Prescribing Controlled Substances – What to Know
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Controlled substances are considered drugs under the Controlled Substances Act, which places drugs into one of five schedules or categories. Each substance is placed in a designated schedule based on its medical use, potential for abuse, dependence potential, and risk to public health. Examples of controlled substances include opioids, stimulants, hallucinogens, anabolic steroids, and depressants. Popular substances are morphine, Oxycodone, Valium, Xanax, LSD, heroin, and methamphetamines.
The federal government oversees all controlled substances’ manufacture, importation, possession, and distribution. Distributors, manufactures, and dispensers must register with the Drug Enforcement Agency (DEA). The mission of the DEA is to enforce the laws and regulations regarding controlled substances and bring to justice any persons involved in illicit drug trafficking in the USA. It also supports non-enforcement programs that work to reduce the availability of illicit controlled drugs in domestic and international markets.
The Five Schedules of Controlled Substances
Schedule I drugs are the most likely to be abused and most likely to cause physical and psychological dependence. Schedule 1 drugs are chemical compounds without any accepted medical applications. Examples include heroin and LSD.
Schedule II drugs have some medical use but still have a high potential for abuse and dependence. These include narcotics. Examples are morphine, codeine, oxycodone, Adderall, fentanyl, methamphetamine, and methadone.
Schedule III substances are less potent than Schedule I and II. They have a low to moderate potential for causing dependence. Schedule III substances include anabolic steroids, testosterone, and ketamine.
Schedule IV drugs have a low potential for abuse compared to Schedule III drugs, and are mostly anti-anxiety or sleeping medications. Examples are Xanax, Valium, Ativan, lorazepam, temazepam, and Klonopin. One common pain medication in this Schedule is tramadol.
Schedule V drugs are mostly preparations containing limited amounts of certain narcotics. For instance, cough syrup with 200 mg of codeine per 100 ml. Other examples of substances in this category are Lyrica and Lomotil.
Prescribing Controlled Substances
For a nurse practitioner or any healthcare provider to prescribe controlled substances, they would need to apply for a DEA certification. The cost to obtain a DEA certification is $888 and must be renewed every threee years. If an NP moves to another state, they must apply for their DEA certification to be transferred to the new state. There is no cost for this but the process can take one to two weeks.
Depending on the state, the NP may additionally need to apply for a furnishing license. This is an additional state license allowing the NP to prescribe controlled substances there. It can be known by other names such as prescriptive authority or controlled substance permit. States have this additional requirement to regulate controlled substances being prescribed.
Many states require the NP to take a three-hour, board-approved controlled substance continuing education course every two years prior to renewal of their license. The purpose of the continuing education is to demonstrate competency in preventing substance abuse or treating patients with substance use disorders.
What is the Prescriptive Drug Monitoring Program?
Before prescribing controlled substances such as opioids and anti-anxiety medications, the NP should check the prescriptive drug monitoring program (PDMP). Each state has its own PDMP which allows the prescriber to look up patients. It will outline the last time the patient filled a prescription for all controlled medications, who the prescriber was, and how many tablets or capsules were dispensed.
PDMPs are the most effective state-level interventions to improve opioid prescribing, protect at-risk patients, and inform clinical practice. When evaluating the effectiveness of PDMPs, findings have shown changes in prescribing behaviors, a decrease in the use of multiple providers by patients, and a decrease in substance abuse treatment admissions.
A PDMP is only useful if healthcare providers check the platform before prescribing controlled substances. To enforce this, some states have executed policies that require providers to check a state PDMP before prescribing any controlled substances. Many practices have integrated the PDMPs into their electronic health record (EHR) systems to make it easier to access for providers. Some states allow clinicians to delegate PDMP access to allied health professionals in their offices. This way, the medical assistant can print out the PDMP report during the patient’s visit, so the prescriber can be prepared.
The PDMP is very important in prescribing controlled substances because it can help prevent “doctor shopping.” Doctor shopping is when a patient jumps from clinic to clinic to obtain prescriptions for controlled medications. Sometimes these patients even cross state borders to obtain these drugs. A doctor-shopping patient shows that they do not have a good relationship with one provider and are likely only interested in being prescribed narcotics. These patients will go to multiple healthcare facilities including the emergency department to get these pills.
Once a pharmacist dispenses a controlled substance to a patient, they must enter the prescription into the state PDMP. This is mainly done promptly, so prescribers can have that information available to them right away. State health departments also use PDMP databases to comprehend the behavior of the opioid epidemic and evaluate interventions.
What is the Controlled Substance Agreement?
If the NP decides to be an ongoing prescriber for controlled substances such as narcotics, they should have a controlled substance agreement in place with each patient. This is a written and signed agreement between a prescriber and a patient using controlled substances. It covers the risks and expectations of taking the medication and is recommended by clinical practice guidelines.
This agreement lists all the rules the patient would need to follow for the NP to continue prescribing narcotics for them. Some of the rules include:
- Agreeing to random urine drug screenings
- Not obtaining a refill of the medication from another provider (this includes even the ER or surgeons)
- Bringing the bottle of pills to each visit to count how many are left (to make sure the patient is not finishing the prescription early by overdosing or selling the drug)
- Naloxone use
- Proper disposal of medications
The purpose of the agreement is to increase adherence and alleviate risk of opioid prescribing.
Patients sign and initial each section of the contract, showing understanding that the provider will stop prescribing the controlled substances if the patient breaks the agreement. Patients agree to the understanding that controlled substances have potential risks and side effects, including the risk of addiction. They agree not to share, sell, or trade their medication with anyone. They understand that the provider may eventually decide to wean them off from controlled substances or refer them to pain management.
Urine Drug Screen
Many NPs who prescribe controlled substances to their patients will order urine drug screens during an appointment or even randomly. A urine drug screen will confirm that the patient is taking the medication as prescribed (it should still be in their system at that time) and that they are not taking any additional illicit drugs.
A urine drug test detects the drug in the urine, a drug metabolite, or biomarkers that may suggest use or misuse. A biomarker is a measurable substance present after taking a drug. A metabolite is a type of biomarker that remains in the body when a drug is processed. Depending on the drug, it can be detected in the urine for days, weeks, or even months after use. If the patient fails the urine drug screen or breaks the controlled substance agreement, the NP can decide to discontinue ongoing refills for the patient.
Electronic Prescribing
Many institutions have moved forward with electronic prescribing (e-prescribe), including controlled substance prescriptions. In fact, some states require that controlled substance prescriptions are only accepted via a prescription that is electronically transmitted to a pharmacy. That means the prescriber or office staff cannot call the prescription into the pharmacy.
A clinician must complete a two-factor authentication to successfully prescribe a controlled substance electronically. Two-factor authentication examples include using a password and receiving a code via a verification application on the prescriber’s phone, which they would have to input into the EHR. This guarantees that only the prescriber can submit the prescription.
E-prescribing controlled substances prevents patients from altering the authentic written prescription. It also prevents patients or clinic staff from stealing prescription paper or pads and writing fake prescriptions. It even addresses concerns about fraud by providing an electronic record that helps evaluate possible misuse of the drugs.
Summary: What NPs Should Know About Prescribing Controlled Substances
Nowadays, many providers want to avoid prescribing controlled substances due to risk of misuse or overdose. However, NPs may find themselves working in institutions that require prescribing controlled substances. Or they may work in rural areas without access to pain management clinics or behavioral health centers. In these cases, the NP should ensure they are registered with the DEA and have a controlled substance permit if their state requires it.
In their practice, NPs should create a controlled substance agreement and implement it with their patients receiving these medications. They should also utilize the PDMP of their state before each prescription, and order urine drug screens routinely. Lastly, NPs ought to e-prescribe controlled medications to prevent fraud.
Sophia Khawly, MSN
WriterSophia Khawly is a traveling nurse practitioner from Miami, Florida. She has been a nurse for 14 years and has worked in nine different states. She likes to travel in her spare time and has visited over 40 countries.
Being a traveling nurse practitioner allows her to combine her love of learning, travel, and serving others. Learn more about Sophia at www.travelingNP.com.