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BACKGROUND: Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra- and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy. METHODS: This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record. RESULTS: A total of 98 patients (43 pre- and 55 post-protocol implementation) were included in this study. There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5–16.5) (ERATS) vs. 19.5 (12.6–36.0) (pre-ERATS), P

BACKGROUND: Florida's House Bill 21 (HB21), implemented into law on July 1, 2018, limited opioid prescriptions for acute pain to a 3-day supply. While the law has been associated with a decrease in opioid prescribing for acute pain, its effect on opioid volume dispensed at the plan level remains unknown. OBJECTIVES: To assess the impact of HB21 on the total volume dispensed of oral Schedule II opioids. We evaluated the change from before to after the law's implementation in (1) total number of opioid units dispensed per month and (2) total morphine milligram equivalent (MMEs) dispensed per month. METHODS: Pharmacy claims from July 2017 to June 2019 were analyzed from a private health plan serving a large Florida employer. We summed the number of units and the total MMEs dispensed for each month per 1,000 enrollees. Units were defined as the total quantity of tablets/capsules dispensed for each Schedule II oral opioid prescription. We used interrupted time series (ITS) models, accounting for autocorrelation, to determine any immediate change after the policy implementation and to estimate trends before and after the policy. RESULTS: We identified 16,226 prescriptions of oral Scheduled II opioids dispensed to 6,315 enrollees over a 2-year period. The HB21 law was associated with an immediate but not statistically significant decrease of 110.25 units dispensed per 1,000 enrollees in the month after implementation (95% CI: -218.84, -1.67; P = 0.06). There was an immediate but not statistically significant decrease of 1,456.29 MMEs dispensed per 1,000 enrollees following HB21 implementation (95% CI: -2,983.87, 71.29; P = 0.07). There were no significant changes in the slopes of the trends for total number of opioid units and total MMEs dispensed after HB21. CONCLUSIONS: Despite substantial lower quantities, there were no significant immediate reductions in total opioid units and MMEs dispensed in the year following the implementation of HB21. Our findings can inform other health plans on the potential effect of such restrictive laws and policies in other states where preexisting declining trends might have a higher impact than restriction policies. Future studies are needed to evaluate long-term intended and unintended consequences, including effects on patients' access to care, resulting from this type of restrictive law. DISCLOSURES: No outside funding supported this study. The authors report no conflicts of interest. Preliminary results of this study were presented at the Virtual ISPOR 2020 Conference held May 18-20, 2020.

BACKGROUND Since early 2016, an increasing number of states passed legislations that limit the duration and/or dosage of initial opioid prescriptions or opioids for acute pain. OBJECTIVE The objective of this study was to assess changes in the number of opioid prescriptions covered by Medicaid and received by Medicaid patients associated with state implementation of legislative limits on initial opioid prescriptions. RESEARCH DESIGN We explored the natural experiment resulting from the staggered implementation of state legislative limits. The analysis adopted a Difference-in-Differences framework and controlled for other major state policies bearing implications for prescription opioid use. The main analysis included 26 states that implemented limits from early 2016 to late 2018. A secondary analysis included all 50 states and the District of Columbia. MEASURES Population-adjusted state-quarter level counts of Schedule II and III opioid prescriptions received by Medicaid patients, based on data from the Medicaid State Drug Utilization Data and state Medicaid enrollment reports for 2013-2018. RESULTS Implementation of legislative limits on initial opioid prescriptions was associated with a 7% reduction in the number of opioid prescriptions per 100 Medicaid enrollees. Such reduction was largely attributable to a reduction in Schedule II opioid prescriptions. Secondary analysis by including all jurisdictions and sensitivity checks supported the robustness of results. CONCLUSION The recent implementation of state legislative limits on initial opioid prescriptions was associated with meaningful reductions in the volume of Schedule II opioid prescriptions received by Medicaid patients.

The growing ranks of nurse practitioners (NPs) in rural areas of the United States have the potential to help alleviate existing primary care shortages. This study uses a nationwide source of claims- and EHR-data from 2017 to construct measures of NP clinical autonomy and complexity of care. Comparisons between rural and urban primary care practices reveal greater clinical autonomy for rural NPs, who were more likely to have an independent patient panel, to practice with less physician supervision, and to prescribe Schedule II controlled substances. In contrast, rural and urban NPs provided care of similar complexity. These findings provide the first claims- and EHR-based evidence for the commonly held perception that NPs practice more autonomously in rural areas than in urban areas.

This study aimed to evaluate the rescheduling of hydrocodone combination products (HCPs) from schedule III (CIII) to schedule II (CII) in patients receiving chronic HCP therapy.This study was a retrospective cohort analysis of administrative pharmacy data from 118 statewide pharmacies from a retail chain in Tennessee. HCP filling histories were analyzed on patients meeting enrollment criteria from July 1, 2014, to October 1, 2015. The average number of tablets dispensed, daily average of the number of tablets dispensed, and monthly average of morphine milligram equivalents (MME) dispensed were compared for the periods of July 1, 2014, to October 5, 2014 (enrollment period before schedule change) and October 6, 2014, to October 1, 2015 (period following schedule change) using a pooled t test.A total of 4536 patients met the inclusion criteria. Of these 4536 patients, 60.6% were female, and 40.4% were male, with an average age of 58 years (patients included in this study were between the ages of 18 and 99 years). The total number of hydrocodone tablets dispensed in the 12 periods after the schedule change dropped from 467,217 to 259,327, a 45.5% reduction (P0.001). Total MME decreased from 4.11 to 2.29 million, a 45.3% reduction (P0.001). The number of study participants still receiving an HCP at the end of the study decreased to an average of 2736 across the 12 periods following the schedule change, a 40% reduction.HCP dispensing and use decreased among patients receiving chronic opioid treatment from a large corporate statewide community pharmacy in Tennessee after a schedule change from CIII to CII. Monthly sums of total tablets dispensed, average daily tablets dispensed, MME, and average daily MME calculated from July 1, 2014, to October 1, 2015, all experienced statistically significant reductions.

On 1 May 2004 the Mineral and Petroleum Resources Development Act 28 of 2002 (MPRDA) not only introduced a new mineral law regime in South Africa but also made provision in the transitional arrangements of Schedule II to the MPRDA (hereinafter "the transitional arrangements") for the conversion of so-called "old-order rights" into (or application for) prospecting or mining rights in terms of the MPRDA. This decision dealt with the duration or term of transitional prospecting rights and the remedies available to a holder of an "old-order prospecting right" upon refusal by the state functionaries to convert the right into a prospecting right in terms of the MPRDA. Item 6 of the transitional arrangements makes provision for the continuation and conversion of "old-order prospecting rights" (see, in general, Badenhorst and Mostert Mineral and Petroleum Law of South Africa (2004) Revision Service Chapter 25.3.1; and Dale, Bekker, Bashall, Chaskalson, Dixon, Grobler, Ash and Loxton South African Mineral and Petroleum Law (2005) SchII-119 to SchII-135).

During the pilot implementation of the International Classification of Functioning (ICF) in Ukraine, data were collected to assess the activity limitations and participation restrictions experienced by adults with asthma with the help of the WHO Disability Assessment Schedule II. Objective: To study the levels of functioning in patients with asthma using the WHODAS II. Results: We examined 89 patients with asthma. The average age of patients was 50.4 ± 4.6 years, 42.9% women. The mean FEV1 was 51.7 ± 8.2%, partly controlled asthma in 85% patients, 71% received high doses of ICS. 43% had higher education, 57% were urban residents. The average score for WHODAS II was 32.8 ± 7.1. Most of the patients (57.1%) had a mild decrease in functioning (WHODAS II overall score 50). The most significant functioning decrease was observed in the “participation in society” (63.4 ± 7.9), then “mobility” (35.7 ± 9.7), “understanding and communication” (28.6 ± 9.7), “self-care” (26.8 ± 11.6), “life activities” (26.3 ± 6.6) and “getting around” (15.7 ± 6.5). Thus, patients with asthma are most concerned about the significant complications or inability to join in community activities; a major role played the difficulty in moving & getting around, understanding and communicating, hygiene, dressing, eating & staying alone, and domestic responsibilities and leisure while interacting with other people almost did not cause issues. So, in patients with asthma, there is a significant limitation of the functioning level, mainly due to difficulties in participation in community activities and mobility issues.

This decision focused on the impact of the Mineral and Petroleum Resources Development Act (28 of 2002, hereinafter “MPRDA”) on an old-order mining right (based upon a mineral lease) which had been converted into a mining right in terms of the transitional arrangements of Schedule II of the MPRDA. In particular, the court held that consideration in the form of a (contractual) royalty, as provided for in the mineral lease, remains payable upon conversion of an old-order mining right by its former holder (miner) to the grantor of the common-law mining right. The outcome of the decision, namely, continued liability for contractual royalties, has far-reaching consequences for such former holders of old-order mining rights. Continued liability would result in double payment of royalties by miners. This is because under the new dispensation, statutory royalties can be imposed by the state (s 3(1)(b) of the MPRDA) and were imposed and became payable upon commencement of the Mineral and Petroleum Resources Royalty Act (28 of 2008) on 1 March 2010. From the said date, in terms of this decision, double royalties would be payable by miners. If correct, it can be taken one step further. Owing to continued receipt of contractual royalties, former holders of common-law mineral rights would not have suffered an expropriation of property by virtue of the provisions of the MPRDA for purposes of item 12(1) of Schedule II of theMPRDA. Such expropriation would have taken place if the contractual duties to pay royalties had indeed been terminated upon cessation of old-order mining rights (as to such a possible claim, see further, Badenhorst and Mostert Mineral and Petroleum Law of South Africa 2004 (Revision service 7) 25–53). These consequences will be explained in more detail in this discussion as well as the correctness or not of the decision. I have written about the acquisition, nature, content, transfer and loss of old order rights before (see Badenhorst “The Make-up of Transitional Rights to Minerals: Something Old, Something New, Something Borrowed, SomethingBlue …? 2011 4 SALJ 763–784) to which the reader is referred. This decision sheds new light on this topic.

In 2010, the Ambulatory Care Drug Database System (ACDD) reported that acetaminophen with hydrocodone topped the list of the three most prescribed medications across 49% of orthopedic facilities. Despite regulatory efforts radiated from the federal level, opioid prescription and addiction continues to exist among orthopedic patients.

With the ongoing public health crisis with prescription opioids, there is a need for safer alternatives for medication management in chronic pain patients. Buprenorphine is a partial mu-opioid agonist which is commonly utilized to treat patients with opioid-use disorders. The purpose of this review is to discuss the potential use of this medication for the treatment of chronic pain instead of resorting to more traditional Schedule II opioids. Buprenorphine offers a safer alternative for patients who require opioids to manage chronic pain, given the unique pharmacological properties that allow it to provide adequate analgesia with less abuse potential.

This paper provides a review of Purdue Pharma, LP's development and marketing of the long-acting oral narcotic OxyContin®. Within five years of the drug's launch, OxyContin® became the number-one prescribed Schedule II narcotic in the United States. This commercial success was in part the result of a marketing campaign that promoted questionably "distinctive" benefits and minimised the very real dangers of OxyContin®, which include abuse, addiction, overdose, and death. The marketing was based on scientifically invalid or unproven claims of safety and efficacy, inappropriate, off-label marketing, and inadequate warnings. When the FDA belatedly asked for changes to some of the marketing language, Purdue exploited these changes to further marketing objectives and misled healthcare practitioners. This case highlights questions of industry and governmental/regulatory accountability and responsibility for the production, marketing and sale of pharmaceutical products that increase risk while driving enhanced profits.

Objective: Prescription opioid misuse represents a social and economic dilemma in the United States. The authors evaluated primary care providers’ (PCPs) prescribing of Schedule II opioids at our institution in Kentucky. Design: Prospective evaluation of PCPs’ prescribing practices over a 3-year period (October 1, 2014 to September 30, 2017) in an outpatient setting. Methods: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards. Special attention focused on Schedule II opioid prescriptions with a quantity > 90, Opana/ Oxycontin, and morphine equivalent daily dosage. Results: A statistically significant increase in the total number of PCPs and PCPs who prescribed Schedule II opioids was observed, while there was a concurrent significant decrease in the average number of Schedule II opioid pills prescribed per PCP, Schedule II opioid prescriptions per PCP, Schedule II opioid pills prescribed per patient by PCPs, Schedule II opioid prescriptions with a quantity > 90 per PCP, and Opana/Oxycontin prescriptions per PCP. A statistically significant decline in the average morphine equivalent daily dosage of Schedule II opioids per PCP was noted. Conclusions: This study reports the benefit of incorporating federal and state regulations and institutional evidence-based guidelines into primary care practice to decrease the number of Schedule II opioids prescribed. Further preventive measures include selecting alternative treatments to opioids and reducing the rates of opioid nonmedical use and overdose while maintaining access to prescription opioids when indicated.

Introduction Schedule II of the 2013 Mental Health Act is part of the legal framework for involuntary admission to a licensed mental healthcare facility in Malta (Mount Carmel Hospital) for observation. Objectives To identify trends in presenting features cited by registered specialists in psychiatry in Schedule II applications as well as impact of time of day on involuntary admission. Methods Schedule II forms relating to all involuntary admissions to Mount Carmel Hospital between 01 June 2018 and 01 June 2019 were retrieved from paper files (n=364). Details relating to reason for using this legal framework were recorded and processed through custom linguistic analysis. Timings of application were also assessed. Data Protection permissions to retrospectively access patient files were obtained. All data collected was de-identified at source. Results The commonest reason for use of Schedule II was psychosis (n=139). Substance abuse was recorded in 68 cases, with alcohol and cannabinoids the commonest substances cited. 155 instances relate to situations of increased risk, the commonest being aggressive behaviour (n=74). 61 cases recorded suicidal intent. Peak use of this schedule occurs between 17:00 and 18:00, which is outside normal working hours. Conclusions Predominance of psychosis as a reason for involuntary admission concurs with trends reported internationally, including recent German, Irish and Dutch reports, as does increased use of involuntary admission with out-of-hours presentations. Practices relating to involuntary admission to a mental healthcare facility in Malta appear to reflect general trends in other European cohorts, despite differing legal frameworks.

In recent years, narcotics have been subject to increased regulation and monitoring because of their side effects and potential for misuse. Currently, variation in prescribing patterns of narcotics among orthopedic surgeons is unknown. The Medicare Part D claims database was used to identify orthopedic surgeons who prescribed at least one schedule II or III narcotic during 2014. The median duration of a narcotic prescription was 8.2 days. The median prescription duration was shortest for hand surgeons (5.6 days) and longest for spine surgeons (12.6 days). Orthopedic surgeons in New York (10.1 days) provided the most narcotics per prescription, with physicians in Vermont (6.2 days) providing the least. Substantial variation exists in narcotic prescribing patterns for orthopedic surgeons at the individual, subspecialty, and statewide levels. With public health focus on reducing narcotics abuse, physician stewardship of these medications will become increasingly relevant.

When prescribing medical treatments identified by federal law as schedule-II controlled substances,11 See 21 U.S.C. § 812 (Schedules of controlled substances, including schedule-II. contemporary ph...

The U.S. consumes about 99% of the world's supply of hydrocodone, primarily in hydrocodone combination products (HCPs). The Drug Enforcement Administration's (DEA) rescheduling of HCPs from Schedule III to the more restrictive Schedule II has changed prescribing patterns. The purpose of our article was to revisit HCP rescheduling to determine the impact this change had and its related consequences. Before 2014, DEA drug classification (scheduling) caused the ＂Vicodin loophole＂ which allowed HCP products to be prescribed under less restrictive conditions than single-entity hydrocodone products or oxycodone combination products. The rescheduling of HCPs to the more restrictive Schedule II has resulted in a decrease in HCP use but increased use of other analgesics. Unintended consequences of the rescheduling may include additional healthcare provider work, the potential for added costs, and patient inconvenience. For some patients, the rescheduling of HCPs may mean that they no longer have access to their preferred or effective analgesic or that they have been switched to another possibly less effective or tolerable analgesic. While the rescheduling has reduced the prescribing of hydrocodone, it is not apparent that it resulted in a net decrease in opioid use.

Opioid prescriptions have the potential for misuse. In October 2014, the federal schedule II prescribing mandate reclassified hydrocodone combination products from schedule III to schedule II drugs that required a written prescription. The aim of this study was to evaluate the opioid-prescribing practices in a graduate endodontic clinic (GEC) before and after the mandate.Electronic health records from all patients treated in the GEC from 2010 to 2018 were reviewed retrospectively for opioid prescribing, the date of prescription, and the Current Dental Terminology code. Where opioid prescribing was documented in the electronic health record, additional data were extracted about pulpal and periapical diagnosis, pain level, opioid type, and prescription details. Prescribing rates were calculated and analyzed by using chi-square, analysis of variance, logistic regression, and multivariable analysis. Significance was set at P.05.Overall, 4851 patients underwent 7841 procedures; 92.2% of patients were never prescribed opioids. The remaining 380 patients underwent 420 procedures, and 509 prescriptions were provided. Prescribing rates were 7.5% (228/3021) before versus 4.0% (192/4820) after the mandate (P.001). Hydrocodone combinations were the most prescribed opioid (77%, 392/509). Tramadol prescribing increased after the mandate (P = .023). Multivariable analysis showed significantly higher prescribing for apicoectomy procedures (P.001). Preoperative pulpal and periapical diagnosis and pain level were not significantly associated with opioid prescribing.An overall reduction in opioid-prescribing rates occurred coincidentally with the 2014 federal mandate. The lack of correlation between prescribing and pain level highlighted the need for evidence-based rather than habitual prescribing protocols in the GEC.

Background and objectives Forty-nine out of 50 states have implemented Prescription Drug Monitoring Programs (PDMPs) to monitor controlled substance (CS) prescribing. PDMPs change health care provider behavior, but few studies have examined changes in CS prescription by health care provider type. Methods Aggregated yearly data, including number of CS prescriptions, doses, and doses per prescription by health care provider type (physician, advanced practice registered nurse [APRN], and dentist) for each year from 2011 to 2017 was provided by the state PDMP, Kentucky All Schedule Prescription Electronic Reporting System (KASPER). In aggregate, this data set included 64,578,307 total prescriptions and 3,982,130,994 total doses of Schedule II-V medications. Results Physicians and dentists showed a trend of decreasing prescriptions and doses for Schedule II opioids from 2012 to 2017 (27-32% reduction in 2017 compared to 2011). APRNs showed a substantive increase in the number of doses and prescriptions (121-204% increase in 2017 compared to 2011), with increases remaining when controlling for number of providers. Physicians increased doses and prescriptions of Schedule II stimulants (37% increase for both doses and prescriptions), but by a smaller magnitude than APRN increases in stimulants (334-360% increase). Dentists showed decreases in Schedule II stimulants prescribed (69-80% reduction). Similar trends, but more modest in magnitude, were observed for Schedule III-IV. Discussion and conclusions Although monitoring and continuing education requirements are similar across all providers in Kentucky, differences in prescription trends for Schedule II opioids and stimulants were noted for physicians, APRNs, and dentists. Scientific significance Changes in prescribing following introduction of mandatory use of KASPER markedly differed based on provider type, with increases observed for APRNs compared with physicians and dentists. These findings advance prior research by providing a detailed examination of prescribing trends by provider type subsequent to a PDMPs mandatory use law. (Am J Addict 2019;00:00-00).

IntroductionSchedule II of the 2013 Mental Health Act is part of the legal framework for involuntary admission to a licensed mental healthcare facility in Malta (Mount Carmel Hospital) for observation.ObjectivesTo identify trends in presenting features cited by registered specialists in psychiatry in Schedule II applications as well as impact of time of day on involuntary admission.MethodsSchedule II forms relating to all involuntary admissions to Mount Carmel Hospital between 01 June 2018 and 01 June 2019 were retrieved from paper files (n=364). Details relating to reason for using this legal framework were recorded and processed through custom linguistic analysis. Timings of application were also assessed. Data Protection permissions to retrospectively access patient files were obtained. All data collected was de-identified at source.ResultsThe commonest reason for use of Schedule II was psychosis (n=139). Substance abuse was recorded in 68 cases, with alcohol and cannabinoids the commonest substances cited. 155 instances relate to situations of increased risk, the commonest being aggressive behaviour (n=74). 61 cases recorded suicidal intent. Peak use of this schedule occurs between 17:00 and 18:00, which is outside normal working hours.ConclusionsPredominance of psychosis as a reason for involuntary admission concurs with trends reported internationally, including recent German, Irish and Dutch reports, as does increased use of involuntary admission with out-of-hours presentations. Practices relating to involuntary admission to a mental healthcare facility in Malta appear to reflect general trends in other European cohorts, despite differing legal frameworks.

The 12-item WHODAS II is widely used for assessing disability among different populations. This study aimed at assessing the psychometric properties of the Persian version of the 12-item WHODAS II among trauma patients.In this methodological study, 220 patients aging 15-65-year-old hospitalized in Shahid Beheshti Hospital, Kashan, Iran, were studied. The WHODAS II was used for data collection. The reliability of this schedule was assessed by evaluating its internal consistency. Its validity was evaluated by using the known-groups approach and the convergent validity method. The exploratory and the confirmatory factor analysis techniques were also used for assessing the factor structure of the schedule.The mean of participants' ages was 34.7±14.5 years. Most of the participants were male patients (84.1%), had multiple injury (77.7%), and had been injured in road traffic accidents (76.8%). The Cronbach's alpha of the WHODAS II was 0.91, confirming its acceptable internal consistency. Known-groups comparisons revealed that this schedule can satisfactorily differentiate among patients with different severity of trauma (P value0.0001). The results of exploratory factor analysis showed that the WHODAS II had a two-factor structure while the confirmatory factor analysis revealed that one-factor model fitted the data.Study findings suggest that the Persian version of the 12-item WHODAS II is a valid and reliable scale for assessing trauma patients' disability. More Large-scale studies are needed for assessing the validity and the reliability of this schedule among other patients.

Observations on the distribution of Nymphalid butterfly, Sordid Emperor (Chitoria sordida sordida (Moore, 1866) in southern Bhutan are presented in this paper. The confirmation is based on four years of observation of species in the warm broadleaf forest of Tsirang during July to October. The species is legally protected under Schedule II of the Indian (Wildlife) Protection Act, 1997.

This paper investigates the impact of legislative changes allowing nurse practitioners to prescribe schedule II controlled substances independently. We find that this legal environment is associated with an increase in treatment admissions for opioid misuse and a decrease in opioid related mortality only when Mandatory Prescription Drugs Monitoring Programs are in place.

The herpetofauna of Andaman and Nicobar Island is diverse and has not been much focused. We present a brief history of herpetofaunal exploration and an annotated checklist in this chapter. A total of 102 species of amphibians and reptiles were occurring in terrestrial and marine environments of Andaman and Nicobar Islands. IUCN status and Scheduled species of Indian Wildlife Protection Act 1972 are also provided. Of the recorded species, 2 species were listed in Schedule I, 3 species under Schedule II, and 36 species under Schedule IV of Indian Wildlife Protection Act 1972.

We examine the effect of prescription opioids on county labor market outcomes, using data from the Prescription Drug Monitoring Programs of ten U.S. states and labor data from the Bureau of Labor Statistics. We achieve causal identofication by exploiting plausibly exogenous variation in the concentration of high-volume prescribers as instruments (using Medicare Part D prescriber data). We find strong adverse effects on labor force participation rates, employment- to-population ratios, and unemployment rates. Notably, a 10 percent increase in prescriptions causes a 0.56 percentage point reduction in labor force participation, similar to the drop attributed to the 1984 liberalization of Disability Insurance.

Introduction There is a lack of evidence-based criteria for the discharge of patients receiving Schedule II and III narcotic medications in the emergency department. The purpose of this study was to understand nurses' perceptions about common practices in the discharge of patients receiving Schedule II and III narcotics in the emergency department in terms of dosage, time, availability of care resources at home, and other discharge criteria. Methods A qualitative exploratory design was used. A sample of emergency nurses was recruited from the preregistered attendees of a national conference. Two focus group sessions were held, and audiotaped in their entirety. The audiotapes were transcribed and analyzed for emerging themes by the research team. Results Identified themes were Time, Physiologic Considerations, Cognitive Considerations, Safety Considerations, Policies, Evidence, Ethical/Legal Concerns, and Nursing Impact. Participants reported drug-to-discharge times of 0 minutes ("gulp and go") to 240 minutes after administration of Schedule II and III narcotics specifically, and "any medication" generally. The most common reason given for a wait of any kind was to assess patients for a reaction. Discussion It is the perception of our respondents that determination of readiness for discharge after a patient has received Schedule II or III narcotics in the emergency department is largely left up to nursing staff. Participants suggest that development of policies and checklists to assist in decision making related to discharge readiness would be useful for both nurses and patients.

Background: The consumption of controlled substances in North Carolina and the nation has created a health crisis with epidemic levels of medication diversion, abuse, overdose and death. Primary care providers are the principal prescribers of controlled substances and at greatest risk of encountering patients that abuse medications. Guidelines recommend patient agreements with monitoring requirements when prescribing opioids and stimulants. Studies have focused on opioids and excluded stimulants. Adherence to recommended monitoring requirements has not been fully evaluated. Methodology: This was a quality improvement project using the Plan-Do-Check-Act procedure. The following outcome measures were evaluated: signed agreement on file, prescription monitoring program (pmp) checks, urine screens, and prescriptions written without a mandatory visit. Implementation: Who: patients aged 19 and over prescribed a long-term Schedule II medication for the chronic conditions of pain and/or attention deficit hyperactivity disorder. What: implemented a patient agreement and measured fidelity to components of the agreement. When: seven months pre- to seven months post-implementation. Where: in an adult primary care practice with approximately 2,500 patients. How: an agreement was implemented with monthly feedback provided. Results: Post-implementation, 94% of patients meeting criteria had a signed agreement in their medical record. Adherence to urine screening improved from 5.3% to 71.1%. Guideline adherence to pmp checks improved from 11.3% to 99.0%. Guideline deviation for prescriptions written without a visit improved from 20.6% to 0%. All improvements were statistically significant (P < .001). Conclusion: A Schedule II controlled substance patient agreement was successfully implemented in a primary care practice reducing risk for both the patient and provider.

Sixteen phenethylamines are now included in Schedules I and II of the United Nations 1971 Convention on Psychotropic Substances. Most of the ring-substituted compounds are in Schedule I, whereas 2C-B, amphetamine, and methamphetamine are listed in Schedule II. Substances in Schedule IV (e.g. benzphetamine) are now regarded as obsolete pharmaceutical products. They all represent the 'old phenethylamines'. By 2013, nearly 100 illicit phenethylamines had been found in the European Union (EU). Of these, nine (MBDB, 4-MTA, PMMA, 2C-I, 2C-T-2, 2C-T-7, TMA-2, 5-IT and 4-MA) were submitted for risk assessment by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). All except MBDB were recommended for EU-wide control. Of the 'new phenethylamines', 2C-B was the most commonly reported, but other 2C compounds were widespread. Many of the ring-substituted phenethylamines are described in the 1991 book PIHKAL. Many fused ring phenethylamines have appeared in the past few years; they include further benzofurans (e.g. 5-and 6-APB), indanylalkylamines (e.g. 5-IAP), dibenzofurans (e.g. 2C-B-FLY) and 2-aminopropylindoles (e.g.5-IT). The recent and rapid rise of phenethylamines with bulky N-substituents (e.g. 25I-NBOMe) has been particularly significant. Although not phenethylamines, it is notable that the thiophene bioisosteres of amphetamine and methamphetamine as well as certain conformationally-restricted variants (e.g. aminoindanes) have been found in recent drug seizures. In the United Kingdom Misuse of Drugs Act, most ring-substituted phenethylamines are either listed by name or are covered by generic definitions dating from 1977. In 2013, temporary generic legislation included a number of benzofurans, indanylalkylamines and certain 'NBOMe' compounds.

Purpose To examine the age and gender-specific trends of Schedule II opioid use among California residents, with special reference to multiple provider users (doctor shoppers). Methods Utilizing data from the California Prescription Drug Monitoring Program, we examined age and gender-specific trends of Schedule II opioid use during calendar years 1999–2007. Specifically, we analyzed the following: (1) the prevalence of Schedule II opioid users among California's population and (2) the proportion of these opioid users who were doctor shoppers (defined as an individual who used more than five different prescribers for all Schedule II opioids he or she obtained in a calendar year). Results Among all age and gender groups, the prevalence of Schedule II opioid users in California increased by 150%–280% and the prevalence of doctor shoppers among users increased by 111%–213% over 9 years. The prevalence of opioid users was lowest among 18–44 year old men (1.25%) and highest among 65-year and older women (5.31%) by 2007. The prevalence of doctor shoppers was approximately 1.4% among those up to age 64 years and 0.5% among those 65 years and older. The gender difference in doctor shoppers among all age groups was negligible. On average, the cumulative morphine-equivalent amount of Schedule II opioid per individual obtained per year was threefold to sixfold higher for doctor shoppers than for the general population across different age and gender groups. Conclusions Age and gender differences in opioid use were relatively small, whereas the trends for use of opioids and multiple providers grew at a disquieting rate. Copyright © 2013 John Wiley & Sons, Ltd.

Doctor shopping (obtaining opioid prescriptions from multiple prescribers) is one example of opioid abuse and diversion. The authors assessed how soon shopping behavior was observed after opioid exposure, number of events per shopper, preferred opioids, and method of payment. This was a cohort study. Individuals with ≤1 dispensing for any opioid in 2008 were followed for 18 months. Shopping behavior was defined as ≤2 prescriptions by different prescribers with ≤1 day of overlap and filled at ≤3 pharmacies. Of 25,161,024 subjects, 0.30% exhibited shopping behavior. Opioid-experienced subjects were 13.7 times more likely to exhibit shopping behavior and had more shopping episodes than opioid-naive subjects. Time to first shopping event was 246.90 ± 163.61 days. Number of episodes was 2.74 ± 4.66. Most subjects with shopping behavior (55.27%) had 1 shopping episode, whereas 9.52% had ≤6 episodes; 88.99% had ≤4 prescribers. Subjects with shopping behavior filled schedule II opioids more often than subjects without shopping behavior (19.51% vs 10.89%) and more often paid in cash (44.85% vs 18.54%). Three of 1000 people exposed to opioids exhibit shopping behavior, on average, 8 months after exposure. Opioid shoppers seek strong opioids, avoid combination products, often pay cash, and obtain prescriptions from few prescribers.

Inappropriate prescribing is a rising threat to the health of Medicare beneficiaries and a drain on Medicare’s finances. In this study we used a randomized controlled trial approach to evaluate a low-cost, light-touch intervention aimed at reducing the inappropriate provision of Schedule II controlled substances in the Medicare Part D program. Potential overprescribers were sent a letter explaining that their practice patterns were highly unlike those of their peers. Using rich administrative data, we were unable to detect an effect of these letters on prescribing. We describe ongoing efforts to build on this null result with alternative interventions. Learning about the potential of light-touch interventions, both effective and ineffective, will help produce a better toolkit for policy makers to improve the value and safety of health care., Laura and John Arnold Foundation, Robert Wood Johnson Foundation

The Maine Prescription Monitoring Program (PMP) was created to prevent prescription drug misuse and diversion. The PMP collects data for all Schedule II, III and IV prescriptions dispensed by pharmacies licensed in Maine. This article presents a retrospective analysis of the PMP for prescribing trends and utilization patterns from state fiscal year 2006 to 2010. The sample included 11,542,850 Schedule prescriptions for 1,024,649 unduplicated patients in a 5-year database of the PMP. The number of controlled prescriptions steadily increased from 2.05 million in 2006 to 2.51 million in 2010. Opioid analgesics and stimulants were found to be the most commonly prescribed and fastest growing scheduled drug categories, respectively. Most individuals (82.9%) accessed their controlled drugs from one to two prescribers and pharmacies. Patients who utilized five prescribers and more used a greater number of pharmacies than those who utilized less than five prescribers (p < 0.001). The dramatic increase in the numbe...

The Drug Enforcement Administration (DEA) in late August successfully concluded its 10-year campaign to move hydrocodone-containing combination products from Schedule III of the Controlled Substances Act to the more tightly regulated Schedule II. DEA stated that the change affects several hundred

Adderall XR® (MAS XR) and Vyvanse™ (LDX) are both schedule II amphetamine-based central nervous system stimulants indicated for the treatment of attention-deficit/hyperactivity disorder. Differences among the two primarily involve dosage form, pharmacokinetic profiles, and abuse potential. MAS XR and LDX are both long-acting stimulants with an approximate duration of action of 10 hours. The long-acting property of LDX is secondary to its prodrug formulation, whereas MAS XR utilizes bead filled capsules that mimic twice daily dosing upon administration. MAS XR is a substrate of CYP 2D6 while LDX does not utilize the cytochrome P450 enzymes for metabolism. There are few efficacy studies that directly compare LDX and MAS XR. There are no head to head abuse liability studies for MAS XR and LDX; however, the prodrug formulation of LDX is proposed to have lower abuse potential.

The World Health Organization Disability Assessment Schedule II (WHO-DAS II) is a non-disease-specific International Classification of Functioning, Disability, and Health-based disability assessment instrument developed to measure activity limitations and restrictions to participation. The aim of this pilot study is to evaluate WHO-DAS II responsiveness in detecting short-time changes following the provision of an Assistive Technology,which is important to define its utility in performing daily activities. Adult inpatients with a diagnosis of Disease of the Nervous System (included in Chapter VI of the ICD-10),who were prescribed an Assistive Technology to be used in the household settings, were enrolled. The WHO-DAS II was administered in individual interview at baseline and at a 2 months follow-up: in this period patients were transitioning from the hospital to home. Changes in disability profiles were detected by calculating the effect size (ES) for each WHO-DAS II domain. Ten patients with different neurological diseases were enrolled. Few longitudinal changes in disability level are reported: mild improvement is observed in the household activities (ES0.28), whereas mild worsening is reported in self-care and participation in society domains (ES – 0.27 and – 0.26,respectively). Our study shows that the WHO-DAS II is responsive in detecting domain-specific changes over a short-term period and provides preliminary encouraging evidence for the utility of its utilization in clinical settings.However, changes in setting between baseline and follow up could have an impact on the findings and interpretation of this study.

The Drug Enforcement Agency (DEA) may be restricting the ability of RNs and LPNs in assisted living communities (ALCs) in some states to provide pain relief for residents. The DEAs enforcement of the requirements of the Controlled Substances Act (CSA) to reduce diversion of controlled substances (particularly Schedule II meds) for criminal or nefarious reasons, has generated a variety of responses by pharmacies, ALCs, and practitioners. Residents are at risk for--and some residents have already experienced--inadequate pain management. The argument seems to turn on whether an ALC (or nursing home or home health nurse) is an "agent" of the physician. The term "agent" is poorly defined in section 1300 of the CSA. It neither confirms that an ALC/long-term care (LTC) nurse/medical aide may function as an agent of the provider nor does the definition preclude the ALC/LTC nurse/medical aide as the agent of the provider. This article is an alert to ALCs to examine their controlled drug procurement and pain management procedures and is also a call to advocacy by ALC nurses.

To describe functioning and disability of patients with Parkinson's Disease (PD) according to the model endorsed by the International Classification of Functioning Disability and Health (ICF).Adult PD patients were consecutively enrolled. The ICF checklist and the WHO Disability Assessment Schedule II (WHO-DAS II) were administered in individual sessions. Hoehn and Yahr Staging (HY) was used to define PD severity. Descriptive analyses have been performed to report on HY and WHO-DAS II scores. ICF categories reported as a problem by more than 20% of patients are described in detail.Ninety-six patients with PD (mean age 64.1, 33.3% females) were enrolled, 48.4% of them were in HY class 2. WHO-DAS II mean score was 18.1 and the most severe limitations are reported in getting around and in participation to social situations. A total of 71 ICF categories reached the threshold of 20%, mostly derived from Activities and Participation domain.We reported information on a broad set of domains, expanding those PD-specific, such as reduced mobility. Our results are useful to define what dimensions have to be considered to expand disability assessment in patients with PD, considering both symptoms, activities and the role of environmental factors.

To describe functioning and disability in patients with stable ischaemic heart disease (IHD) according to the model endorsed by the International Classification of Functioning Disability and Health (ICF).Adult patients with IHD undergoing rehabilitation were consecutively enrolled. The ICF checklist and the WHO Disability Assessment Schedule II (WHO-DAS II) were administered in individual sessions. Patients' clinical status was described following NYAH criteria (New York Heart Association). Descriptive analyses were performed to report on clinical variables and WHO-DAS II scores. ICF categories reported as a problem by more than 20% of patients were described in detail.One hundred patients (mean age 62.9; 91% males, 71% in NYHA class II) were enrolled. Mean WHO-DAS II score was 23.9, and the most severe limitations are reported in life activities, getting around and in participation to social situations. A total of 30 ICF categories reached the threshold of 20%, 17 Body Functions and Structures, 13 Activities and Participation.ICF application in patients with IHD enables to enlarge the perspective on their health status, and provide useful information to follow the healthcare process from the acute setting to the outpatient management.

To describe functioning and disability in patients with multiple sclerosis (MS) according to the model endorsed by the International Classification of Functioning Disability and Health (ICF).Adult patients with MS were consecutively enrolled. The Expanded Disability Status Scale (EDSS), the WHO Disability Assessment Schedule II (WHO-DAS II) and the ICF checklist were administered in individual sessions. Descriptive analyses were performed to report on EDSS and WHO-DAS II scores. ICF categories reported as a problem by more than 20% of patients were described in detail.One hundred patients (70 females, mean age 41.7), 73 with relapsing-remitting MS were enrolled. Mean WHO-DAS II score was 10.6 and 58 ICF categories were selected: 23 Body Functions and Structures, 21 Activities and Participation and 14 Environmental Factors.The ICF can be successfully implemented in clinical and rehabilitation of patients with MS, because it enables to describe its multiple facets. Little differences between capacity and performance in ICF categories connected with activities of daily living, and presence of technical aids and other environmental factors are reported. On the contrary, in categories related to relationships, performance was worse than capacity thus revealing attitudinal barriers.

This study is a preliminary psychometric evaluation of the Korean language version of the Health Behavior Schedule-II as a predictor of compliance or adherence to 12 health related habits. The 12 habits are (1) performing breast self-exams; (2) obtaining pap smear screens; (3) taking medication as prescribed; (4) not smoking cigarettes; (5) wearing a bike safety helmet (if applicable); (6) protecting skin from sun; (7) flossing teeth daily; (8) wearing a seat-belt; (9) limiting alcohol consumption; (10) practicing safe sex; (11) exercising regularly; and (12) eating a healthy diet. Predictors of compliance on the Schedule include 45 situational and behavioral competency factors. Past studies have shown the Schedule to be useful for a multiethnic sample of university students in Honolulu, USA and for a mono-ethnic university sample in Stuttgart, Germany. Among a mono-ethnic university sample in Seoul, Republic of Korea, this study found the Korean version of the Schedule yielded acceptable internal consistency and stability reliability estimates. Construct validity was supported for prediction of compliance to 11 of the 12 health behaviors. Compliance enhancement implications are offered.

Multiple same-day prescriptions for Schedule II medications offer the flexibility to provide continuous access to necessary medication without requiring that stabilized patients unnecessarily visit their prescriber on a monthly basis. The federal Drug Enforcement Administration recently promulgated a new regulation that specifically authorizes the use of multiple prescriptions. This is a change in policy within the agency. Health care professionals must communicate to each other that this useful practice is now recognized as being completely legal.

Advanced practice nurses play significant roles in providing care to patients with advanced disease. Their roles are enhanced when they can prescribe controlled substances, especially opioid analgesics essential for the management of moderate to severe pain in persons at the end of life. A review of state laws and regulations shows that although advanced practice nurses have some degree of prescriptive authority in all 50 states and the District of Columbia, there are restrictions on their prescribing of controlled substances. In 40 states, advanced practice nurses have differing authorities to prescribe schedule II-V controlled substances; in eight states they can prescribe only schedule III-V drugs. Three states do not allow advanced practice nurses to prescribe controlled substances. Inappropriate restrictions on the ability of advanced practice nurses to prescribe the full range of controlled substances needed to control pain and other symptoms may negatively affect quality of care, especially in persons at the end of life.