This training article outlines best practices for the safe, effective, and responsible prescribing of controlled substances. It covers critical topics such as risk assessment, legal and regulatory considerations, and strategies to minimize misuse.
Controlled Substance Prescribing Principles:
Prescribing Principle
Rationale
Check PDMP before initiating medication and every 6 months
Identifies high-risk prescribing patterns (e.g., doctor shopping, duplicate therapies)
Helps prevent unintended polypharmacy or dangerous combinations
Encourages a team-based approach to managing complex patients
Use the lowest effective dose for the shortest appropriate duration
Minimizes tolerance, dependence, and withdrawal risks
Reduces side effects and potential for misuse
Supports a trial-based approach that can be reassessed as needed
Match quantity prescribed to intended frequency and treatment duration
Prevents accumulation of unused medication that could be misused or diverted
Encourages more frequent check-ins to reassess clinical benefit and safety
Reinforces the temporary/conditional nature of controlled substance prescriptions
Confirm a clear clinical indication, supported by documentation
Provides medical-legal protection
Supports continuity of care and cross-provider communication
Ensures the medication is aligned with guidelines and best practices (e.g., DSM-5 for ADHD, panic disorder, etc.)
Monitor for substance abuse risk factors: early refills, multiple prescribers, patterned or inconsistent use
These are red flags for misuse, dependence, or diversion
Early detection allows for earlier intervention or alternative treatment planning
Patterns help you identify when a patient’s behavior is inconsistent with the treatment plan
Avoid co-prescribing stimulants and benzodiazepines unless clinically justified
Combination increases risk of overdose, sedation-activation cycles, and misuse
These meds work in opposing ways which may mask toxicity
Long-term use of both increases risk of SUD and functional impairment
Ensure continuity of care with appropriate follow up monitoring
Enables regular assessment to confirm the medication is effective and well-tolerated
Prevents gaps in care that can lead to misuse, withdrawal, or crisis refills
Improves adherence by keeping patients engaged in care and aligned with the treatment plan
Benzodiazepine Specific Prescribing Guide:
This resource is intended to support safe prescribing of benzodiazepines, Z-drugs, and other sedative-hypnotic agents.
Prescribing Guide
Rationale
Avoid Routine Daily Use When Possible
Daily use increases risk of tolerance, dependence, and withdrawal
Intermittent or as-needed use (e.g., for procedures or acute panic) may achieve therapeutic goals with lower risk
Avoids masking underlying psychiatric issues that may be better treated with non-benzodiazepine options
If daily use is necessary, establish a taper plan
Avoid automatic refills or default continuation
Prevents unintentional long-term use without ongoing clinical evaluation
Reduces potential for medication misuse, dependence, or adverse effects by requiring active decision-making at each refill
Avoid Use in High-Risk Populations Unless Clearly Justified
Populations to avoid or use with extreme caution:
Older adults (↑ fall risk, cognitive impairment)
Patients with untreated sleep apnea
Patients with current substance use disorder (SUD)
History of trauma or PTSD (risk of emotional blunting or dissociation)
These patients are at elevated risk of harm, including overdose, confusion, sedation, or addiction
Benzodiazepine Max Dosages:
Use this chart to reference commonly prescribed formulations and ensure that dosing aligns with FDA-approved maximums and current best practice recommendations.
Note: If prescribing above the listed maximums, documentation must include a clear clinical rationale, assessment of risks versus benefits, and a plan for close monitoring.
Category
Generic Name
Common Brand(s)
Max Daily Dose
Clinical Notes
Z-Drugs
Zolpidem IR
Ambien
10 mg
Reduce dose for females and older adults; risk of next-day sedation
Intermezzo: for middle-of-the-night use only (>= 4 hours to wake)
Zaleplon
Sonata
20 mg
Very short half-life; for sleep initiation only
Eszopiclone
Lunesta
3 mg
Metallic taste; next-day sedation risk
Suvorexant
Belsomra
20 mg
Orexin antagonist; may cause abnormal dreams, sleep paralysis
Adjunctive Sedating Agents (Non-Benzo)
Gabapentin
Neurontin
3600 mg
Watch for sedation and misuse; adjust for renal function
Pregabalin
Lyrica
600 mg
Schedule V; taper if discontinuing
Mirtazapine
Remeron
45 mg
Sedating at low doses; monitor for weight gain, hyperlipidemia
Benzodiazepines
Alprazolam
Xanax
4 mg
Short-acting; high abuse potential
Lorazepam
Ativan
10 mg
Intermediate-acting; safer in hepatic impairment
Clonazepam
Klonopin
4 mg
Long-acting; risk of sedation and accumulation
Diazepam
Valium
40 mg
Very long half-life; caution in elderly
Chlordiazepoxide
Librium
100 mg
Used for alcohol withdrawal; long-acting
Temazepam
Restoril
30 mg
Commonly prescribed for sleep; short duration
Triazolam
Halcion
0.5 mg
Ultra short-acting; amnestic and rebound risk high
Harm Reduction & Deprescribing Guidance:
Prescribing Guide
Rationale
When to Consider Tapering
Use beyond 4 weeks without re-evaluation
Sedation, memory impairment, paradoxical agitation, or falls
Co-prescription with opioids, alcohol, or other CNS depressants
History of substance use disorder or misuse
Patient request or preference for non-medication strategies
Tapering Recommendations
Reduce dose by 10–25% every 1–2 weeks, adjusted to risk and stability
Some patients require slower taper with close monitoring
Short-acting agents: consider cross-taper to longer-acting
Long-acting agents: taper directly with follow-up
Pause taper if withdrawal symptoms become severe
Harm Reduction Practices
Avoid abrupt discontinuation after long-term use
Engage patient in planning and set expectations
Educate about withdrawal symptoms and timelines
Consider CBT-I or behavioral therapy referral
Encourage sleep diaries, relaxation, and sleep hygiene
Monitor weekly early in taper if possible
Refer high-risk patients to specialty or addiction care
Stimulant Prescribing Guidelines:
This resource is intended to support safe prescribing of stimulant and wakefulness-promoting agents.
Stimulant Prescribing Guide:
Prescribing Guide
Rationale
Confirm Accurate Diagnosis with Standardized Criteria
Ensures treatment is targeted for clinically validated conditions such as ADHD or narcolepsy
Avoids inappropriate prescribing for nonspecific symptoms like fatigue or concentration difficulties
Supports insurance authorization and continuity of care
Screen for Cardiovascular Risk Before Initiation
Stimulants increase heart rate and blood pressure, which can exacerbate underlying cardiac disease
Baseline vitals (BP, HR) and, if indicated, ECG or cardiology consult prevent adverse cardiac events
Avoid Prescribing Stimulants to Patients with Active Substance Use Disorder Unless Carefully Justified
Stimulants have abuse potential and can exacerbate or trigger relapse in patients with SUD
Risk mitigation includes regular drug screening and use of long-acting formulations
Note: Rula’s This platform is not equipped to treat stimulant use disorder with stimulant medications. If patients require this type of care, we recommend transferring them to an inpatient treatment program.
Stimulant Max Dosages:
Use this chart to reference commonly prescribed formulations and ensure that dosing aligns with FDA-approved maximums and current best practice recommendations.
Note: If prescribing above listed maximums documentation must include clinical justification and risk/benefit rationale.