Central nervous system depressant

DEA schedule IV controlled substance: potential for dependence and abuse, especially in context of concurrent multisubstance abuse

Known to cause tolerance, with potential for withdrawal syndrome

Studies demonstrate cognitive impairment with prolonged use (> 1 year) that may be irreversible

Current guidelines recommend avoidance in older patients

Establish a formal narcotic agreement, with periodic random urine drug screening

Discontinuation must be tapered to avoid precipitating withdrawal syndrome

Adding imipramine (Tofranil) or melatonin to support progressive tapering may enable higher rates of sustained discontinuation

Consider alternative pharmacotherapies (i.e., sedating antidepressants, antiepileptics, antihistamines)

May be helpful to provide written information on associated risks and the plan for gradually reduced use

Limited clinical indications for use (e.g., congestive heart failure)

Should not be used as an antihypertensive unless concomitant advanced chronic kidney disease (i.e., glomerular filtration rate < 30 mL per minute per 1.73 m²) is also present

Review old records to determine indication for use

No known concerns with discontinuation

DEA schedule II controlled substance: moderate to high potential for abuse and dependence

Risk of endocrinopathy associated with chronic use

Potential consequences for patient quality of life, including opioid-induced depression, osteoporosis, hyperalgesia, decreased libido, and concerns of diminished fertility (women) or erectile dysfunction (men)

Establish a formal narcotic agreement, with periodic random urine drug screening

Conduct a thorough review of pain history and any prior workup or interventions

Consider use of adjunctive therapies (e.g., gabapentin [Neurontin], amitriptyline)

Consider referral to a comprehensive pain management team

Prolonged use is appropriate only for specific indications (e.g., erosive esophagitis)

Prolonged use (> 1 year) may increase the risk of fragility fractures, osteoporosis, and Clostridium difficile colitis or other enteric infections

Weak or conflicting data also suggest increased risk of community-acquired pneumonia, interstitial nephritis (rare, idiosyncratic reaction), benign gastric polyps, hypomagnesemia, and vitamin B₁₂ deficiency (in older patients)

No guidelines currently available for weaning

Potential for rebound acid hypersecretion or recurrence of GERD symptoms

On-demand proton pump inhibitor dosing strategy demonstrates equal effectiveness, lower cost, and superior patient satisfaction compared with continuous therapy for endoscopy-negative GERD

Schedule close follow-up when weaning older patients and other susceptible populations with comorbidities