Perilous Drug Prescribing: One, Two, or Three?

Carolyn Buppert, MSN, JD

Disclosures

April 09, 2019

To submit a legal/professional healthcare question for future consideration, write to the editor at lstokowski@medscape.net (include "Ask the Expert" in subject line).

Question

A clinician asks this question about drug prescribing:

Combining benzodiazepines, opioids, and muscle relaxants can be deadly, and we are cautioned not to prescribe all three medications for one patient. Am I taking on a legal risk if I prescribe any of these medications? How about two of them for the same patient?
Response from Carolyn Buppert, MSN, JD
Healthcare attorney

Prescribing even one member of this drug triad can expose the prescriber to review and scrutiny by law enforcement. If a patient overdoses on opioids, the clinician who prescribed the medication can expect that records will be subpoenaed and reviewed. Prescribing two of the three drugs is even more risky: I have heard from clinicians who have been sanctioned by licensing boards and reported to law enforcement because they prescribed an opioid and a benzodiazepine repeatedly. I advise practitioners not to prescribe any more than one of these three drugs for any individual patient. If the combination is truly medically necessary, include in documentation your rationale for prescribing both medications.

Don't prescribe even one of these medications without performing and documenting a thorough assessment and diagnosing a condition that necessitates the prescription. Ask the patient what else he or she is taking before prescribing, and check the state's prescription drug monitoring program to see what is listed for the patient. An individual may be receiving an opioid from one provider, a benzodiazepine from another provider, and a muscle relaxant from a third provider.

Answer these questions before prescribing any of these medications:

  • Does this patient have a medical diagnosis that calls for this medication?

  • Could the benefit be achieved with a medication that is not controlled, such as a nonsteroidal drug, or through physical therapy or other nonpharmacologic treatment?

  • Have I assessed this patient's risk for abuse, using one of the available tools?

  • Have I checked the prescription drug monitoring program?

  • Have I ordered and received the results of a urine drug screen?

  • Do I have a written agreement with this patient about the goals of care and the conditions under which I will prescribe this medication?

  • Am I prepared to follow-up and assess whether the medication is effective? Will I stop prescribing the medication and taper it off if the patient is not improving?

  • Have I familiarized myself with my state's opioid prescribing guidelines, and am I following them?

  • Have I counseled the patient about the risks associated with this medication, the dangers of combining medications, and to avoid alcohol while taking this medication?

Be prepared to identify the guideline you are following if your prescribing is questioned by a licensing board or law enforcement.

Suggested Reading

  1. Fudin J. The perfect storm: opioid risks and 'the Holy Trinity.' Pharmacy Times. September 24, 2014. Source

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