamine; 2,5-DMA;(E) 2,5-dimethoxy-4-ethylamphetamine, some trade or other names: DOET;(F) 4-methoxyamphetamine, some trade or other names: 4-methoxy-αmethylphenethylamine; paramethoxyamphetamine, PMA;(G) 5-methoxy-3,4-methylenedioxyamphetamine;(H) 4-methyl-2,5-dimethoxy-amphetamine, some trade and other names: 4-methyl-2,5-dimethoxy-α-methylphenethylamine; "DOM"; and "STP";(I) 3,4-methylenedioxy amphetamine;(J) 3,4-methylenedioxymethamphetamine (MDMA);(K) 3,4-methylenedioxy-N-ethylamphetamine, also known as N-ethyl- alphamethyl-3,4(methylenedioxy)phenethylamine, N-ethyl MDA, MDE, MDEA;(L) N-hydroxy-3,4-methylenedioxyamphetamine, also known as N-hydroxy-alphamethyl-3,4(methylenedioxy)phenethylamine, and N-hydroxy MDA;(M) 3,4,5-trimethoxy amphetamine;(N) Bufotenine, some trade and other names: 3-(β-Dimethylaminoethyl)-5-hydroxyindole; 3-(2-dimethylaminoethyl)-5-indolol; N, N-dimethylserotonin; 5-hydroxy-N,Ndimethyltryptamine; mappine;(O) Diethyltryptamine, some trade and other names: N,N-Diethyltryptamine; DET;(P) Dimethyltryptamine, some trade or other names: DMT;(Q) Ibogaine, some trade and other names: 7-Ethyl-6,6β,7,8,9,10,12,13-octahydro-2-methoxy-6,9-methano-5H-pyrido [1', 2':1,2] azepino [5,4-b] indole; Tabernanthe iboga;(R) Lysergic acid diethylamide;(S) Marijuana;(T) Mescaline;(U) Parahexyl, some trade or other names: 3-Hexyl-1-hydroxy-7,8,9,10-tetrahydro-6,6,9-trimethyl-6H-dibenzo[b,d]pyran; Synhexyl;(V) Peyote, meaning all parts of the plant presently classified botanically as Lophophora williamsii (Lemaire), whether growing or not, the seeds thereof, any extract from any part of such plant, and every compound, manufacture, salts, derivative, mixture, or preparation ofsuch plant, its seeds or extracts (Interprets 21 USC 812(c), Schedule I(c) (12));(W) N-ethyl-3-piperidyl benzilate;(X) N-methyl-3-piperidyl benzilate;(Y) Psilocybin;(Z) Psilocyn;(AA) Tetrahydrocannabinols, naturally contained in a plant of the genus Cannabis (cannabis plant), as well as synthetic equivalents of the substances contained in the cannabis plant, or in the resinous extractives of Cannabis, sp. and/or synthetic substances, derivatives, and their isomers with similar chemical structure and pharmacological activity to those substances contained in the plant, such as the following: 1 cis or trans tetrahydrocannabinol, and their optical isomers ?6 cis or trans tetrahydrocannabinol, andUtah CodePage 14their optical isomers 3,4 cis or trans tetrahydrocannabinol, and its optical isomers, and since the nomenclature of these substances is not internationally standardized, compounds of these structures, regardless of numerical designation of atomic positions covered;(BB) Ethylamine analog of phencyclidine, some trade or other names: Nethyl-1-phenylcyclohexylamine, (1-phenylcyclohexyl)ethylamine, N-(1-phenylcyclohexyl)ethylamine, cyclohexamine, PCE;(CC) Pyrrolidine analog of phencyclidine, some trade or other names: 1-(1-phenylcyclohexyl)-pyrrolidine, PCPy, PHP;(DD) Thiophene analog of phencyclidine, some trade or other names: 1-[1-(2-thienyl)-cyclohexyl]-piperidine, 2-thienylanalog of phencyclidine, TPCP, TCP; and(EE) 1-[1-(2-thienyl)cyclohexyl]pyrrolidine, some other names: TCPy.(iv) Unless specifically excepted or unless listed in another schedule, any material compound, mixture, or preparation which contains any quantity of the following substances having a depressant effect on the central nervous system, including its salts, isomers, and salts of isomers when the existence of the salts, isomers, and salts of isomers is possible within the specific chemical designation:(A) Mecloqualone; and(B) Methaqualone.(v) Any material, compound, mixture, or preparation containing any quantity of the following substances having a stimulant effect on the central nervous system, including their salts, isomers, and salts of isomers:(A) Aminorex, some other names: aminoxaphen; 2-amino-5-phenyl-2-oxazoline; or 4,5-dihydro-5-phenyl-2-oxazolamine;(B) Cathinone, some trade or other names: 2-amino-1-phenyl-1-propanone, alphaaminopropiophenone, 2-aminopropiophenone, and norephedrone;(C) Fenethylline;(D) Methcathinone, some other names: 2-(methylamino)-propiophenone; alpha-(methylamino)propiophenone; 2-(methylamino)-1-phenylpropan-1-one; alpha-Nmethylaminopropiophenone; monomethylpropion; ephedrone; N-methylcathinone;methylcathinone; AL-464; AL-422; AL-463 and UR1432, its salts, optical isomers, and salts of optical isomers;(E) (±)cis-4-methylaminorex ((±)cis-4,5-dihydro-4-methyl-5-phenyl-2-oxazolamine);(F) N-ethylamphetamine; and(G) N,N-dimethylamphetamine, also known as N,N-alpha-trimethyl-benzeneethanamine; N,Nalpha-trimethylphenethylamine.(vi) Any material, compound, mixture, or preparation which contains any quantity of the following substances, including their optical isomers, salts, and salts of isomers, subject to temporary emergency scheduling:(A) N-[1-benzyl-4-piperidyl]-N-phenylpropanamide (benzylfentanyl); and(B) N-[1- (2-thienyl)methyl-4-piperidyl]-N-phenylpropanamide (thenylfentanyl).(vii) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of gamma hydroxy butyrate (gamma hydrobutyric acid), including its salts, isomers, and salts of isomers.(b) Schedule II:(i) Unless specifically excepted or unless listed in another schedule, any of the following substances whether produced directly or indirectly by extraction from substances ofUtah CodePage 15vegetable origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis:(A) Opium and opiate, and any salt, compound, derivative, or preparation of opium or opiate, excluding apomorphine, dextrorphan, nalbuphine, nalmefene, naloxone, and naltrexone, and their respective salts, but including:(I) Raw opium;(II) Opium extracts;(III) Opium fluid;(IV) Powdered opium;(V) Granulated opium;(VI) Tincture of opium;(VII) Codeine;(VIII) Ethylmorphine;(IX) Etorphine hydrochloride;(X) Hydrocodone;(XI) Hydromorphone;(XII) Metopon;(XIII) Morphine;(XIV) Oxycodone;(XV) Oxymorphone; and(XVI) Thebaine;(B) Any salt, compound, derivative, or preparation which is chemically equivalent or identical with any of the substances referred to in Subsection (2)(b)(i)(A), except that these substances may not include the isoquinoline alkaloids of opium;(C) Opium poppy and poppy straw;(D) Coca leaves, and any salt, compound, derivative, or preparation of coca leaves, and any salt, compound, derivative, or preparation which is chemically equivalent or identical with any of these substances, and includes cocaine and ecgonine, their salts, isomers, derivatives, and salts of isomers and derivatives, whether derived from the coca plant or synthetically produced, except the substances may not include decocainized coca leaves or extraction of coca leaves, which extractions do not contain cocaine or ecgonine; and(E) Concentrate of poppy straw, which means the crude extract of poppy straw in either liquid, solid, or powder form which contains the phenanthrene alkaloids of the opium poppy.(ii) Unless specifically excepted or unless listed in another schedule, any of the following opiates, including their isomers, esters, ethers, salts, and salts of isomers, esters, and ethers, when the existence of the isomers, esters, ethers, and salts is possible within the specific chemical designation, except dextrorphan and levopropoxyphene:(A) Alfentanil;(B) Alphaprodine;(C) Anileridine;(D) Bezitramide;(E) Bulk dextropropoxyphene (non dosage forms);(F) Carfentanil;(G) Dihydrocodeine;(H) Diphenoxylate;(I) Fentanyl;(J) Isomethadone;Utah CodePage 16(K) Levo-alphacetylmethadol, some other names: levo-alpha-acetylmethadol, levomethadylacetate, or LAAM;(L) Levomethorphan;(M) Levorphanol;(N) Metazocine;(O) Methadone;(P) Methadone-Intermediate, 4-cyano-2-dimethylamino-4, 4-diphenyl butane;(Q) Moramide-Intermediate, 2-methyl-3-morpholino-1, 1-diphenylpropane-carboxylic acid;(R) Pethidine (meperidine);(S) Pethidine-Intermediate-A, 4-cyano-1-methyl-4-phenylpiperidine;(T) Pethidine-Intermediate-B, ethyl-4-phenylpiperidine-4-carboxylate;(U) Pethidine-Intermediate-C, 1-methyl-4-phenylpiperidine-4-carboxylic acid;(V) Phenazocine;(W) Piminodine;(X) Racemethorphan;(Y) Racemorphan;(Z) Remifentanil; and(AA) Sufentanil.(iii) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of the following substances having a stimulant effect on the central nervous system:(A) Amphetamine, its salts, optical isomers, and salts of its optical isomers;(B) Methamphetamine, its salts, isomers, and salts of its isomers;(C) Phenmetrazine and its salts; and(D) Methylphenidate.(iv) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of the following substances having a depressant effect on the central nervous system, including its salts, isomers, and salts of isomers when the existence of the salts, isomers, and salts of isomers is possible within the specific chemical designation:(A) Amobarbital;(B) Glutethimide;(C) Pentobarbital;(D) Phencyclidine;(E) Phencyclidine immediate precursors: 1-phenylcyclohexylamine and 1-piperidinocyclohexanecarbonitrile (PCC); and(F) Secobarbital.(v)(A) Unless specifically excepted or unless listed in another schedule, any material,compound, mixture, or preparation which contains any quantity of Phenylacetone.(B) Some of these substances may be known by trade or other names: phenyl-2-propanone;P2P; benzyl methyl ketone; and methyl benzyl ketone.(vi) Nabilone, another name for nabilone: (±)-trans-3-(1,1-dimethylheptyl)-6,6a,7,8,10,10ahexahydro-1-hydroxy-6, 6-dimethyl-9H-dibenzo[b,d]pyran-9-one.(vii) A drug product or preparation that contains any component of marijuana, including tetrahydrocannabinol, and is approved by the United States Food and Drug Administration and scheduled by the Drug Enforcement Administration in Schedule II of the federal Controlled Substances Act, Title II, P.L. 91-513.Utah CodePage 17(c) Schedule III:(i) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of the following substances having a stimulant effect on the central nervous system, including its salts, isomers whether optical, position, or geometric, and salts of the isomers when the existence of the salts, isomers, and salts of isomers is possible within the specific chemical designation:(A) Those compounds, mixtures, or preparations in dosage unit form containing any stimulant substances listed in Schedule II, which compounds, mixtures, or preparations were listed on August 25, 1971, as excepted compounds under Section 1308.32 of Title 21 of the Code of Federal Regulations, and any other drug of the quantitive composition shown in that list for those drugs or which is the same except that it contains a lesser quantity of controlled substances;(B) Benzphetamine;(C) Chlorphentermine;(D) Clortermine; and(E) Phendimetrazine.(ii) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of the following substances having a depressant effect on the central nervous system:(A) Any compound, mixture, or preparation containing amobarbital, secobarbital,pentobarbital, or any salt of any of them, and one or more other active medicinalingredients that are not listed in any schedule;(B) Any suppository dosage form containing amobarbital, secobarbital, or pentobarbital, or any salt of any of these drugs which are approved by the Food and Drug Administration for marketing only as a suppository;(C) Any substance which contains any quantity of a derivative of barbituric acid or any salt of any of them;(D) Chlorhexadol;(E) Buprenorphine;(F) Any drug product containing gamma-hydroxybutyric acid, including its salts, isomers, and salts of isomers, for which an application is approved under the federal Food, Drug, and Cosmetic Act, Section 505;(G) Ketamine, its salts, isomers, and salts of isomers, some other names for ketamine: ± -2-(2-chlorophenyl)-2-(methylamino)-cyclohexanone;(H) Lysergic acid;(I) Lysergic acid amide;(J) Methyprylon;(K) Sulfondiethylmethane;(L) Sulfonethylmethane;(M) Sulfonmethane; and(N) Tiletamine and zolazepam or any of their salts, some trade or other names for atiletamine-zolazepam combination product: Telazol, some trade or other names fortiletamine: 2-(ethylamino)-2-(2-thienyl)-cyclohexanone, some trade or other namesfor zolazepam: 4-(2-fluorophenyl)-6,8-dihydro-1,3,8-trimethylpyrazolo-[3,4-e] [1,4]-diazepin-7(1H)-one, flupyrazapon.(iii) Dronabinol (synthetic) in sesame oil and encapsulated in a soft gelatin capsule in a U.S. Food and Drug Administration approved drug product, some other names for dronabinol:Utah CodePage 18(6aR-trans)-6a,7,8,10a-tetrahydro-6,6,9-trimethyl-3-pentyl-6H-dibenzo[b,d]pyran-1-ol, or (-)-delta-9-(trans)-tetrahydrocannabinol.(iv) Nalorphine.(v) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation containing limited quantities of any of the following narcotic drugs or their salts calculated as the free anhydrous base or alkaloid:(A) Not more than 1.8 grams of codeine per 100 milliliters or not more than 90 milligrams per dosage unit, with an equal or greater quantity of an isoquinoline alkaloid of opium;(B) Not more than 1.8 grams of codeine per 100 milliliters or not more than 90 milligrams per dosage unit, with one or more active non-narcotic ingredients in recognized therapeutic amounts;(C) Not more than 300 milligrams of dihydrocodeinone per 100 milliliters or not more than 15 milligrams per dosage unit, with a fourfold or greater quantity of an isoquinoline alkaloid of opium;(D) Not more than 300 milligrams of dihydrocodeinone per 100 milliliters or not more than 15 milligrams per dosage unit, with one or more active, non-narcotic ingredients in recognized therapeutic amounts;(E) Not more than 1.8 grams of dihydrocodeine per 100 milliliters or not more than 90 milligrams per dosage unit, with one or more active non-narcotic ingredients in recognized therapeutic amounts;(F) Not more than 300 milligrams of ethylmorphine per 100 milliliters or not more than 15 milligrams per dosage unit, with one or more active, non-narcotic ingredients in recognized therapeutic amounts;(G) Not more than 500 milligrams of opium per 100 milliliters or per 100 grams, or not more than 25 milligrams per dosage unit, with one or more active, non-narcotic ingredients in recognized therapeutic amounts; and(H) Not more than 50 milligrams of morphine per 100 milliliters or per 100 grams with one or more active, non-narcotic ingredients in recognized therapeutic amounts.(vi) Unless specifically excepted or unless listed in another schedule, anabolic steroids including any of the following or any isomer, ester, salt, or derivative of the following that promotes muscle growth:(A) Boldenone;(B) Chlorotestosterone (4-chlortestosterone);(C) Clostebol;(D) Dehydrochlormethyltestosterone;(E) Dihydrotestosterone (4-dihydrotestosterone);(F) Drostanolone;(G) Ethylestrenol;(H) Fluoxymesterone;(I) Formebulone (formebolone);(J) Mesterolone;(K) Methandienone;(L) Methandranone;(M) Methandriol;(N) Methandrostenolone;(O) Methenolone;(P) Methyltestosterone;(Q) Mibolerone;Utah CodePage 19(R) Nandrolone;(S) Norethandrolone;(T) Oxandrolone;(U) Oxymesterone;(V) Oxymetholone;(W) Stanolone;(X) Stanozolol;(Y) Testolactone;(Z) Testosterone; and(AA) Trenbolone.(vii) Anabolic steroids expressly intended for administration through implants to cattle or other nonhuman species and approved by the Secretary of Health and Human Services for use may not be classified as a controlled substance.(viii) A drug product or preparation that contains any component of marijuana, including tetrahydrocannabinol, and is approved by the United States Food and Drug Administration and scheduled by the Drug Enforcement Administration in Schedule III of the federal Controlled Substances Act, Title II, P.L. 91-513.(ix) Nabiximols.(d) Schedule IV:(i) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation containing not more than 1 milligram of difenoxin and not less than 25 micrograms of atropine sulfate per dosage unit, or any salts of any of them.(ii) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of the following substances, including its salts, isomers, and salts of isomers when the existence of the salts, isomers, and salts of isomers is possible within the specific chemical designation:(A) Alprazolam;(B) Barbital;(C) Bromazepam;(D) Butorphanol;(E) Camazepam;(F) Carisoprodol;(G) Chloral betaine;(H) Chloral hydrate;(I) Chlordiazepoxide;(J) Clobazam;(K) Clonazepam;(L) Clorazepate;(M) Clotiazepam;(N) Cloxazolam;(O) Delorazepam;(P) Diazepam;(Q) Dichloralphenazone;(R) Estazolam;(S) Ethchlorvynol;(T) Ethinamate;(U) Ethyl loflazepate;(V) Fludiazepam;Utah CodePage 20(W) Flunitrazepam;(X) Flurazepam;(Y) Halazepam;(Z) Haloxazolam;(AA) Ketazolam;(BB) Loprazolam;(CC) Lorazepam;(DD) Lormetazepam;(EE) Mebutamate;(FF) Medazepam;(GG) Meprobamate;(HH) Methohexital;(II) Methylphenobarbital (mephobarbital);(JJ) Midazolam;(KK) Nimetazepam;(LL) Nitrazepam;(MM) Nordiazepam;(NN) Oxazepam;(OO) Oxazolam;(PP) Paraldehyde;(QQ) Pentazocine;(RR) Petrichloral;(SS) Phenobarbital;(TT) Pinazepam;(UU) Prazepam;(VV) Quazepam;(WW) Temazepam;(XX) Tetrazepam;(YY) Tramadol;(ZZ) Triazolam;(AAA) Zaleplon; and(BBB) Zolpidem.(iii) Any material, compound, mixture, or preparation of fenfluramine which contains any quantity of the following substances, including its salts, isomers whether optical, position, or geometric, and salts of the isomers when the existence of the salts, isomers, and salts of isomers is possible.(iv) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of the following substances having a stimulant effect on the central nervous system, including its salts, isomers whether optical, position, or geometric isomers, and salts of the isomers when the existence of the salts, isomers, and salts of isomers is possible within the specific chemical designation:(A) Cathine ((+)-norpseudoephedrine);(B) Diethylpropion;(C) Fencamfamine;(D) Fenproprex;(E) Mazindol;(F) Mefenorex;(G) Modafinil;Utah CodePage 21(H) Pemoline, including organometallic complexes and chelates thereof;(I) Phentermine;(J) Pipradrol;(K) Sibutramine; and(L) SPA ((-)-1-dimethylamino-1,2-diphenylethane).(v) Unless specifically excepted or unless listed in another schedule, any material, compound, mixture, or preparation which contains any quantity of dextropropoxyphene (alpha-(+)-4-dimethylamino-1, 2-diphenyl-3-methyl-2-propionoxybutane), including its salts.(vi) A drug product or preparation that contains any component of marijuana and is approved by the United States Food and Drug Administration and scheduled by the Drug Enforcement Administration in Schedule IV of the federal Controlled Substances Act, Title II, P.L. 91-513.(e) Schedule V:(i) Any compound, mixture, or preparation containing any of the following limited quantities of narcotic drugs or their salts calculated as the free anhydrous base or alkaloid, which includes one or more non-narcotic active medicinal ingredients in sufficient proportion to confer upon the compound, mixture, or preparation valuable medicinal qualities other than those possessed by the narcotic drug alone:(A) not more than 200 milligrams of codeine per 100 milliliters or per 100 grams;(B) not more than 100 milligrams of dihydrocodeine per 100 milliliters or per 100 grams;(C) not more than 100 milligrams of ethylmorphine per 100 milliliters or per 100 grams;(D) not more than 2.5 milligrams of diphenoxylate and not less than 25 micrograms ofatropine sulfate per dosage unit;(E) not more than 100 milligrams of opium per 100 milliliters or per 100 grams;(F) not more than 0.5 milligram of difenoxin and not less than 25 micrograms of atropine sulfate per dosage unit; and(G) unless specifically exempted or excluded or unless listed in another schedule, any material, compound, mixture, or preparation which contains Pyrovalerone having a stimulant effect on the central nervous system, including its salts, isomers, and salts of isomers.(ii) A drug product or preparation that contains any component of marijuana, including cannabidiol, and is approved by the United States Food and Drug Administration and scheduled by the Drug Enforcement Administration in Schedule V of the federal Controlled Substances Act, Title II, P.L. 91-513.Amended by Chapter 12, 2020 General Session58-37-4.2 Listed controlled substances. The following substances, their analogs, homologs, and synthetic equivalents are listed controlled substances:(1) AB-001;(2) AB-PINACA; N-[1-(aminocarbonyl)-2-methylpropyl]-1-pentyl-1H-indazole-3-carboxamide;(3) AB-FUBINACA; N-[1-(aminocarbonyl)-2-methylpropyl]-1-[(4-fluorophenyl) methyl]-1Hindazole-3-carboxamide;(4) AB-CHMINACA (N-(1-Amino-3-methyl-1-oxobutan-2-yl)-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide);(5) ADB-CHMINACA (N-[(2S)-1-amino-3,3-dimethyl-1-oxobutan-2-yl]-1-(cyclohexylmethyl)indazole-3-carboxamide);Utah CodePage 22(6) ADB-FUBINACA (N-(1-amino-3,3-dimethyl-1oxobutan-2-yl)-1- (4-fluorobenzyl)-1H-indazole-3-caboxamide);(7) AKB48;(8) alpha-Pyrrolidinohexanophenone (alpha-PHP) (1-Phenyl-2-(pyrrolidin-1-yl)hexan-1-one);(9) alpha-Pyrrolidinovalerophenone (alpha-PVP);(10) AM-694 (1-[(5-fluoropentyl)-1H-indol-3-yl]-(2-iodophenyl)methanone);(11) AM-1248;(12) AM-2201 (1-(5-fluoropentyl)-3-(1-naphthoyl)indole);(13) AM-2233;(14) AM-679;(15) A796,260;(16) Butylone;(17) CP 47,497 and its C6, C8, and C9 homologs (2-[(1R,3S)-3-hydroxycyclohexyl] -5-(2-methyloctan-2-yl)phenol);(18) Diisopropyltryptamine (DiPT);(19) Ethylone;(20) Ethylphenidate;(21) Fluoroisocathinone;(22) Fluoromethamphetamine;(23) Fluoromethcathinone;(24) FUB-AMB; methyl (1-(4-fluorobenzyl)-1H-indazole-3-carbonyl)valinate;(25) HU-210; (6aR,10aR)-9-(hydroxymethyl)-6,6-dimethyl-3-(2-methyloctan-2-yl) -6a,7,10,10atetrahydrobenzo[c]chromen-1-ol;(26) HU-211; Dexanabinol,(6aS,10aS)-9-(hydroxymethyl)-6,6-dimethyl-3-(2-methyloctan-2-yl)-6a,7,10,10a-tetrahydrobenzo[c]chromen-1-ol;(27) JWH-015; (2-methyl-1-propyl-1H-indol-3-yl)-1-naphthalenyl-methanone;(28) JWH-018; Naphthalen-1-yl-(pentylindol-3-yl)methanone {also known as 1-Pentyl-3-(1-naphthoyl)indole};(29) JWH-019; 1-hexyl-3-(1-naphthoyl)indole;(30) JWH-073; Naphthalen-1-yl(1-butylindol-3-yl)methanone {also known as 1-Butyl-3-(1-naphthoyl)indole};(31) JWH-081; 4-methoxynaphthalen-1-yl-(1-pentylindol-3-yl)methanone;(32) JWH-122; CAS#619294-47-2; (1-Pentyl-3-(4-methyl-1-naphthoyl)indole);(33) JWH-200; 1-(2-(4-(morpholinyl)ethyl))-3-(1-naphthoyl)indole;(34) JWH-203; 1-pentyl-3-(2-chlorophenylacetyl)indole;(35) JWH-210; 4-ethyl-1-naphthalenyl(1-pentyl-1H-indol-3-yl)-methanone;(36) JWH-250; 1-pentyl-3-(2-methoxyphenylacetyl)indole;(37) JWH-251; 2-(2-methylphenyl)-1-(1-pentyl-1H-indol-3-yl)ethanone;(38) JWH-398; 1-pentyl-3-(4-chloro-1-naphthoyl)indole;(39) MAM-2201;(40) MAM-2201; (1-(5-fluoropentyl)-1H-indol-3-yl)(4-ethyl-1-naphthalenyl)-methanone;(41) Methoxetamine;(42) Naphyrone;(43) PB-22; 1-pentyl-1H-indole-3-carboxylic acid 8-quinolinyl ester;(44) Pentedrone;(45) Pentylone;(46) RCS-4; 1-pentyl-3-(4-methoxybenzoyl)indole;Utah CodePage 23(47) RCS-8; 1-(2-cyclohexylethyl)-3-(2-methoxyphenylacetyl)indole {also known as BTW-8 andSR-18};(48) STS-135;(49) UR-144;(50) UR-144 N-(5-chloropentyl) analog;(51) XLR11;(52) 2C-C;(53) 2C-D;(54) 2C-E;(55) 2C-H;(56) 2C-I;(57) 2C-N;(58) 2C-P;(59) 2C-T-2;(60) 2C-T-4;(61) 2NE1;(62) 25I-NBOMe;(63) 2,5-Dimethoxy-4-chloroamphetamine (DOC);(64) 4-Fluoro MDMB-BUTINACA (Methyl 2-(1-(4-fluorobutyl)-1H-indazole-3-carboxamido)-3,3-dimethylbutanoate);(65) 4-methylmethcathinone {also known as mephedrone};(66) 3,4-methylenedioxypyrovalerone {also known as MDPV};(67) 3,4-Methylenedioxymethcathinone {also known as methylone};(68) 4-methoxymethcathinone;(69) 4-Methyl-alpha-pyrrolidinopropiophenone;(70) 4-Methylethcathinone;(71) 5F-AKB48; 1-(5-flouropentyl)-N-tricyclo[3.3.1.13,7]dec-1-yl-1H-indazole-3- carboxamide;(72) 5-Fluoro ADB (Methyl N-{[1-(5-fluoropentyl)-1H-indazol-3-yl]carbonyl}-3-methyl-valinate);(73) 5-Fluoro AMB (Methyl N-{[1-(5-fluoropentyl)-1H-indazol-3-yl]carbonyl}valinate);(74) 5-fluoro-PB-22; 1-(5-fluoropentyl)-1H-indole-3-carboxylic acid 8-quinolinyl ester;(75) 5-Iodo-2-aminoindane (5-IAI);(76) 5-MeO-DALT;(77) 25B-NBOMe; 2-(r-bromo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl) methyl]ethanamine;(78) 25C-NBOMe; 2-(4Chloro-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl) methyl]ethanamine; and(79) 25H-NBOMe; 2-(2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine.Amended by Chapter 26, 2020 General Session58-37-5.5 Recognized controlled substance analogs.(1) A substance listed under Subsection (2) is an analog, as defined in Subsection 58-37-2(1)(g),if the substance, in any quantity, and in any material, compound, mixture, or preparation, is present in:(a) any product manufactured, distributed, or possessed for the purpose of human consumption;or(b) any product, the use or administration of which results in human consumption.(2) Substances referred to in Subsection (1) include, but are not limited to:(a) gamma butyrolactone (GBL);Utah CodePage 24(b) butyrolactone;(c) 1,2 butanolide;(d) 2-oxanolone;(e) tetrahydro-2-furanone;(f) dihydro-2 (3H)-furanone;(g) tetramethylene glycol;(h) 1,4 butanediol; and(i) gamma valerolactone.Amended by Chapter 250, 2008 General Session58-37-6

License to manufacture, produce, distribute, dispense, administer, or conduct research -- Issuance by division -- Denial, suspension, or revocation -- Records required --

Prescriptions.(1)(a) The division may adopt rules relating to the licensing and control of the manufacture,distribution, production, prescription, administration, dispensing, conducting of research with, and performing of laboratory analysis upon controlled substances within this state.(b) The division may assess reasonable fees to defray the cost of issuing original and renewal licenses under this chapter pursuant to Section 63J-1-504.(2)(a)(i) Every person who manufactures, produces, distributes, prescribes, dispenses, administers, conducts research with, or performs laboratory analysis upon any controlled substance in Schedules I through V within this state, or who proposes to engage in manufacturing, producing, distributing, prescribing, dispensing, administering, conducting research with, or performing laboratory analysis upon controlled substances included in Schedules I through V within this state shall obtain a license issued by the division.(ii) The division shall issue each license under this chapter in accordance with a two-year renewal cycle established by rule. The division may by rule extend or shorten a renewal period by as much as one year to stagger the renewal cycles it administers.(b) Persons licensed to manufacture, produce, distribute, prescribe, dispense, administer, conduct research with, or perform laboratory analysis upon controlled substances in Schedules I through V within this state may possess, manufacture, produce, distribute, prescribe, dispense, administer, conduct research with, or perform laboratory analysis upon those substances to the extent authorized by their license and in conformity with this chapter.(c) The following persons are not required to obtain a license and may lawfully possess controlled substances included in Schedules II through V under this section:(i) an agent or employee, except a sales representative, of any registered manufacturer, distributor, or dispenser of any controlled substance, if the agent or employee is acting in the usual course of the agent or employee's business or employment; however, nothing in this subsection shall be interpreted to permit an agent, employee, sales representative, or detail man to maintain an inventory of controlled substances separate from the location of the person's employer's registered and licensed place of business;(ii) a motor carrier or warehouseman, or an employee of a motor carrier or warehouseman, who possesses a controlled substance in the usual course of the person's business or employment; andUtah CodePage 25(iii) an ultimate user, or a person who possesses any controlled substance pursuant to a lawful order of a practitioner.(d) The division may enact rules waiving the license requirement for certain manufacturers, producers, distributors, prescribers, dispensers, administrators, research practitioners, or laboratories performing analysis if waiving the license requirement is consistent with public health and safety.(e) A separate license is required at each principal place of business or professional practice where the applicant manufactures, produces, distributes, dispenses, conducts research with, or performs laboratory analysis upon controlled substances.(f) The division may enact rules providing for the inspection of a licensee or applicant's establishment, and may inspect the establishment according to those rules.(3)(a)(i) Upon proper application, the division shall license a qualified applicant to manufacture, produce, distribute, conduct research with, or perform laboratory analysis upon controlled substances included in Schedules I through V, unless it determines that issuance of a license is inconsistent with the public interest.(ii) The division may not issue a license to any person to prescribe, dispense, or administer a Schedule I controlled substance except under Subsection (3)(a)(i).(iii) In determining public interest under this Subsection (3)(a), the division shall consider whether the applicant has:(A) maintained effective controls against diversion of controlled substances and any Schedule I or II substance compounded from any controlled substance into channels other than legitimate medical, scientific, or industrial channels;(B) complied with applicable state and local law;(C) been convicted under federal or state laws relating to the manufacture, distribution, or dispensing of substances;(D) past experience in the manufacture of controlled dangerous substances;(E) established effective controls against diversion; and(F) complied with any other factors that the division establishes that promote the public health and safety.(b) Licenses granted under Subsection (3)(a) do not entitle a licensee to manufacture, produce, distribute, conduct research with, or perform laboratory analysis upon controlled substances in Schedule I other than those specified in the license.(c)(i) Practitioners shall be licensed to administer, dispense, or conduct research with substances in Schedules II through V if they are authorized to administer, dispense, or conduct research under the laws of this state.(ii) The division need not require a separate license for practitioners engaging in research with non-narcotic controlled substances in Schedules II through V where the licensee is already licensed under this chapter in another capacity.(iii) With respect to research involving narcotic substances in Schedules II through V, or where the division by rule requires a separate license for research of non-narcotic substances in Schedules II through V, a practitioner shall apply to the division prior to conducting research.(iv) Licensing for purposes of bona fide research with controlled substances by a practitioner considered qualified may be denied only on a ground specified in Subsection (4), or upon evidence that the applicant will abuse or unlawfully transfer or fail to safeguard the practitioner's supply of substances against diversion from medical or scientific use adequately.Utah CodePage 26(v) Practitioners registered under federal law to conduct research in Schedule I substances may conduct research in Schedule I substances within this state upon providing the division with evidence of federal registration.(d) Compliance by manufacturers, producers, and distributors with the provisions of federal law respecting registration, excluding fees, entitles them to be licensed under this chapter.(e) The division shall initially license those persons who own or operate an establishment engaged in the manufacture, production, distribution, dispensation, or administration of controlled substances prior to April 3, 1980, and who are licensed by the state.(4)(a) Any license issued pursuant to Subsection (2) or (3) may be denied, suspended, placed on probation, or revoked by the division upon finding that the applicant or licensee has:(i) materially falsified any application filed or required pursuant to this chapter;(ii) been convicted of an offense under this chapter or any law of the United States, or any state, relating to any substance defined as a controlled substance;(iii) been convicted of a felony under any other law of the United States or any state within five years of the date of the issuance of the license;(iv) had a federal registration or license denied, suspended, or revoked by competent federal authority and is no longer authorized to manufacture, distribute, prescribe, or dispense controlled substances;(v) had the licensee's license suspended or revoked by competent authority of another state for a violation of laws or regulations comparable to those of this state relating to the manufacture, distribution, or dispensing of controlled substances;(vi) violated any division rule that reflects adversely on the licensee's reliability and integrity with respect to controlled substances;(vii) refused inspection of records required to be maintained under this chapter by a person authorized to inspect them; or(viii) prescribed, dispensed, administered, or injected an anabolic steroid for the purpose of manipulating human hormonal structure so as to:(A) increase muscle mass, strength, or weight without medical necessity and without a written prescription by any practitioner in the course of the practitioner's professional practice; or(B) improve performance in any form of human exercise, sport, or game.(b) The division may limit revocation or suspension of a license to a particular controlled substance with respect to which grounds for revocation or suspension exist.(c)(i) Proceedings to deny, revoke, or suspend a license shall be conducted pursuant to this section and in accordance with the procedures set forth in Title 58, Chapter 1, Division of Occupational and Professional Licensing Act, and conducted in conjunction with the appropriate representative committee designated by the director of the department.(ii) Nothing in this Subsection (4)(c) gives the Division of Occupational and Professional Licensing exclusive authority in proceedings to deny, revoke, or suspend licenses, except where the division is designated by law to perform those functions, or, when not designated by law, is designated by the executive director of the Department of Commerce to conduct the proceedings.(d)(i) The division may suspend any license simultaneously with the institution of proceedings under this section if it finds there is an imminent danger to the public health or safety.(ii) Suspension shall continue in effect until the conclusion of proceedings, including judicial review, unless withdrawn by the division or dissolved by a court of competent jurisdiction.Utah CodePage 27(e)(i) If a license is suspended or revoked under this Subsection (4), all controlled substancesowned or possessed by the licensee may be placed under seal in the discretion of thedivision.(ii) Disposition may not be made of substances under seal until the time for taking an appeal has elapsed, or until all appeals have been concluded, unless a court, upon application, orders the sale of perishable substances and the proceeds deposited with the court.(iii) If a revocation order becomes final, all controlled substances shall be forfeited.(f) The division shall promptly notify the Drug Enforcement Administration of all orders suspending or revoking a license and all forfeitures of controlled substances.(g) If an individual's Drug Enforcement Administration registration is denied, revoked, surrendered, or suspended, the division shall immediately suspend the individual's controlled substance license, which shall only be reinstated by the division upon reinstatement of the federal registration, unless the division has taken further administrative action under Subsection (4)(a)(iv), which would be grounds for the continued denial of the controlled substance license.(5)(a) A person licensed under Subsection (2) or (3) shall maintain records and inventories in conformance with the rrecord-keepingand inventory requirements of federal and state law and any additional rules issued by the division.(b)(i) A physician, dentist, naturopathic physician, veterinarian, practitioner, or other individual who is authorized to administer or professionally use a controlled substance shall keep a record of the drugs received by the individual and a record of all drugs administered, dispensed, or professionally used by the individual otherwise than by a prescription.(ii) An individual using small quantities or solutions or other preparations of those drugs for local application has complied with this Subsection (5)(b) if the individual keeps a record of the quantity, character, and potency of those solutions or preparations purchased or prepared by the individual, and of the dates when purchased or prepared.(6) Controlled substances in Schedules I through V may be distributed only by a licensee and pursuant to an order form prepared in compliance with division rules or a lawful order under the rules and regulations of the United States.(7)(a) An individual may not write or authorize a prescription for a controlled substance unless the individual is:(i) a practitioner authorized to prescribe drugs and medicine under the laws of this state or under the laws of another state having similar standards; and(ii) licensed under this chapter or under the laws of another state having similar standards.(b) An individual other than a pharmacist licensed under the laws of this state, or the pharmacist's licensed intern, as required by Sections 58-17b-303 and 58-17b-304, may not dispense a controlled substance.(c)(i) A controlled substance may not be dispensed without the written prescription of a practitioner, if the written prescription is required by the federal Controlled Substances Act.(ii) That written prescription shall be made in accordance with Subsection (7)(a) and in conformity with Subsection (7)(d).Utah CodePage 28(iii) In emergency situations, as defined by division rule, controlled substances may be dispensed upon oral prescription of a practitioner, if reduced promptly to writing on forms designated by the division and filed by the pharmacy.(iv) Prescriptions reduced to writing by a pharmacist shall be in conformity with Subsection (7)(d).(d) Except for emergency situations designated by the division, an individual may not issue, fill, compound, or dispense a prescription for a controlled substance unless the prescription is signed by the prescriber in ink or indelible pencil or is signed with an electronic signature of the prescriber as authorized by division rule, and contains the following information:(i) the name, address, and registry number of the prescriber;(ii) the name, address, and age of the person to whom or for whom the prescription is issued;(iii) the date of issuance of the prescription; and(iv) the name, quantity, and specific directions for use by the ultimate user of the controlled substance.(e) A prescription may not be written, issued, filled, or dispensed for a Schedule I controlled substance unless:(i) the individual who writes the prescription is licensed under Subsection (2); and(ii) the prescribed controlled substance is to be used in research.(f) Except when administered directly to an ultimate user by a licensed practitioner, controlled substances are subject to the restrictions of this Subsection (7)(f).(i) A prescription for a Schedule II substance may not be refilled.(ii) A Schedule II controlled substance may not be filled in a quantity to exceed a one-month's supply, as directed on the daily dosage rate of the prescriptions.(iii)(A) Except as provided in Subsection (7)(f)(iii)(B), a prescription for a Schedule II or Schedule III controlled substance that is an opiate and that is issued for an acute condition shall be completely or partially filled in a quantity not to exceed a seven-day supply as directed on the daily dosage rate of the prescription.(B) Subsection (7)(f)(iii)(A) does not apply to a prescription issued for surgery when the practitioner determined that a quantity exceeding seven days is needed, in which case the practitioner may prescribe up to a 30-day supply, with a partial fill at the discretion of the practitioner.(C) Subsection (7)(f)(iii)(A) does not apply to prescriptions issued for complex or chronic conditions that are documented as being complex or chronic in the medical record.(D) A pharmacist is not required to verify that a prescription is in compliance with Subsection(7)(f)(iii).(iv) A Schedule III or IV controlled substance may be filled only within six months of issuance, and may not be refilled more than six months after the date of its original issuance or be refilled more than five times after the date of the prescription unless renewed by the practitioner.(v) All other controlled substances in Schedule V may be refilled as the prescriber's prescription directs, but they may not be refilled one year after the date the prescription was issued unless renewed by the practitioner.(vi) Any prescription for a Schedule II substance may not be dispensed if it is not presented to a pharmacist for dispensing by a pharmacist or a pharmacy intern within 30 days after the date the prescription was issued, or 30 days after the dispensing date, if that date is specified separately from the date of issue.Utah CodePage 29(vii) A practitioner may issue more than one prescription at the same time for the same Schedule II controlled substance, but only under the following conditions:(A) no more than three prescriptions for the same Schedule II controlled substance may be issued at the same time;(B) no one prescription may exceed a 30-day supply; and(C) a second or third prescription shall include the date of issuance and the date for dispensing.(g)(i) Beginning January 1, 2022, each prescription issued for a controlled substance shall be transmitted electronically as an electronic prescription unless the prescription is:(A) for a patient residing in an assisted living facility as that term is defined in Section 26-21-2,a long-term care facility as that term is defined in Section 58-31b-102, or a correctional facility as that term is defined in Section 64-13-1;(B) issued by a veterinarian licensed under Title 58, Chapter 28, Veterinary Practice Act;(C) dispensed by a Department of Veterans Affairs pharmacy;(D) issued during a temporary technical or electronic failure at the practitioner's or pharmacy's location; or(E) issued in an emergency situation.(ii) The division, in collaboration with the appropriate boards that govern the licensure of the licensees who are authorized by the division to prescribe or to dispense controlled substances, shall make rules in accordance with Title 63G, Chapter 3, Utah AdministrativeRulemaking Act to:(A) require that controlled substances prescribed or dispensed under Subsection (7)(g)(i)(D) indicate on the prescription that the prescribing practitioner or the pharmacy is experiencing technical difficulty or an electronic failure;(B) define an emergency situation for purposes of Subsection (7)(g)(i)(E);(C) establish additional exemptions to the electronic prescription requirements established in this Subsection (7)(g);(D) establish guidelines under which a prescribing practitioner or a pharmacy may obtain an extension of up to two additional years to comply with Subsection (7)(g)(i);(E) establish a protocol to follow if the pharmacy that receives the electronic prescription is not able to fill the prescription; and(F) establish requirements that comply with federal laws and regulations for software used to issue and dispense electronic prescriptions.(h) An order for a controlled substance in Schedules II through V for use by an inpatient or an outpatient of a licensed hospital is exempt from all requirements of this Subsection (7) if theorder is:(i) issued or made by a prescribing practitioner who holds an unrestricted registration with the federal Drug Enforcement Administration and an active Utah controlled substance license in good standing issued by the division under this section, or a medical resident who is exempted from licensure under Subsection 58-1-307(1)(c);(ii) authorized by the prescribing practitioner treating the patient and the prescribing practitioner designates the quantity ordered;(iii) entered upon the record of the patient, the record is signed by the prescriber affirming the prescriber's authorization of the order within 48 hours after filling or administering the order,and the patient's record reflects the quantity actually administered; and(iv) filled and dispensed by a pharmacist practicing the pharmacist's profession within the physical structure of the hospital, or the order is taken from a supply lawfully maintainedUtah CodePage 30by the hospital, and the amount taken from the supply is administered directly to the patientauthorized to receive it.(i) A practitioner licensed under this chapter may not prescribe, administer, or dispense a controlled substance to a child without first obtaining the consent required in Section 78B-3-406 of a parent, guardian, or person standing in loco parentis of the child except in cases of an emergency. For purposes of Subsection (7)(i), "child" has the same meaning as defined in Section 78A-6-105, an "emergency" means any physical condition requiring the administration of a controlled substance for immediate relief of pain or suffering.(j) A practitioner licensed under this chapter may not prescribe or administer dosages of a controlled substance in excess of medically recognized quantities necessary to treat the ailment, malady, or condition of the ultimate user.(k) A practitioner licensed under this chapter may not prescribe, administer, or dispense any controlled substance to another person knowing that the other person is using a false name, address, or other personal information for the purpose of securing the controlled substance.(l) A person who is licensed under this chapter to manufacture, distribute, or dispense a controlled substance may not manufacture, distribute, or dispense a controlled substance to another licensee or any other authorized person not authorized by this license.(m) A person licensed under this chapter may not omit, remove, alter, or obliterate a symbol required by this chapter or by a rule issued under this chapter.(n) A person licensed under this chapter may not refuse or fail to make, keep, or furnish any record notification, order form, statement, invoice, or information required under this chapter.(o) A person licensed under this chapter may not refuse entry into any premises for inspection as authorized by this chapter.(p) A person licensed under this chapter may not furnish false or fraudulent material information in any application, report, or other document required to be kept by this chapter or willfully make any false statement in any prescription, order, report, or record required by this chapter.(8)(a)(i) Any person licensed under this chapter who is found by the division to have violated any of the provisions of Subsections (7)(k) through (o) or Subsection (10) is subject to a penalty not to exceed $5,000. The division shall determine the procedure for adjudication of any violations in accordance with Sections 58-1-106 and 58-1-108.(ii) The division shall deposit all penalties collected under Subsection (8)(a)(i) in the General Fund as a dedicated credit to be used by the division under Subsection 58-37f-502(1).(iii) The director may collect a penalty that is not paid by:(A) referring the matter to a collection agency; or(B) bringing an action in the district court of the county where the person against whom the penalty is imposed resides or in the county where the office of the director is located.(iv) A county attorney or the attorney general of the state shall provide legal assistance and advice to the director in action to collect a penalty.(v) A court shall award reasonable attorney fees and costs to the prevailing party in an action brought by the division to collect a penalty.(b) Any person who knowingly and intentionally violates Subsections (7)(h) through (j) or Subsection (10) is:(i) upon first conviction, guilty of a class B misdemeanor;(ii) upon second conviction, guilty of a class A misdemeanor; and(iii) on the third or subsequent conviction, guilty of a third-degree felony.Utah CodePage 31(c) Any person who knowingly and intentionally violates Subsections (7)(k) through (o) shall upon conviction be guilty of a third-degree felony.(9) Any information communicated to any licensed practitioner in an attempt to unlawfully procure, or to procure the administration of, a controlled substance is not considered to be a privileged communication.(10) A person holding a valid license under this chapter who is engaged in medical research may produce, possess, administer, prescribe, or dispense a controlled substance for research purposes as licensed under Subsection (2) but may not otherwise prescribe or dispense a controlled substance listed in Section 58-37-4.2.Amended by Chapter 81, 2020 General Session 58-37-6.5 Continuing education for controlled substance prescribers.(1) For the purposes of this section:(a) "Controlled substance prescriber" means an individual, other than a veterinarian, who:(i) is licensed to prescribe a controlled substance under Title 58, Chapter 37, Utah Controlled Substances Act; and(ii) possesses the authority, in accordance with the individual's scope of practice, to prescribe schedule II controlled substances and schedule III controlled substances that are applicable to opioid narcotics, hypnotic depressants, or psychostimulants.(b) "D.O." means an osteopathic physician and surgeon licensed under Title 58, Chapter 68, Utah Osteopathic Medical Practice Act.(c) "FDA" means the United States Food and Drug Administration.(d) "M.D." means a physician and surgeon licensed under Title 58, Chapter 67, Utah Medical Practice Act.(e) "SBIRT" means the Screening, Brief Intervention, and Referral to Treatment approach used by the federal Substance Abuse and Mental Health Services Administration or defined by the division, in consultation with the Division of Substance Abuse and Mental Health, by administrative rule, in accordance with Title 63G, Chapter 3, Utah Administrative RulemakingAct.(2)(a) Beginning with the licensing period that begins after January 1, 2014, as a condition precedent for license renewal, each controlled substance prescriber shall complete at least 3.5 continuing education hours per licensing period that satisfy the requirements of Subsection (3).(b)(i) Beginning with the licensing period that begins after January 1, 2024, as a condition precedent for license renewal, each controlled substance prescriber shall complete at least 3.5 continuing education hours in an SBIRT-training class that satisfies the requirements of Subsection (4).(ii) Completion of the SBIRT-training class, in compliance with Subsection (2)(b)(i), fulfills the continuing education hours requirement in Subsection (3) for the licensing period in which the class was completed.(iii) A controlled substance prescriber:(A) need only take the SBIRT-training class once during the controlled substance prescriber's licensure in the state; and(B) shall provide a complete record of the SBIRT-training class in order to be reimbursed for SBIRT services to patients, in accordance with Section 26-18-22 and Section 49-20-416.Utah CodePage 32(3) A controlled substance prescriber shall complete at least 3.5 hours of continuing education in one or more controlled substance prescribing classes, except dentists who shall complete at least two hours, that satisfy the requirements of Subsections (4) and (6).(4) A controlled substance prescribing class shall:(a) satisfy the division's requirements for the continuing education required for the renewal of the controlled substance prescriber's respective license type;(b) be delivered by an accredited or approved continuing education provider recognized by the division as offering continuing education appropriate for the controlled substance prescriber's respective license type; and(c) include a post-course knowledge assessment.(5) An M.D. or D.O. completing continuing professional education hours under Subsection (4) shall complete those hours in classes that qualify for the American Medical Association Physician's Recognition Award Category 1 Credit.(6) The 3.5 hours of the controlled substance prescribing classes under Subsection (4) shall include educational content covering the following:(a) the scope of the controlled substance abuse problem in Utah and the nation;(b) all elements of the FDA Blueprint for Prescriber Education under the FDA's ExtendedRelease and Long-Acting Opioid Analgesics Risk Evaluation and Mitigation Strategy, as published July 9, 2012, or as it may be subsequently revised;(c) the national and Utah-specific resources available to prescribers to assist in an appropriate controlled substance and opioid prescribing;(d) patient record documentation for controlled substance and opioid prescribing; and(e) office policies, procedures, and implementation.(7)(a) The division, in consultation with the Utah Medical Association Foundation, shall determine whether a particular controlled substance prescribing class satisfies the educational content requirements of Subsections (4) and (6) for an M.D. or D.O.(b) The division, in consultation with the applicable professional licensing boards, shall determine whether a particular controlled substance prescribing class satisfies the educational content requirements of Subsections (4) and (6) for a controlled substance prescriber other than an M.D. or D.O.(c) The division may by rule establish a committee that may audit compliance with the Utah Risk Evaluation and Mitigation Strategy (REMS) Educational Programming Project grant, that satisfies the educational content requirements of Subsections (4) and (6) for a controlled substance prescriber.(8) A controlled substance prescribing class required under this section:(a) maybe held:(i) in conjunction with other continuing professional education programs; and(ii) online; and(b) does not increase the total number of state-required continuing professional education hours required for prescriber licensing.(9) The division may establish rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to implement this section.(10) A controlled substance prescriber who, on or after July 1, 2017, obtains a waiver to treat opioid dependency with narcotic medications, in accordance with the Drug Addiction Treatment Act of 2000, 21 U.S.C. Sec. 823 et seq., may use the waiver to satisfy the 3.5 hours of the continuing education requirement under Subsection (3) for two consecutive licensing periods.Utah CodePage 33Amended by Chapter 318, 2018 General Session58-37-7 Labeling and packaging controlled substance -- Informational pamphlet for opiates.(1) A person licensed pursuant to this act may not distribute a controlled substance unless it is packaged and labeled in compliance with the requirements of Section 305 of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970.(2) No person except a pharmacist for the purpose of filling a prescription shall alter, deface, or remove any label affixed by the manufacturer.(3) Whenever a pharmacist sells or dispenses any controlled substance on a prescription issued by a practitioner, the pharmacist shall affix to the container in which the substance is sold or dispensed:(a) a label showing the:(i) pharmacy name and address;(ii) serial number; and(iii) date of initial filling;(b) the prescription number, the name of the patient, or if the patient is an animal, the name o the owner of the animal and the species of the animal;(c) the name of the practitioner by whom the prescription was written;(d) any directions stated on the prescription; and(e) any directions required by rules and regulations promulgated by the department.(4) Whenever a pharmacist sells or dispenses a Schedule II or Schedule III controlled substance that is an opiate. A pharmacist shall affix a warning to the container or the lid for the container in which the substance is sold or dispensed that contains the following text :(a) "Caution: Opioid. Risk of overdose and addiction"; or(b) any other language that is approved by the Department of Health.(5)(a) A pharmacist who sells or dispenses a Schedule II or Schedule III controlled substance that is an opiate shall, if available from the Department of Health, prominently display at the point of sale the informational pamphlet developed by the Department of Health under Section 26-55-109.(b) The board and the Department of Health shall encourage pharmacists to use the informational pamphlet to engage in patient counseling regarding the risks associated with taking opiates.(c) The requirement in Subsection (5)(a) does not apply to a pharmacist if the pharmacist is unable to obtain the informational pamphlet from the Department of Health for any reason.(6) A person may not alter the face or remove any label so long as any of the original contents remain.(7)(a) An individual to whom or for whose use any controlled substance has been prescribed, sold, or dispensed by a practitioner and the owner of any animal for which any controlled the substance has been prescribed, sold, or dispensed by a veterinarian may lawfully possess it only in the container in which it was delivered to the individual by the person selling or dispensing it.(b) It is a defense to a prosecution under this subsection that the person being prosecuted produces in court a valid prescription for the controlled substance or the original container with the label attached.Amended by Chapter 145, 2018 General SessionUtah CodePage 3458-37-8 Prohibited acts -- Penalties.(1) Prohibited acts A -- Penalties and reporting:(a) Except as authorized by this chapter, it is unlawful for a person to knowingly and intentionally:(i) produce, manufacture, or dispense, or to possess with intent to produce, manufacture, or dispense, a controlled or counterfeit substance;(ii) distribute a controlled or counterfeit substance, or to agree, consent, offer or arrange to distribute a controlled or counterfeit substance;(iii) possess a controlled or counterfeit substance with intent to distribute; or(iv) engage in a continuing criminal enterprise where:(A) the person participates, directs, or engages in conduct that results in a violation of Chapter 37, Utah Controlled Substances Act, Chapter 37a, Utah Drug ParaphernaliaAct, Chapter 37b, Imitation Controlled Substances Act, Chapter 37c, Utah Controlled Substance Precursor Act, or Chapter 37d, Clandestine Drug Lab Act, that is a felony; and(B) the violation is a part of a continuing series of two or more violations of Chapter 37,Utah Controlled Substances Act, Chapter 37a, Utah Drug Paraphernalia Act, Chapter37b, Imitation Controlled Substances Act, Chapter 37c, Utah Controlled SubstancePrecursor Act, or Chapter 37d, Clandestine Drug Lab Act, on separate occasions that are undertaken in concert with five or more persons with respect to whom the person occupies a position of organizer, supervisor, or any other position of management.(b) A person convicted of violating Subsection (1)(a) with respect to:(i) a substance or a counterfeit of a substance classified in Schedule I or II, a controlledsubstance analog or gamma-hydroxybutyric acid as listed in Schedule III is guilty of asecond-degree felony, punishable by imprisonment for not more than 15 years, and upon a second or subsequent conviction is guilty of a first-degree felony;(ii) a substance or a counterfeit of a substance classified in Schedule III or IV, or marijuana, or aa substance listed in Section 58-37-4.2 is guilty of a third-degree felony, and upon a second or a subsequent conviction is guilty of a second-degree felony; or(iii) a substance or a counterfeit of a substance classified in Schedule V is guilty of class A misdemeanor and upon a second or subsequent conviction is guilty of a third-degree felony.(c) A person who has been convicted of a violation of Subsection (1)(a)(ii) or (iii) maybe sentenced to imprisonment for an indeterminate term as provided by law, but if the trier of fact finds a firearm as defined in Section 76-10-501 was used, carried, or possessed on the person or in the person's immediate possession during the commission or in furtherance of the offense, the court shall additionally sentence the person convicted for a term of one year to run consecutively and not concurrently, and the court may additionally sentence the personconvicted for an indeterminate term not to exceed five years to run consecutively and not concurrently.(d)(i) A person convicted of violating Subsection (1)(a)(iv) is guilty of a first-degree felony punishable by imprisonment for an indeterminate term of not less than:(A) seven years and which may be for life; or(B) 15 years and which may be for life if the trier of fact determined that the defendant knew or reasonably should have known that any subordinate under Subsection (1)(a)(iv)(B) was under 18 years of age.(ii) Imposition or execution of the sentence may not be suspended, and the person is not eligible for probation.Utah CodePage 35(iii) Subsection (1)(d)(i)(B) does not apply to any defendant who, at the time of the offense, was under 18 years of age.(e) The Administrative Office of the Courts shall report to the Division of Occupational and Professional Licensing the name, case number, date of conviction, and if known, the date of birth of each person convicted of violating Subsection (1)(a).(2) Prohibited acts B -- Penalties and reporting:(a) It is unlawful:(i) for a person knowingly and intentionally to possess or use a controlled substance analog of a controlled substance, unless it was obtained under a valid prescription or order, directly from a practitioner while acting in the course of the person's professional practice, or as otherwise authorized by this chapter;(ii) for an owner, tenant, licensee, or person in control of a building, room, tenement, vehicle, boat, aircraft, or other places knowingly and intentionally to permit them to be occupied by persons unlawfully possessing, using, or distributing controlled substances in any of those locations; or(iii) for a person knowingly and intentionally to possess an altered or forged prescription or written order for a controlled substance.(b) A person convicted of violating Subsection (2)(a)(i) with respect to:(i) marijuana, if the amount is 100 pounds or more, is guilty of a second-degree felony; or(ii) a substance classified in Schedule I or II, or a controlled substance analog, is guilty of a class A misdemeanor on a first or second conviction, and on a third or subsequent conviction if each prior offense was committed within seven years before the date of the current conviction or the date of the offense upon which the current conviction is based is guilty of a third-degree felony.(c) Upon a person's conviction of a violation of this Subsection (2) subsequent to a conviction under Subsection (1)(a), that person shall be sentenced to one degree greater penalty than provided in this Subsection (2).(d) A person who violates Subsection (2)(a)(i) with respect to all other controlled substances not included in Subsection (2)(b)(i) or (ii), including a substance listed in Section 58-37-4.2, or marijuana, is guilty of a class B misdemeanor.(i) Upon a third conviction, the person is guilty of a class A misdemeanor if each prior offense was committed within seven years before the date of the current conviction or the date of the offense upon which the current conviction is based.(ii) Upon a fourth or subsequent conviction, the person is guilty of a third-degree felony if each prior offense was committed within seven years of the date of the current conviction or the date of the offense upon which the current conviction is based.(e) A person convicted of violating Subsection (2)(a)(i) while inside the exterior boundaries of the property occupied by a correctional facility as defined in Section 64-13-1 or a public jail or other places of confinement shall be sentenced to a penalty one degree greater than provided in Subsection (2)(b), and if the conviction is with respect to controlled substances as listed in:(i) Subsection (2)(b), the person may be sentenced to imprisonment for an indeterminate term as provided by law, and:(A) the court shall additionally sentence the person convicted to a term of one year to run consecutively and not concurrently; and(B) the court may additionally sentence the person convicted for an indeterminate term not to exceed five years to run consecutively and not concurrently; andUtah CodePage 36(ii) Subsection (2)(d), the person may be sentenced to imprisonment for an indeterminate term as provided by law, and the court shall additionally sentence the person convicted to a term of six months to run consecutively and not concurrently.(f) A person convicted of violating Subsection (2)(a)(ii) or (iii) is:(i) on a first conviction, guilty of a class B misdemeanor;(ii) on a second conviction, guilty of a class A misdemeanor; and(iii) on a third or subsequent conviction, guilty of a third-degree felony.(g) A person is subject to the penalties under Subsection (2)(h) who, in an offense not amountingto a violation of Section 76-5-207:(i) violates Subsection (2)(a)(i) by knowingly and intentionally having in the person'sbody any measurable amount of a controlled substance, except for 11-nor-9-carboxytetrahydrocannabinol; and(ii)(A) if the controlled substance is not marijuana, operates a motor vehicle as defined in Section 76-5-207 in a negligent manner, causing serious bodily injury as defined in Section 76-1-601 or the death of another; or(B) if the controlled substance is marijuana, operates a motor vehicle as defined in Section 76-5-207 in a criminally negligent manner, causing serious bodily injury as defined inSection 76-1-601 or the death of another.(h) A person who violates Subsection (2)(g) by having in the person's body:(i) a controlled substance classified under Schedule I, other than those described in Subsection(2)(h)(ii), or a controlled substance classified under Schedule II is guilty of a second-degree felony;(ii) except as provided in Subsection (2)(g)(ii)(B), marijuana, tetrahydrocannabinols, orequivalents described in Subsection 58-37-4(2)(a)(iii)(S) or (AA), or a substance listed in Section 58-37-4.2 is guilty of a third-degree felony; or(iii) a controlled substance classified under Schedules III, IV, or V is guilty of a class A misdemeanor.(i) A person is guilty of a separate offense for each victim suffering serious bodily injury or death as a result of the person's negligent driving in violation of Subsection(2)(g) whether or not the injuries arise from the same episode of driving.(j) The Administrative Office of the Courts shall report to the Division of Occupational and Professional Licensing the name, case number, date of conviction, and if known, the date ofbirth of each person convicted of violating Subsection (2)(a).(3) Prohibited acts C -- Penalties:(a) It is unlawful for a person knowingly and intentionally:(i) to use in the course of the manufacture or distribution of a controlled substance a license number which is fictitious, revoked, suspended, or issued to another person or, for the purpose of obtaining a controlled substance, to assume the title of, or represent oneself to be, a manufacturer, wholesaler, apothecary, physician, dentist, veterinarian, or another authorized person;(ii) to acquire or obtain possession of, to procure or attempt to procure the administration of, to obtain a prescription for, to prescribe or dispense to a person known to be attempting to acquire or obtain possession of, or to procure the administration of a controlled substance by misrepresentation or failure by the person to disclose receiving a controlled substance from another source, fraud, forgery, deception, subterfuge, alteration of a prescription or written order for a controlled substance, or the use of a false name or address;Utah CodePage 37(iii) to make a false or forged prescription or written order for a controlled substance, or to utter the same, or to alter a prescription or written order issued or written under the terms of this chapter; or(iv) to make, distribute, or possess a punch, die, plate, stone, or other thing designed to print, imprint, or reproduce the trademark, trade name, or other identifying mark, imprint, or device of another or any likeness of any of the foregoing upon any drug or container or labeling so as to render a drug a counterfeit controlled substance.(b)(i) A first or second conviction under Subsection (3)(a)(i), (ii), or (iii) is a class A misdemeanor.(ii) A third or subsequent conviction under Subsection (3)(a)(i), (ii), or (iii) is a third-degree felony.(c) A violation of Subsection (3)(a)(iv) is a third-degree felony.(4) Prohibited acts D -- Penalties:(a) Notwithstanding other provisions of this section, a person not authorized under this chapter who commits any act that is unlawful under Subsection (1)(a) or Section 58-37b-4 is upon conviction subject to the penalties and classifications under this Subsection (4) if the trier of fact finds the act is committed:(i) in a public or private elementary or secondary school or on the grounds of any of those schools during the hours of 6 a.m. through 10 p.m.;(ii) in a public or private vocational school or postsecondary institution or on the grounds of any of those schools or institutions during the hours of 6 a.m. through 10 p.m.;(iii) in or on the grounds of a preschool or child-care facility during the preschool's or facility's hours of operation;(iv) in a public park, amusement park, arcade, or recreation center when the public or amusement park, arcade, or recreation center is open to the public;(v) in or on the grounds of a house of worship as defined in Section 76-10-501;(vi) in or on the grounds of a library when the library is open to the public;(vii) within an area that is within 100 feet of any structure, facility, or grounds included in Subsections (4)(a)(i), (ii), (iii), (iv), (v), and (vi);(viii) in the presence of a person younger than 18 years of age, regardless of where the actoccurs; or(ix) for the purpose of facilitating, arranging, or causing the transport, delivery, or distribution of a substance in violation of this section to an inmate or on the grounds of a correctional facility as defined in Section 76-8-311.3.(b)(i) A person convicted under this Subsection (4) is guilty of a first-degree felony and shall be imprisoned for a term of not less than five years if the penalty that would otherwise have been established but for this Subsection (4) would have been a first-degree felony.(ii) Imposition or execution of the sentence may not be suspended, and the person is not eligible for probation.(c) If the classification that would otherwise have been established would have been less than a first-degree felony but for this Subsection (4), a person convicted under this Subsection(4) is guilty of one degree more than the maximum penalty prescribed for that offense. This Subsection (4)(c) does not apply to a violation of Subsection (2)(g).(d)(i) If the violation is of Subsection (4)(a)(ix):Utah CodePage 38(A) the person may be sentenced to imprisonment for an indeterminate term as provided by law, and the court shall additionally sentence the person convicted for a term of one year to run consecutively and not concurrently; and(B) the court may additionally sentence the person convicted for an indeterminate term not to exceed five years to run consecutively and not concurrently; and(ii) the penalties under this Subsection (4)(d) also apply to a person who, acting with the mentalstate required for the commission of an offense directly or indirectly solicits, requests, commands coerces, encourages, or intentionally aids another person to commit a violation of Subsection (4)(a)(ix).(e) It is not a defense to a prosecution under this Subsection (4) that:(i) the actor mistakenly believed the individual to be 18 years of age or older at the time of the offense or was unaware of the individual's true age; or(ii) the actor mistakenly believed that the location where the act occurred was not as described in Subsection (4)(a) or was unaware that the location where the act occurred was as described in Subsection (4)(a).(5) A violation of this chapter for which no penalty is specified is a class B misdemeanor.(6)(a) For purposes of penalty enhancement under Subsections (1) and (2), a plea of guilty or no contest to a violation or attempted violation of this section or a plea which is held in abeyance under Title 77, Chapter 2a, Pleas in Abeyance, is the equivalent of a conviction, even if the charge has been subsequently reduced or dismissed in accordance with the plea in abeyance agreement.(b) A prior conviction used for a penalty enhancement under Subsection (2) shall be a conviction that is:(i) from a separate criminal episode than the current charge; and(ii) from a conviction that is separate from any other conviction used to enhance the current charge.(7) A person may be charged and sentenced for a violation of this section, notwithstanding a charge and sentence for a violation of any other section of this chapter.(8)(a) A penalty imposed for violation of this section is in addition to, and not in lieu of, a civil or administrative penalty or sanction authorized by law.(b) When a violation of this chapter violates federal law or the law of another state, conviction or acquittal under federal law or the law of another state for the same act is a bar to prosecution in this state.(9) In any prosecution for a violation of this chapter, evidence or proof that shows a person or persons produced, manufactured, possessed, distributed, or dispensed a controlled substance or substances is prima facie evidence that the person or persons did so with knowledge of the character of the substance or substances.(10) This section does not prohibit a veterinarian, in good faith and in the course of the veterinarian's professional practice only and not for humans, from prescribing, dispensing, or administering controlled substances or from causing the substances to be administered by an assistant or orderly under the veterinarian's direction and supervision.(11) Civil or criminal liability may not be imposed under this section on:(a) a person registered under this chapter who manufactures, distributes, or possesses an imitation controlled substance for use as a placebo or investigational new drug by a registered practitioner in the ordinary course of professional practice or research; orUtah CodePage 39(b) a law enforcement officer acting in the course and legitimate scope of the officer's employment.(12)(a) Civil or criminal liability may not be imposed under this section on any Indian, as defined in Section 58-37-2, who uses, possesses, or transports peyote for bona fide traditional ceremonial purposes in connection with the practice of traditional Indian religion as defined in Section 58-37-2.(b) In a prosecution alleging violation of this section regarding peyote as defined in Section 58-37-4, it is an affirmative defense that the peyote was used, possessed, or transported by an Indian for bona fide traditional ceremonial purposes in connection with the practice of traditional Indian religion.(c)(i) The defendant shall provide written notice of intent to claim an affirmative defense under thisSubsection (12) as soon as practicable, but no later than 10 days before trial.(ii) The notice shall include the specific claims of the affirmative defense.(iii) The court may waive the notice requirement in the interest of justice for a good cause shown, if the prosecutor is not unfairly prejudiced by the lack of timely notice.(d) The defendant shall establish the affirmative defense under this Subsection (12) by a preponderance of the evidence. If the defense is established, it is a complete defense to the charges.(13)(a) It is an affirmative defense that the person produced, possessed, or administered a controlled substance listed in Section 58-37-4.2 if the person was:(i) engaged in medical research; and(ii) a holder of a valid license to possess controlled substances under Section 58-37-6.(b) It is not a defense under Subsection (13)(a) that the person prescribed or dispensed a controlled substance listed in Section 58-37-4.2.(14) It is an affirmative defense that the person possessed, in the person's body, a controlled substance listed in Section 58-37-4.2 if:(a) the person was the subject of medical research conducted by a holder of a valid license to possess controlled substances under Section 58-37-6; and(b) the substance was administered to the person by the medical researcher.(15) The application of any increase in a penalty under this section to a violation of Subsection (2)(a)(i) may not result in any greater penalty than a second-degree felony. This Subsection (15)takes precedence over any conflicting provision of this section.(16)(a) It is an affirmative defense to an allegation of the commission of an offense listed in Subsection (16)(b) that the person or bystander:(i) reasonably believes that the person or another person is experiencing an overdose event due to the ingestion, injection, inhalation, or other introduction into the human body of a controlled substance or other substance;(ii) reports, or assists a person who reports, in good faith the overdose event to a medical provider, an emergency medical service provider as defined in Section 26-8a-102, a law enforcement officer, a 911 emergency call system, or an emergency dispatch system, or the person is the subject of a report made under this Subsection (16);(iii) provides in the report under Subsection (16)(a)(ii) a functional description of the actual location of the overdose event that facilitates responding to the person experiencing the overdose event;Utah CodePage 40(iv) remains at the location of the person experiencing the overdose event until a responding law enforcement officer or emergency medical service provider arrives or remains at the medical care facility where the person experiencing an overdose event is located until a responding law enforcement officer arrives;(v) cooperates with the responding medical provider, emergency medical service provider, and law enforcement officer, including providing information regarding the person experiencing the overdose event and any substances the person may have injected, inhaled, or otherwise introduced into the person's body; and(vi) is alleged to have committed the offense in the same course of events from which the reported overdose arose.(b) The offenses referred to in Subsection (16)(a) are:(i) the possession or use of less than 16 ounces of marijuana;(ii) the possession or use of a scheduled or listed controlled substance other than marijuana;and(iii) any violation of Chapter 37a, Utah Drug Paraphernalia Act, or Chapter 37b, Imitation Controlled Substances Act.(c) As used in this Subsection (16) and in Section 76-3-203.11, "good faith" does not include seeking medical assistance under this section during the course of a law enforcement agency's execution of a search warrant, execution of an arrest warrant, or another lawful search.(17) If any provision of this chapter or the application of any provision to any person or circumstances is held invalid, the remainder of this chapter shall be given effect without the invalid provision or application.(18) A legislative body of a political subdivision may not enact an ordinance that is less restrictive than any provision of this chapter.(19) If a minor who is under 18 years of age is found by a court to have violated this section, the court may order the minor to complete:(a) a screening as defined in Section 41-6a-501;(b) an assessment as defined in Section 41-6a-501 if the screening indicates an assessment to be appropriate; and(c) an educational series as defined in Section 41-6a-501 or substance use disorder treatment asindicated by an assessment.Amended by Chapter 12, 2020 General SessionAmended by Chapter 117, 2020 General SessionAmended by Chapter 131, 2020 General SessionAmended by Chapter 191, 2020 General SessionAmended by Chapter 354, 2020 General Session58-37-8.5 Applicability of Title 76 prosecutions under this chapter. Unless specifically excluded in or inconsistent with the provisions of this chapter, the provisionsof Title 76, Chapter 1, General Provisions, Chapter 2, Principles of Criminal Responsibility, Chapter3, Punishments, and Chapter 4, Inchoate Offenses, are fully applicable to prosecutions under thischapter.Enacted by Chapter 64, 1997 General Session58-37-9 Investigators -- Status of peace officers.Utah CodePage 41 Investigators for the Department of Commerce shall for the purpose of enforcing the provisions of this chapter have the status of peace officers.Amended by Chapter 20, 1995 General Session58-37-10 Search warrants -- Administrative inspection warrants -- Inspections and seizures of property without a warrant.(1) Search warrants relating to offenses involving controlled substances may be authorized pursuant to the Utah Rules of Criminal Procedure.(2) Issuance and execution of administrative inspection warrants shall be as follows:(a) Any judge or magistrate of this state within his jurisdiction upon proper oath or affirmation showing probable cause may issue warrants for the purpose of conducting administrative inspections authorized by this act or regulations thereunder and seizures of property appropriate to such inspections. Probable cause for purposes of this act exists upon showing a valid public interest in the effective enforcement of the act or rules promulgated thereunder sufficient to justify administrative inspection of the area, premises, building, or conveyance inthe circumstances specified in the application for the warrant.(b) A warrant shall issue only upon an affidavit of an officer or employee duly designated and having knowledge of the facts alleged sworn to before a judge or magistrate, which establish the grounds for issuing the warrant. If the judge or magistrate is satisfied that grounds for the application exist or that there is probable cause to believe they exist, he shall issue a warrant identifying the area, premises, building, or conveyance to be inspected, the purpose of the inspection, and if appropriate, the type of property to be inspected, if any. The warrant shall:(i) state the grounds for its issuance and the name of each person whose affidavit has been taken to support it;(ii) be directed to a person authorized by Section 58-37-9 of this act to execute it;(iii) command the person to whom it is directed to inspect the area, premises, building, or conveyance identified for the purpose specified and if appropriate, direct the seizure of the property specified;(iv) identify the item or types of property to be seized, if any; and(v) direct that it be served during normal business hours and designate the judge or magistrate to whom it shall be returned.(c) A warrant issued pursuant to this section must be executed and returned within 10 days after its date unless, upon a showing of a need for additional time, the court instructs otherwise in the warrant. If the property is seized pursuant to a warrant, the person executing the warrant shall give to the person from whom or from whose premises the property was taken a copy of the warrant and a receipt for the property taken or leave the copy and receipt at the place where the property was taken. Return of the warrant shall be made promptly and beaccompanied by a written inventory of any property taken. The inventory shall be made in the presence of the person executing the warrant and of the person from whose possession or premises the property was taken if they are present, or in the presence of at least one credible person other than the person executing the warrant. A copy of the inventory shall be delivered to the person from whom or from whose premises the property was taken and to the applicant for the warrant.(d) The judge or magistrate who issued the warrant under this section shall attach a copy of the return and all other papers to the warrant and file them with the court.(3) The department is authorized to make administrative inspections of controlled premises in accordance with the following provisions:Utah CodePage 42(a) For purposes of this section only, "controlled premises" means:(i) Places where persons licensed or exempted from licensing requirements under this act are required to keep records.(ii) Places including factories, warehouses, establishments, and conveyances where persons licensed or exempted from licensing requirements are permitted to possess, manufacture, compound, process, sell, deliver, or otherwise dispose of any controlled substance.(b) When authorized by an administrative inspection warrant, a law enforcement officer or the employee designated in Section 58-37-9, upon presenting the warrant and appropriate credentials to the owner, operator, or agent in charge, has the right to enter controlled premises for the purpose of conducting an administrative inspection.(c) When authorized by an administrative inspection warrant, a law enforcement officer or the employee designated in Section 58-37-9 has the right:(i) To inspect and copy records required by this chapter.(ii) To inspect within reasonable limits and a reasonable manner, the controlled premises, and all pertinent equipment finished and unfinished material, containers, and labeling found, and except as provided in Subsection (3)(e), all other things including records, files, papers, processes, controls, and facilities subject to regulation and control by this chapter or by rules promulgated by the department.(iii) To inventory and take stock of any controlled substance and obtain samples of any substance.(d) This section shall not be construed to prevent the inspection of books and records without a warrant pursuant to an administrative subpoena issued by a court or the department, nor shall it be construed to prevent entries and administrative inspections, including seizures of property without a warrant:(i) with the consent of the owner, operator, or agent in charge of the controlled premises;(ii) in situations presenting imminent danger to health or safety;(iii) in situations involving inspection of conveyances where there is reasonable cause to believe that the mobility of the conveyance makes it impracticable to obtain a warrant;(iv) in any other exceptional or emergency circumstance where time or opportunity to apply for a warrant is lacking; and(v) in all other situations where a warrant is not constitutionally required.(e) No inspection authorized by this section shall extend to financial data, sales data other than shipment data or pricing data unless the owner, operator, or agent in charge of the controlled premises consents in writing.Amended by Chapter 278, 2013 General Session58-37-11 District court jurisdiction to enjoin violations -- Jury trial.(1) The district courts of this state shall have jurisdiction in proceedings in accordance with the rules of those courts to enjoin violations of this act.(2) If an alleged violation of an injunction or restraining order issued under this section occurs, the accused may demand a jury trial in accordance with the rules of the district courts.Enacted by Chapter 145, 1971 General Session58-37-12 Enforcement -- Coordination and cooperation of federal and state agencies --Powers.Utah CodePage 43 The department and all law enforcement agencies charged with enforcing this act shallcooperate with federal and other state agencies in discharging their responsibilities concerningtraffic in controlled substances and in suppressing the abuse of controlled substances. To thisend, they are authorized to:(1) Arrange for the exchange of information between government officials concerning the use and abuse of dangerous substances.(2) Coordinate and cooperate in training programs in controlled substance law enforcement at the local and state levels.(3) Cooperate with the United States Department of Justice and the Utah Department of Public Safety by establishing a centralized unit that will receive, catalog, file, and collect statistics, including records of drug-dependent persons and other controlled substance law offenders within the state, and make the information available for federal, state, and local law enforcement purposes.(4) Conduct programs of eradication aimed at destroying the wild or illicit growth of plant species from which controlled substances may be extracted.Amended by Chapter 64, 1997 General Session58-37-14 Resort for illegal use or possession of controlled substances deemed commonnuisance -- District court power to suppress and enjoin.(1) Any store, shop, warehouse, dwelling house, building, vehicle, boat, aircraft, or other places to which users or possessors of any controlled substances, listed in schedules I through V, resort or where use or possession of any substances violates this act, or which is used for illegal keeping, storing or selling any substances listed as controlled substances in schedules I through V shall be deemed a common nuisance. No person shall open, keep, or maintain anysuch place.(2) The district court has the power to make any order necessary or reasonable to suppress any nuisance and to enjoin any person or persons from doing any act calculated to cause or permit the continuation of a nuisance.Enacted by Chapter 145, 1971 General Session58-37-15 Burden of proof in proceedings on violations -- Enforcement officers exempt from liability.(1) It is not necessary for the state to negate any exemption or exception set forth in this act in anythe complaint, information, indictment or other pleading or trial, hearing, or other proceedings under this act, and the burden of proof of any exemption or exception is upon the person claiming its benefit.(2) In absence of proof that a person is the duly authorized holder of an appropriate license, registration, order form, or prescription issued under this act, he shall be presumed not to be the holder of a license, registration, order form, or prescription, and the burden of proof is upon him to rebut the presumption.(3) No liability shall be imposed upon any duly authorized state or federal officer engaged in the enforcement of this act, which is engaged in the enforcement of any law, municipal ordinance, or regulation relating to controlled substances.Enacted by Chapter 145, 1971 General SessionUtah CodePage 4458-37-17 Judicial review.(1) Any person aggrieved by a department's final order may obtain judicial review.(2) Venue for judicial review of informal adjudicative proceedings is in the district court of Salt Lake County.Amended by Chapter 161, 1987 General Session58-37-18 Prior prosecutions and proceedings continued -- Uniform construction.(1)(a) Prosecution for violation of any law or offense occurring prior to the effective date of this act shall not be affected by this act; provided, that sentences imposed after the effective date of this act may not exceed the maximum terms specified and the judge has the discretion to impose any minimum sentence.(b) Civil seizures, forfeitures, and injunctive proceedings commenced prior to the effective date of this act shall not be affected by this act.(c) All administrative proceedings pending before any agency or court on the effective date ofthis act shall be continued and brought to final determination in accordance with laws andregulations in effect prior to the effective date of this act. Drugs placed under control prior to enactment of this act which are not listed within schedules I through V shall be automatically controlled and listed in the appropriate schedule without further proceedings.(2) This act does not affect rights and duties that matured, penalties that are incurred, and proceedings that are begun before its effective date.(3) This act shall be construed to effectuate its general purpose to make uniform the law of those states which enact it where laws are similar to this act.Enacted by Chapter 145, 1971 General Session 58-37-19 Opiate prescription consultation.(1) As used in this section:(a) "Hospice" means the same as that term is defined in Section 26-21-2.(b) "Initial opiate prescription" means a prescription for an opiate to a patient who:(i) has never previously been issued a prescription for an opiate; or(ii) was previously issued a prescription for an opiate, but the date on which the current prescription is being issued is more than one year after the date on which an opiate was previously prescribed or administered to the patient.(c) "Prescriber" means an individual authorized to prescribe a controlled substance under this chapter.(2) Except as provided in Subsection (3), a prescriber may not issue an initial opiate prescription without discussing with the patient or the patient's parent or guardian if the patient is under 18 years of age and is not an emancipated minor:(a) the risks of addiction and overdose associated with opiate drugs;(b) the dangers of taking opiates with alcohol, benzodiazepines, and other central nervous system depressants;(c) the reasons why the prescription is necessary;(d) alternative treatments that may be available; and(e) other risks associated with the use of the drugs being prescribed.(3) This section does not apply to a prescription for:(a) a patient who is currently in active treatment for cancer;Utah CodePage 45(b) a patient who is receiving hospice care from a licensed hospice; or(c) a medication that is being prescribed to a patient for the treatment of the patient's substance abuse or opiate dependence.Enacted by Chapter 130, 2019 General Session.

Enhancing Healthcare Team Outcomes

Chronic pain is a significant condition that affects many millions of people. It is an important public health concern with considerable morbidity and mortality and associated opiate drug diversion and misuse. Thus chronic pain is best managed with an interprofessional approach. Managing chronic pain requires an interprofessional team of healthcare professionals, including a primary care physician, nursing team, pharmacist, and pain medicine specialists. Without proper management, the patient's quality of life can have a deleterious impact. The evaluation and treatment of such patients are paramount, but health professionals must work as a team to avoid drug diversion and misuse.

Chronic pain correlates with several severe complications, including severe depression and suicide attempts and ideation. The lifetime prevalence for chronic pain patients attempting suicide attempt was shown to be between 5% and 14%; suicidal ideation was approximately 20%.[12] These complications often require psychiatric intervention and advanced pharmacological or interventional therapies. Severe symptoms must receive treatment immediately, leading to an increase in healthcare costs. It is of the utmost importance to identify the risk factors and perform a thorough assessment of the patient with chronic pain as well as monitor for progression of symptoms. A team approach is an ideal way to limit the effects of chronic pain and its complications.

Evaluation of a patient with acute pain by the primary care provider to prevent the progression of chronic pain is the recommended first step.
Conservative chronic pain management should begin when symptoms are mild or moderate, including physical therapy, cognitive-behavioral therapy, and pharmacological management.
A pharmacist or other expert knowledgeable in the medications frequently utilized to treat chronic pain should evaluate the medication regimen to include medication reconciliation to preclude any drug-drug interactions and alert the healthcare team regarding any concerns.
The patient should follow up with a primary care provider and pain specialists as necessary regularly to assess and effectively treat the patient's pain.
Clinicians must address comorbid psychiatric disorders. This action may require the involvement of a psychiatrist, depending on the severity of the patient's symptoms.
If symptoms worsen on follow up or if there is a concerning escalation of pharmacological therapy such as with opioids, a referral to a pain medicine specialist merits consideration.
If the patient has exhausted various pharmacological and nonpharmacological treatment options, interventional procedures can be a consideration.
If the patient expresses concern for suicidal ideation or plan at any time, an emergent psychiatric team should evaluate the patient immediately.
Patients who have developed opioid dependence secondary to pharmacological therapy should be offered treatment, possibly referral for addiction treatment or detoxification if indicated. The patient should be put on a medication weaning schedule or possibly medications to treat opioid dependence.
Based on CDC recommendations, patients on high-dose opioid medications or patients with risk factors for opioid overdose (e.g., obesity, sleep apnea, concurrent benzodiazepine use, etc.) should receive naloxone at home for the emergent treatment of an unintentional overdose.

The interprofessional team should openly discuss and communicate clearly about the management of each patient so that the patient receives optimal care delivery. This area is where nurses and pharmacists can play a crucial role by verifying patient compliance with the treatment plan and monitoring progress (or lack of) with the present treatment plan. Nurses and pharmacists can help monitor for adverse medication side effects, concerns regarding diversion or misuse of opioids, and communicate any areas of concern to the treating clinicians. Effective, open interprofessional communication is crucial in the optimal management of chronic pain and minimizing the negative effects of chronic pain in the patient. [Level 2]

References

[1]

Imtiaz S, Shield KD, Fischer B, Elton-Marshall T, Sornpaisarn B, Probst C, Rehm J. Recent changes in trends of opioid overdose deaths in North America. Substance abuse treatment, prevention, and policy. 2020 Aug 31:15(1):66. doi: 10.1186/s13011-020-00308-z. Epub 2020 Aug 31 [PubMed PMID: 32867799]

[2]

Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. The journal of pain. 2015 Aug:16(8):769-80. doi: 10.1016/j.jpain.2015.05.002. Epub 2015 May 29 [PubMed PMID: 26028573]

[3]

Alford DP, Krebs EE, Chen IA, Nicolaidis C, Bair MJ, Liebschutz J. Update in pain medicine. Journal of general internal medicine. 2010 Nov:25(11):1222-6. doi: 10.1007/s11606-010-1452-4. Epub 2010 Jul 15 [PubMed PMID: 20632120]

[4]

Pizzo PA, Clark NM. Alleviating suffering 101--pain relief in the United States. The New England journal of medicine. 2012 Jan 19:366(3):197-9. doi: 10.1056/NEJMp1109084. Epub [PubMed PMID: 22256802]

[5]

Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Korwisi B, Kosek E, Lavand'homme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, Vlaeyen JWS, Wang SJ. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019 Jan:160(1):19-27. doi: 10.1097/j.pain.0000000000001384. Epub [PubMed PMID: 30586067]

[6]

Dydyk AM, Conermann T. Chronic Pain. StatPearls. 2023 Jan:(): [PubMed PMID: 31971706]

[7]

Hardt J, Jacobsen C, Goldberg J, Nickel R, Buchwald D. Prevalence of chronic pain in a representative sample in the United States. Pain medicine (Malden, Mass.). 2008 Oct:9(7):803-12. doi: 10.1111/j.1526-4637.2008.00425.x. Epub 2008 Mar 11 [PubMed PMID: 18346058]

[8]

Annagür BB, Uguz F, Apiliogullari S, Kara I, Gunduz S. Psychiatric disorders and association with quality of sleep and quality of life in patients with chronic pain: a SCID-based study. Pain medicine (Malden, Mass.). 2014 May:15(5):772-81. doi: 10.1111/pme.12390. Epub 2014 Feb 25 [PubMed PMID: 24612225]

Level 2 (mid-level) evidence

[9]

Yasaei R, Peterson E, Saadabadi A. Chronic Pain Syndrome. StatPearls. 2023 Jan:(): [PubMed PMID: 29262143]

[10]

Haffajee RL, Mello MM. Drug Companies' Liability for the Opioid Epidemic. The New England journal of medicine. 2017 Dec 14:377(24):2301-2305. doi: 10.1056/NEJMp1710756. Epub [PubMed PMID: 29236640]

[11]

Feldt KS, Ryden MB, Miles S. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture. Journal of the American Geriatrics Society. 1998 Sep:46(9):1079-85 [PubMed PMID: 9736099]

[12]

Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychological medicine. 2006 May:36(5):575-86 [PubMed PMID: 16420727]

[13]

Petrosky E, Harpaz R, Fowler KA, Bohm MK, Helmick CG, Yuan K, Betz CJ. Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System. Annals of internal medicine. 2018 Oct 2:169(7):448-455. doi: 10.7326/M18-0830. Epub 2018 Sep 11 [PubMed PMID: 30208405]

[14]

LaForge KS, Yuferov V, Kreek MJ. Opioid receptor and peptide gene polymorphisms: potential implications for addictions. European journal of pharmacology. 2000 Dec 27:410(2-3):249-268 [PubMed PMID: 11134674]

Level 3 (low-level) evidence

[15]

Kreek MJ, Bart G, Lilly C, LaForge KS, Nielsen DA. Pharmacogenetics and human molecular genetics of opiate and cocaine addictions and their treatments. Pharmacological reviews. 2005 Mar:57(1):1-26 [PubMed PMID: 15734726]

[16]

Caffrey CR, Lank PM. When good times go bad: managing 'legal high' complications in the emergency department. Open access emergency medicine : OAEM. 2018:10():9-23. doi: 10.2147/OAEM.S120120. Epub 2017 Dec 20 [PubMed PMID: 29302196]

[17]

Brady JE, Giglio R, Keyes KM, DiMaggio C, Li G. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Injury epidemiology. 2017 Dec:4(1):24. doi: 10.1186/s40621-017-0118-7. Epub 2017 Aug 7 [PubMed PMID: 28762157]

Level 1 (high-level) evidence

[18]

Scher C, Meador L, Van Cleave JH, Reid MC. Moving Beyond Pain as the Fifth Vital Sign and Patient Satisfaction Scores to Improve Pain Care in the 21st Century. Pain management nursing : official journal of the American Society of Pain Management Nurses. 2018 Apr:19(2):125-129. doi: 10.1016/j.pmn.2017.10.010. Epub 2017 Dec 15 [PubMed PMID: 29249620]

[19]

Grewal N, Huecker MR. Opioid Prescribing. StatPearls. 2023 Jan:(): [PubMed PMID: 31869184]

[20]

Schiller EY, Goyal A, Mechanic OJ. Opioid Overdose. StatPearls. 2023 Jan:(): [PubMed PMID: 29262202]

[21]

Lyle Cooper R, Thompson J, Edgerton R, Watson J, MacMaster SA, Kalliny M, Huffman MM, Juarez P, Mathews-Juarez P, Tabatabai M, Singh KP. Modeling dynamics of fatal opioid overdose by state and across time. Preventive medicine reports. 2020 Dec:20():101184. doi: 10.1016/j.pmedr.2020.101184. Epub 2020 Aug 26 [PubMed PMID: 32995141]

[22]

. Bernhard Naunyn (1839-1925), clinician, teacher, scientist. JAMA. 1969 May 19:208(7):1182-3 [PubMed PMID: 4894191]

[23]

Cofano S, Patel P, Yellon R. Hydrocodone. StatPearls. 2024 Jan:(): [PubMed PMID: 30725973]

[24]

Murphy PB, Bechmann S, Barrett MJ. Morphine. StatPearls. 2024 Jan:(): [PubMed PMID: 30252371]

[25]

Sadiq NM, Dice TJ, Mead T. Oxycodone. StatPearls. 2024 Jan:(): [PubMed PMID: 29489158]

[26]

Oelhaf RC, Del Pozo E, Azadfard M. Opioid Toxicity. StatPearls. 2023 Jan:(): [PubMed PMID: 28613731]

[27]

AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. Journal of the American Geriatrics Society. 2002 Jun:50(6 Suppl):S205-24 [PubMed PMID: 12067390]

[28]

Closs SJ, Briggs M. Patients' verbal descriptions of pain and discomfort following orthopaedic surgery. International journal of nursing studies. 2002 Jul:39(5):563-72 [PubMed PMID: 11996877]

[29]

Raina R, Krishnappa V, Gupta M. Management of pain in end-stage renal disease patients: Short review. Hemodialysis international. International Symposium on Home Hemodialysis. 2018 Jul:22(3):290-296. doi: 10.1111/hdi.12622. Epub 2017 Dec 11 [PubMed PMID: 29227577]

[30]

Krebs EE, Lorenz KA, Bair MJ, Damush TM, Wu J, Sutherland JM, Asch SM, Kroenke K. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. Journal of general internal medicine. 2009 Jun:24(6):733-8. doi: 10.1007/s11606-009-0981-1. Epub 2009 May 6 [PubMed PMID: 19418100]

Level 2 (mid-level) evidence

[31]

Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009 Nov-Dec:50(6):613-21. doi: 10.1176/appi.psy.50.6.613. Epub [PubMed PMID: 19996233]

[32]

Prins A, Bovin MJ, Smolenski DJ, Marx BP, Kimerling R, Jenkins-Guarnieri MA, Kaloupek DG, Schnurr PP, Kaiser AP, Leyva YE, Tiet QQ. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample. Journal of general internal medicine. 2016 Oct:31(10):1206-11. doi: 10.1007/s11606-016-3703-5. Epub 2016 May 11 [PubMed PMID: 27170304]

[33]

Polomano RC, Galloway KT, Kent ML, Brandon-Edwards H, Kwon KN, Morales C, Buckenmaier C' 3rd. Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population. Pain medicine (Malden, Mass.). 2016 Aug:17(8):1505-19. doi: 10.1093/pm/pnw105. Epub 2016 Jun 6 [PubMed PMID: 27272528]

[34]

Friedrichsdorf SJ, Giordano J, Desai Dakoji K, Warmuth A, Daughtry C, Schulz CA. Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints. Children (Basel, Switzerland). 2016 Dec 10:3(4): [PubMed PMID: 27973405]

[35]

Beyer JE, Denyes MJ, Villarruel AM. The creation, validation, and continuing development of the Oucher: a measure of pain intensity in children. Journal of pediatric nursing. 1992 Oct:7(5):335-46 [PubMed PMID: 1479552]

Level 1 (high-level) evidence

[36]

Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010 Nov:126(5):e1168-98. doi: 10.1542/peds.2010-1609. Epub 2010 Oct 4 [PubMed PMID: 20921070]

Level 1 (high-level) evidence

[37]

Breau LM, Camfield C, McGrath PJ, Rosmus C, Finley GA. Measuring pain accurately in children with cognitive impairments: refinement of a caregiver scale. The Journal of pediatrics. 2001 May:138(5):721-7 [PubMed PMID: 11343050]

[38]

Breau LM, McGrath PJ, Camfield CS, Finley GA. Psychometric properties of the non-communicating children's pain checklist-revised. Pain. 2002 Sep:99(1-2):349-57 [PubMed PMID: 12237214]

[39]

Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatric anaesthesia. 2006 Mar:16(3):258-65 [PubMed PMID: 16490089]

[40]

Solodiuk J, Curley MA. Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS). Journal of pediatric nursing. 2003 Aug:18(4):295-9 [PubMed PMID: 12923744]

Level 3 (low-level) evidence

[41]

Hunt A, Burne R. Medical and nursing problems of children with neurodegenerative disease. Palliative medicine. 1995 Jan:9(1):19-26 [PubMed PMID: 7719515]

Level 2 (mid-level) evidence

[42]

Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesthesia and analgesia. 2002 Nov:95(5):1224-9, table of contents [PubMed PMID: 12401598]

Level 1 (high-level) evidence

[43]

Keller S, Bann CM, Dodd SL, Schein J, Mendoza TR, Cleeland CS. Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. The Clinical journal of pain. 2004 Sep-Oct:20(5):309-18 [PubMed PMID: 15322437]

[44]

Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Annals of the Academy of Medicine, Singapore. 1994 Mar:23(2):129-38 [PubMed PMID: 8080219]

[45]

Dworkin RH, Turk DC, Revicki DA, Harding G, Coyne KS, Peirce-Sandner S, Bhagwat D, Everton D, Burke LB, Cowan P, Farrar JT, Hertz S, Max MB, Rappaport BA, Melzack R. Development and initial validation of an expanded and revised version of the Short-form McGill Pain Questionnaire (SF-MPQ-2). Pain. 2009 Jul:144(1-2):35-42. doi: 10.1016/j.pain.2009.02.007. Epub 2009 Apr 7 [PubMed PMID: 19356853]

Level 1 (high-level) evidence

[46]

Price DD. Psychological and neural mechanisms of the affective dimension of pain. Science (New York, N.Y.). 2000 Jun 9:288(5472):1769-72 [PubMed PMID: 10846154]

Level 3 (low-level) evidence

[47]

Clark L, Jones K, Pennington K. Pain assessment practices with nursing home residents. Western journal of nursing research. 2004 Nov:26(7):733-50 [PubMed PMID: 15466611]

[48]

Long CJ. The relationship between surgical outcome and MMPI profiles in chronic pain patients. Journal of clinical psychology. 1981 Oct:37(4):744-9 [PubMed PMID: 6458625]

Level 2 (mid-level) evidence

[49]

BECK AT, WARD CH, MENDELSON M, MOCK J, ERBAUGH J. An inventory for measuring depression. Archives of general psychiatry. 1961 Jun:4():561-71 [PubMed PMID: 13688369]

[50]

Azadfard M, Huecker MR, Leaming JM. Opioid Addiction. StatPearls. 2023 Jan:(): [PubMed PMID: 28846246]

[51]

Brott NR, Peterson E, Cascella M. Opioid, Risk Tool. StatPearls. 2023 Jan:(): [PubMed PMID: 31985940]

[52]

Lee CS, Kim D, Park SY, Lee SC, Kim YC, Moon JY. Usefulness of the Korean Version of the CAGE-Adapted to Include Drugs Combined With Clinical Predictors to Screen for Opioid-Related Aberrant Behavior. Anesthesia and analgesia. 2019 Sep:129(3):864-873. doi: 10.1213/ANE.0000000000003580. Epub [PubMed PMID: 31425231]

[53]

Atluri S, Akbik H, Sudarshan G. Prevention of opioid abuse in chronic non-cancer pain: an algorithmic, evidence based approach. Pain physician. 2012 Jul:15(3 Suppl):ES177-89 [PubMed PMID: 22786456]

[54]

Arnow BA, Hunkeler EM, Blasey CM, Lee J, Constantino MJ, Fireman B, Kraemer HC, Dea R, Robinson R, Hayward C. Comorbid depression, chronic pain, and disability in primary care. Psychosomatic medicine. 2006 Mar-Apr:68(2):262-8 [PubMed PMID: 16554392]

[55]

Fishbain DA, Cole B, Lewis JE, Gao J. Does pain interfere with antidepressant depression treatment response and remission in patients with depression and pain? An evidence-based structured review. Pain medicine (Malden, Mass.). 2014 Sep:15(9):1522-39. doi: 10.1111/pme.12448. Epub 2014 Aug 19 [PubMed PMID: 25139618]

Level 2 (mid-level) evidence

[56]

Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet (London, England). 2011 Jun 25:377(9784):2226-35. doi: 10.1016/S0140-6736(11)60402-9. Epub [PubMed PMID: 21704872]

[57]

Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK, Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine. 2007 Oct 2:147(7):478-91 [PubMed PMID: 17909209]

Level 3 (low-level) evidence

[58]

Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, Dinçer F, Dziedzic K, Häuselmann HJ, Herrero-Beaumont G, Kaklamanis P, Lohmander S, Maheu E, Martín-Mola E, Pavelka K, Punzi L, Reiter S, Sautner J, Smolen J, Verbruggen G, Zimmermann-Górska I. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Annals of the rheumatic diseases. 2007 Mar:66(3):377-88 [PubMed PMID: 17046965]

[59]

Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and cartilage. 2008 Feb:16(2):137-62. doi: 10.1016/j.joca.2007.12.013. Epub [PubMed PMID: 18279766]

Level 1 (high-level) evidence

[60]

Bjordal JM, Ljunggren AE, Klovning A, Slørdal L. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials. BMJ (Clinical research ed.). 2004 Dec 4:329(7478):1317 [PubMed PMID: 15561731]

Level 1 (high-level) evidence

[61]

Fendrick AM, Greenberg BP. A review of the benefits and risks of nonsteroidal anti-inflammatory drugs in the management of mild-to-moderate osteoarthritis. Osteopathic medicine and primary care. 2009 Jan 6:3():1. doi: 10.1186/1750-4732-3-1. Epub 2009 Jan 6 [PubMed PMID: 19126235]

[62]

Rasmussen-Barr E, Held U, Grooten WJA, Roelofs PDDM, Koes BW, van Tulder MW, Wertli MM. Nonsteroidal Anti-inflammatory Drugs for Sciatica: An Updated Cochrane Review. Spine. 2017 Apr 15:42(8):586-594. doi: 10.1097/BRS.0000000000002092. Epub [PubMed PMID: 28399072]

[63]

Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, Kalso EA, Loeser JD, Miaskowski C, Nurmikko TJ, Portenoy RK, Rice ASC, Stacey BR, Treede RD, Turk DC, Wallace MS. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007 Dec 5:132(3):237-251. doi: 10.1016/j.pain.2007.08.033. Epub 2007 Oct 24 [PubMed PMID: 17920770]

Level 3 (low-level) evidence

[64]

McNicol ED, Midbari A, Eisenberg E. Opioids for neuropathic pain. The Cochrane database of systematic reviews. 2013 Aug 29:2013(8):CD006146. doi: 10.1002/14651858.CD006146.pub2. Epub 2013 Aug 29 [PubMed PMID: 23986501]

Level 1 (high-level) evidence

[65]

Von Korff M, Kolodny A, Deyo RA, Chou R. Long-term opioid therapy reconsidered. Annals of internal medicine. 2011 Sep 6:155(5):325-8. doi: 10.7326/0003-4819-155-5-201109060-00011. Epub [PubMed PMID: 21893626]

[66]

Santos J, Alarcão J, Fareleira F, Vaz-Carneiro A, Costa J. Tapentadol for chronic musculoskeletal pain in adults. The Cochrane database of systematic reviews. 2015 May 27:2015(5):CD009923. doi: 10.1002/14651858.CD009923.pub2. Epub 2015 May 27 [PubMed PMID: 26017279]

Level 1 (high-level) evidence

[67]

Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, Kroenke K, Bair MJ, Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6:319(9):872-882. doi: 10.1001/jama.2018.0899. Epub [PubMed PMID: 29509867]

Level 1 (high-level) evidence

[68]

Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, O'Connor PG, Passik SD, Pasternak GW, Portenoy RK, Rich BA, Roberts RG, Todd KH, Miaskowski C, American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The journal of pain. 2009 Feb:10(2):113-30. doi: 10.1016/j.jpain.2008.10.008. Epub [PubMed PMID: 19187889]

[69]

Frieden TR, Houry D. Reducing the Risks of Relief--The CDC Opioid-Prescribing Guideline. The New England journal of medicine. 2016 Apr 21:374(16):1501-4. doi: 10.1056/NEJMp1515917. Epub 2016 Mar 15 [PubMed PMID: 26977701]

[70]

Dublin S, Walker RL, Shortreed SM, Ludman EJ, Sherman KJ, Hansen RN, Thakral M, Saunders K, Parchman ML, Von Korff M. Impact of initiatives to reduce prescription opioid risks on medically attended injuries in people using chronic opioid therapy. Pharmacoepidemiology and drug safety. 2019 Jan:28(1):90-96. doi: 10.1002/pds.4678. Epub 2018 Oct 30 [PubMed PMID: 30375121]

[71]

Von Korff M, Dublin S, Walker RL, Parchman M, Shortreed SM, Hansen RN, Saunders K. The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy. The journal of pain. 2016 Jan:17(1):101-10. doi: 10.1016/j.jpain.2015.10.002. Epub 2015 Oct 22 [PubMed PMID: 26476264]

[72]

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports. 2016 Mar 18:65(1):1-49. doi: 10.15585/mmwr.rr6501e1. Epub 2016 Mar 18 [PubMed PMID: 26987082]

[73]

Els C, Jackson TD, Kunyk D, Lappi VG, Sonnenberg B, Hagtvedt R, Sharma S, Kolahdooz F, Straube S. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. The Cochrane database of systematic reviews. 2017 Oct 30:10(10):CD012509. doi: 10.1002/14651858.CD012509.pub2. Epub 2017 Oct 30 [PubMed PMID: 29084357]

Level 3 (low-level) evidence

[74]

Freynhagen R, Bennett MI. Diagnosis and management of neuropathic pain. BMJ (Clinical research ed.). 2009 Aug 12:339():b3002. doi: 10.1136/bmj.b3002. Epub 2009 Aug 12 [PubMed PMID: 19675082]

[75]

Gilron I, Baron R, Jensen T. Neuropathic pain: principles of diagnosis and treatment. Mayo Clinic proceedings. 2015 Apr:90(4):532-45. doi: 10.1016/j.mayocp.2015.01.018. Epub [PubMed PMID: 25841257]

[76]

Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, Gilron I, Haanpää M, Hansson P, Jensen TS, Kamerman PR, Lund K, Moore A, Raja SN, Rice AS, Rowbotham M, Sena E, Siddall P, Smith BH, Wallace M. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. The Lancet. Neurology. 2015 Feb:14(2):162-73. doi: 10.1016/S1474-4422(14)70251-0. Epub 2015 Jan 7 [PubMed PMID: 25575710]

Level 1 (high-level) evidence

[77]

Derry S, Bell RF, Straube S, Wiffen PJ, Aldington D, Moore RA. Pregabalin for neuropathic pain in adults. The Cochrane database of systematic reviews. 2019 Jan 23:1(1):CD007076. doi: 10.1002/14651858.CD007076.pub3. Epub 2019 Jan 23 [PubMed PMID: 30673120]

Level 1 (high-level) evidence

[78]

Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, Nurmikko T, Zakrzewska JM. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008 Oct 7:71(15):1183-90. doi: 10.1212/01.wnl.0000326598.83183.04. Epub 2008 Aug 20 [PubMed PMID: 18716236]

Level 1 (high-level) evidence

[79]

Wiffen PJ, Derry S, Moore RA, McQuay HJ. Carbamazepine for acute and chronic pain in adults. The Cochrane database of systematic reviews. 2011 Jan 19:(1):CD005451. doi: 10.1002/14651858.CD005451.pub2. Epub 2011 Jan 19 [PubMed PMID: 21249671]

Level 1 (high-level) evidence

[80]

McQuay HJ, Tramèr M, Nye BA, Carroll D, Wiffen PJ, Moore RA. A systematic review of antidepressants in neuropathic pain. Pain. 1996 Dec:68(2-3):217-27 [PubMed PMID: 9121808]

Level 1 (high-level) evidence

[81]

Sindrup SH, Otto M, Finnerup NB, Jensen TS. Antidepressants in the treatment of neuropathic pain. Basic & clinical pharmacology & toxicology. 2005 Jun:96(6):399-409 [PubMed PMID: 15910402]

[82]

. Duloxetine (Cymbalta) for diabetic neuropathic pain. The Medical letter on drugs and therapeutics. 2005 Aug 15-29:47(1215-1216):67-8 [PubMed PMID: 16103866]

Level 3 (low-level) evidence

[83]

Lunn MP, Hughes RA, Wiffen PJ. Duloxetine for treating painful neuropathy or chronic pain. The Cochrane database of systematic reviews. 2009 Oct 7:(4):CD007115. doi: 10.1002/14651858.CD007115.pub2. Epub 2009 Oct 7 [PubMed PMID: 19821395]

Level 1 (high-level) evidence

[84]

Aiyer R, Barkin RL, Bhatia A. Treatment of Neuropathic Pain with Venlafaxine: A Systematic Review. Pain medicine (Malden, Mass.). 2017 Oct 1:18(10):1999-2012. doi: 10.1093/pm/pnw261. Epub [PubMed PMID: 27837032]

Level 1 (high-level) evidence

[85]

Khaliq W, Alam S, Puri N. Topical lidocaine for the treatment of postherpetic neuralgia. The Cochrane database of systematic reviews. 2007 Apr 18:(2):CD004846 [PubMed PMID: 17443559]

Level 1 (high-level) evidence

[86]

Derry S, Wiffen PJ, Moore RA, Quinlan J. Topical lidocaine for neuropathic pain in adults. The Cochrane database of systematic reviews. 2014 Jul 24:2014(7):CD010958. doi: 10.1002/14651858.CD010958.pub2. Epub 2014 Jul 24 [PubMed PMID: 25058164]

Level 1 (high-level) evidence

[87]

Massey T, Derry S, Moore RA, McQuay HJ. Topical NSAIDs for acute pain in adults. The Cochrane database of systematic reviews. 2010 Jun 16:(6):CD007402. doi: 10.1002/14651858.CD007402.pub2. Epub 2010 Jun 16 [PubMed PMID: 20556778]

Level 1 (high-level) evidence

[88]

Haroutiunian S, Drennan DA, Lipman AG. Topical NSAID therapy for musculoskeletal pain. Pain medicine (Malden, Mass.). 2010 Apr:11(4):535-49. doi: 10.1111/j.1526-4637.2010.00809.x. Epub 2010 Mar 4 [PubMed PMID: 20210866]

[89]

Mason L, Moore RA, Derry S, Edwards JE, McQuay HJ. Systematic review of topical capsaicin for the treatment of chronic pain. BMJ (Clinical research ed.). 2004 Apr 24:328(7446):991 [PubMed PMID: 15033881]

Level 1 (high-level) evidence

[90]

Xiao L, Mackey S, Hui H, Xong D, Zhang Q, Zhang D. Subcutaneous injection of botulinum toxin a is beneficial in postherpetic neuralgia. Pain medicine (Malden, Mass.). 2010 Dec:11(12):1827-33. doi: 10.1111/j.1526-4637.2010.01003.x. Epub [PubMed PMID: 21134121]

Level 1 (high-level) evidence

[91]

Nugent SM, Morasco BJ, O'Neil ME, Freeman M, Low A, Kondo K, Elven C, Zakher B, Motu'apuaka M, Paynter R, Kansagara D. The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms: A Systematic Review. Annals of internal medicine. 2017 Sep 5:167(5):319-331. doi: 10.7326/M17-0155. Epub 2017 Aug 15 [PubMed PMID: 28806817]

Level 3 (low-level) evidence

[92]

Martimbianco ALC, Porfírio GJ, Pacheco RL, Torloni MR, Riera R. Transcutaneous electrical nerve stimulation (TENS) for chronic neck pain. The Cochrane database of systematic reviews. 2019 Dec 12:12(12):CD011927. doi: 10.1002/14651858.CD011927.pub2. Epub 2019 Dec 12 [PubMed PMID: 31830313]

Level 1 (high-level) evidence

[93]

Cruccu G, Aziz TZ, Garcia-Larrea L, Hansson P, Jensen TS, Lefaucheur JP, Simpson BA, Taylor RS. EFNS guidelines on neurostimulation therapy for neuropathic pain. European journal of neurology. 2007 Sep:14(9):952-70 [PubMed PMID: 17718686]

Level 1 (high-level) evidence

[94]

North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005:56(1):98-106; discussion 106-7 [PubMed PMID: 15617591]

Level 1 (high-level) evidence

[95]

Eldabe S, Kumar K, Buchser E, Taylor RS. An analysis of the components of pain, function, and health-related quality of life in patients with failed back surgery syndrome treated with spinal cord stimulation or conventional medical management. Neuromodulation : journal of the International Neuromodulation Society. 2010 Jul:13(3):201-9. doi: 10.1111/j.1525-1403.2009.00271.x. Epub 2010 Feb 22 [PubMed PMID: 21992833]

Level 2 (mid-level) evidence

[96]

de Vos CC, Meier K, Zaalberg PB, Nijhuis HJ, Duyvendak W, Vesper J, Enggaard TP, Lenders MW. Spinal cord stimulation in patients with painful diabetic neuropathy: a multicentre randomized clinical trial. Pain. 2014 Nov:155(11):2426-31. doi: 10.1016/j.pain.2014.08.031. Epub 2014 Aug 29 [PubMed PMID: 25180016]

Level 1 (high-level) evidence

[97]

Hunter C, Davé N, Diwan S, Deer T. Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment. Pain practice : the official journal of World Institute of Pain. 2013 Jan:13(1):3-17. doi: 10.1111/j.1533-2500.2012.00558.x. Epub 2012 Apr 23 [PubMed PMID: 22521096]

Level 3 (low-level) evidence

[98]

Kapural L, Nagem H, Tlucek H, Sessler DI. Spinal cord stimulation for chronic visceral abdominal pain. Pain medicine (Malden, Mass.). 2010 Mar:11(3):347-55. doi: 10.1111/j.1526-4637.2009.00785.x. Epub 2010 Jan 15 [PubMed PMID: 20088856]

[99]

Lamer TJ, Moeschler SM, Gazelka HM, Hooten WM, Bendel MA, Murad MH. Spinal Stimulation for the Treatment of Intractable Spine and Limb Pain: A Systematic Review of RCTs and Meta-Analysis. Mayo Clinic proceedings. 2019 Aug:94(8):1475-1487. doi: 10.1016/j.mayocp.2018.12.037. Epub 2019 Jul 3 [PubMed PMID: 31279543]

Level 1 (high-level) evidence

[100]

Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ (Clinical research ed.). 2013 Jan 30:346():f174. doi: 10.1136/bmj.f174. Epub 2013 Jan 30 [PubMed PMID: 23372174]

[101]

Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001 Nov:94(2):149-158. doi: 10.1016/S0304-3959(01)00349-9. Epub [PubMed PMID: 11690728]

Level 1 (high-level) evidence

[102]

Kemler MA, de Vet HC, Barendse GA, van den Wildenberg FA, van Kleef M. Effect of spinal cord stimulation for chronic complex regional pain syndrome Type I: five-year final follow-up of patients in a randomized controlled trial. Journal of neurosurgery. 2008 Feb:108(2):292-8. doi: 10.3171/JNS/2008/108/2/0292. Epub [PubMed PMID: 18240925]

Level 1 (high-level) evidence

[103]

Watkins PB, Kaplowitz N, Slattery JT, Colonese CR, Colucci SV, Stewart PW, Harris SC. Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial. JAMA. 2006 Jul 5:296(1):87-93 [PubMed PMID: 16820551]

Level 1 (high-level) evidence

[104]

Holubek WJ, Kalman S, Hoffman RS. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology (Baltimore, Md.). 2006 Apr:43(4):880; author reply 882 [PubMed PMID: 16557558]

Level 3 (low-level) evidence

[105]

Jalan R, Williams R, Bernuau J. Paracetamol: are therapeutic doses entirely safe? Lancet (London, England). 2006 Dec 23:368(9554):2195-6 [PubMed PMID: 17189017]

[106]

Cavalcante AN, Sprung J, Schroeder DR, Weingarten TN. Multimodal Analgesic Therapy With Gabapentin and Its Association With Postoperative Respiratory Depression. Anesthesia and analgesia. 2017 Jul:125(1):141-146. doi: 10.1213/ANE.0000000000001719. Epub [PubMed PMID: 27984223]

[107]

Gomes T, Greaves S, van den Brink W, Antoniou T, Mamdani MM, Paterson JM, Martins D, Juurlink DN. Pregabalin and the Risk for Opioid-Related Death: A Nested Case-Control Study. Annals of internal medicine. 2018 Nov 20:169(10):732-734. doi: 10.7326/M18-1136. Epub 2018 Aug 21 [PubMed PMID: 30140853]

Level 2 (mid-level) evidence

[108]

Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain physician. 2011 Mar-Apr:14(2):145-61 [PubMed PMID: 21412369]

[109]

Hayek SM, Veizi E, Hanes M. Treatment-Limiting Complications of Percutaneous Spinal Cord Stimulator Implants: A Review of Eight Years of Experience From an Academic Center Database. Neuromodulation : journal of the International Neuromodulation Society. 2015 Oct:18(7):603-8; discussion 608-9. doi: 10.1111/ner.12312. Epub 2015 Jun 5 [PubMed PMID: 26053499]

[110]

Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Thomson S, Raso L, Burton A, DeAndres J, Buchser E, Buvanendran A, Liem L, Kumar K, Rizvi S, Feler C, Abejon D, Anderson J, Eldabe S, Kim P, Leong M, Hayek S, McDowell G 2nd, Poree L, Brooks ES, McJunkin T, Lynch P, Kapural L, Foreman RD, Caraway D, Alo K, Narouze S, Levy RM, North R, Neuromodulation Appropriateness Consensus Committee. The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation : journal of the International Neuromodulation Society. 2014 Aug:17(6):571-97; discussion 597-8. doi: 10.1111/ner.12206. Epub [PubMed PMID: 25112891]

Level 3 (low-level) evidence

[111]

Kumar K, Buchser E, Linderoth B, Meglio M, Van Buyten JP. Avoiding complications from spinal cord stimulation: practical recommendations from an international panel of experts. Neuromodulation : journal of the International Neuromodulation Society. 2007 Jan:10(1):24-33. doi: 10.1111/j.1525-1403.2007.00084.x. Epub [PubMed PMID: 22151809]

[112]

Osborne MD, Ghazi SM, Palmer SC, Boone KM, Sletten CD, Nottmeier EW. Spinal cord stimulator--trial lead migration study. Pain medicine (Malden, Mass.). 2011 Feb:12(2):204-8. doi: 10.1111/j.1526-4637.2010.01019.x. Epub 2010 Dec 10 [PubMed PMID: 21143759]

[113]

Vallejo R, Kramer J, Benyamin R. Neuromodulation of the cervical spinal cord in the treatment of chronic intractable neck and upper extremity pain: a case series and review of the literature. Pain physician. 2007 Mar:10(2):305-11 [PubMed PMID: 17387353]

Level 3 (low-level) evidence

[114]

Wolter T, Kieselbach K. Cervical spinal cord stimulation: an analysis of 23 patients with long-term follow-up. Pain physician. 2012 May-Jun:15(3):203-12 [PubMed PMID: 22622904]

Level 2 (mid-level) evidence

[115]

North RB, Kidd DH, Petrucci L, Dorsi MJ. Spinal cord stimulation electrode design: a prospective, randomized, controlled trial comparing percutaneous with laminectomy electrodes: part II-clinical outcomes. Neurosurgery. 2005 Nov:57(5):990-6; discussion 990-6 [PubMed PMID: 16284568]

Level 1 (high-level) evidence

[116]

Henderson JM, Schade CM, Sasaki J, Caraway DL, Oakley JC. Prevention of mechanical failures in implanted spinal cord stimulation systems. Neuromodulation : journal of the International Neuromodulation Society. 2006 Jul:9(3):183-91. doi: 10.1111/j.1525-1403.2006.00059.x. Epub [PubMed PMID: 22151706]

[117]

Bedder MD, Bedder HF. Spinal cord stimulation surgical technique for the nonsurgically trained. Neuromodulation : journal of the International Neuromodulation Society. 2009 Apr:12 Suppl 1():1-19. doi: 10.1111/j.1525-1403.2009.00194.x. Epub [PubMed PMID: 22151467]

[118]

Rudiger J, Thomson S. Infection rate of spinal cord stimulators after a screening trial period. A 53-month third party follow-up. Neuromodulation : journal of the International Neuromodulation Society. 2011 Mar-Apr:14(2):136-41; discussion 141. doi: 10.1111/j.1525-1403.2010.00317.x. Epub 2010 Nov 4 [PubMed PMID: 21992200]

Level 2 (mid-level) evidence

[119]

Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. Journal of neurosurgery. 2004 Mar:100(3 Suppl Spine):254-67 [PubMed PMID: 15029914]

[120]

Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogenesis, prevention and treatment. British journal of anaesthesia. 2003 Nov:91(5):718-29 [PubMed PMID: 14570796]

[121]

Costigan SN, Sprigge JS. Dural puncture: the patients' perspective. A patient survey of cases at a DGH maternity unit 1983-1993. Acta anaesthesiologica Scandinavica. 1996 Jul:40(6):710-4 [PubMed PMID: 8836266]

Level 3 (low-level) evidence

[122]

Petraglia FW 3rd, Farber SH, Gramer R, Verla T, Wang F, Thomas S, Parente B, Lad SP. The Incidence of Spinal Cord Injury in Implantation of Percutaneous and Paddle Electrodes for Spinal Cord Stimulation. Neuromodulation : journal of the International Neuromodulation Society. 2016 Jan:19(1):85-90. doi: 10.1111/ner.12370. Epub 2015 Dec 8 [PubMed PMID: 26644210]

[123]

Lopez MJ, Tadi P. Drug Enforcement Administration Drug Scheduling. StatPearls. 2023 Jan:(): [PubMed PMID: 32491358]

[124]

Gabay M. The federal controlled substances act: schedules and pharmacy registration. Hospital pharmacy. 2013 Jun:48(6):473-4. doi: 10.1310/hpj4806-473. Epub [PubMed PMID: 24421507]

[125]

Larrat EP, Marcoux RM, Vogenberg FR. Implications of recent controlled substance policy initiatives. P & T : a peer-reviewed journal for formulary management. 2014 Feb:39(2):126-8 [PubMed PMID: 24669180]

[126]

Gabay M. Federal controlled substances act: controlled substances prescriptions. Hospital pharmacy. 2013 Sep:48(8):644-5. doi: 10.1310/hpj4808-644. Epub [PubMed PMID: 24421533]

[127]

Preuss CV, Kalava A, King KC. Prescription of Controlled Substances: Benefits and Risks. StatPearls. 2023 Jan:(): [PubMed PMID: 30726003]

[128]

Weyandt LL, Oster DR, Marraccini ME, Gudmundsdottir BG, Munro BA, Rathkey ES, McCallum A. Prescription stimulant medication misuse: Where are we and where do we go from here? Experimental and clinical psychopharmacology. 2016 Oct:24(5):400-414. doi: 10.1037/pha0000093. Epub [PubMed PMID: 27690507]

[129]

Clinton HA, Hunter AA, Logan SB, Lapidus GD. Evaluating opioid overdose using the National Violent Death Reporting System, 2016. Drug and alcohol dependence. 2019 Jan 1:194():371-376. doi: 10.1016/j.drugalcdep.2018.11.002. Epub 2018 Nov 15 [PubMed PMID: 30481691]

[130]

Rose AJ, McBain R, Schuler MS, LaRochelle MR, Ganz DA, Kilambi V, Stein BD, Bernson D, Chui KKH, Land T, Walley AY, Stopka TJ. Effect of Age on Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011 to 2015. Journal of the American Geriatrics Society. 2019 Jan:67(1):128-132. doi: 10.1111/jgs.15659. Epub 2018 Nov 24 [PubMed PMID: 30471102]

[131]

Jones CM, Lurie PG, Throckmorton DC. Effect of US Drug Enforcement Administration's Rescheduling of Hydrocodone Combination Analgesic Products on Opioid Analgesic Prescribing. JAMA internal medicine. 2016 Mar:176(3):399-402. doi: 10.1001/jamainternmed.2015.7799. Epub [PubMed PMID: 26809459]

[132]

Drug Enforcement Administration, Department of Justice. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II. Final rule. Federal register. 2014 Aug 22:79(163):49661-82 [PubMed PMID: 25167591]

[133]

Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of Opioids by Different Types of Medicare Prescribers. JAMA internal medicine. 2016 Feb:176(2):259-61. doi: 10.1001/jamainternmed.2015.6662. Epub [PubMed PMID: 26658497]