Prescribing Controlled Substances FAQs


Board rules governing controlled substances prescribing

540-X-4, Alabama Controlled Substances Certificate
540-X-12, Qualified Alabama Controlled Substances Certificate (P. A.)
540-X-17, Guidelines and Standards for the Utilization of Controlled Substances for Weight Reduction
540-X-18, Qualified Alabama Controlled Substances Certificate (CRNP/CNM)
540-X-19, Standards for Pain Management Services
540-X-20, Limited Purpose Schedule II Permit (P. A./CRNP/CNM)

All of these rules can be accessed through the Alabama Administrative Code web site


Morphine Milligram Equivalents (MMEs)

The Board does not recommend a particular calculator. Use the one that you prefer. Below are links to a variety of MME calculators. This list is not exhaustive nor is it an endorsement of these sites:


Opioid dose reference guide with indicators of when a PDMP check is required


PDMP query results display MME values.  You can query by patient or query yourself to determine MMEs being prescribed to your patients.  Look for the column entitled "MED."  If you do not see the column, view in landscape mode.


Tapentadol/atypical opioids and buprenorphine

FDA-approved daily dosage thresholds are higher for Tapentadol and other atypical opioids. The Board has not placed limits on dosage amounts but does require RMS and PDMP checks for dosages over certain MMEs.


Validated risk-assessment tools

The use of validated risk assessment tools as a part of your risk and abuse mitigation strategies is a suggestion by the Board for best practices.  Their use will vary from patient to patient.  For some practices, their use may not be appropriate at all. 

Not using the validated risk assessment tools is not a violation of the rule; however, failure to incorporate any risk and abuse mitigation strategies could be used to determine a practice pattern and whether it is within the recognized standard of care.

The following are examples of validates risk-assessment tools. This is not an exhaustive list. There may be other validated risk-assessment tools that you prefer.


CME requirement for Alabama Controlled Substances Certificate registrants 

 Beginning Jan. 1, 2018, all Alabama Controlled Substances Certificate holders will be required to obtain two (2) AMA PRA Category 1 (TM) credits or equivalent (Cat. 1-A, prescribed hours, cognates) every two years in the areas of:

  • Controlled substance prescribing practices,
  • Recognizing signs of the abuse or misuse of controlled substances, or
  • Controlled substance prescribing for chronic pain management. 

This is a requirement.  Failure to obtain the required CME is a violation of the rule and could result in disciplinary action.


I hold an ACSC but I am exempt from the annual 25 credit requirement for license renewal, do I still have to obtain these credits?

Yes.  ACSC holders who are otherwise exempt from the CME requirement (residents, fellows, initial licensure year, military service) must still obtain the two credits every two years.


Does the Board have to pre-approve the courses I take?  Does it have to be a live activity?  Does it have to be obtained in Alabama? 

No.  You do not need to obtain pre-approval from the Board of the course you choose, just be sure the course confers Category 1 credit and is in one of the areas described above.  The course may be live, through the internet, or any other method as long as the activity confers Category 1 credit.  It does not have to be obtained in Alabama.

How do I find appropriate courses?

An internet search of "Category 1 controlled substances prescribing," or something more tailored to your practice, such as prescribing ADD medicine or prescribing for chronic pain, should give multiple results.  ACSC holders that do not write prescriptions for controlled substances could take a course concerning the use of fentanyl during surgery, for example.

The Board maintains a list of controlled substances CME opportunities (maintained as a courtesy; not an exhaustive list)


If I obtain the CME in 2017 (or earlier) will that meet the new requirement?

No.  this requirement is interpreted to encompass credits earned in the calendar year 2018 and forward.  Credits earned in 2017 or earlier may not be carried forward to meet this requirement.


I am a nurse practitioner or physician assistant with a QACSC -- do I have to meet the new CME requirement in the Risk and Abuse Mitigation Strategies rule?

No.  QACSC holders have an existing CME requirement to which they should adhere (see Rules 540-X- 540-X-12-.05(3) and 540-X-18-.05(2)).


I do not prescribe opioids at all, does the CME requirement apply to me?

Yes.  All physicians holding an ACSC are subject to the new CME requirement.  The CME can be in the areas of prescribing of controlled substances generally and recognizing the signs of abuse and misuse.  CME activities in the specific areas of prescribing controlled substances in the treatment of ADD or mental disorders, for example, would meet the requirement.


Querying the PDMP 

These are requirements, and failure to meet them could be deemed a violation of the rule.

The RMS rule requires the following:

  • For 30 MME or less per day, use PDMP in a manner consistent with good clinical practice

  • For more than 30 MME per day, review PDMP at least two times per year and document use of REMS in medical record

  • For more than 90 MME per day*, review PDMP every time prescriptions are written, on the same day the prescriptions are written, and document use of REMs in medical record

    *Cumulative of all prescriptions written on the same day

Exemptions  

The rule exempts the PDMP query requirements for controlled substances prescriptions written for:

  • Nursing home patients

  • Hospice patients, where the prescription indicates hospice on the physical prescription

  • Treatment of active, malignant pain*, or

  • Intra-operative care**

  • In-hospital (in-patient orders) prescribing (PDMP query rule does apply to prescriptions written at discharge)

*Active, malignant pain means active cancer pain; it does not include acute pain, chronic malignant (cancer) pain, or other chronic pain

 **Intra-operative care means c.s. ordered, administered, or prescribed and filled in a hospital in connection with a procedure; it does not include prescriptions written to go home with the patient.


Is PDMP query required for future fills of Schedule II prescriptions for over 90 MME with delayed fill instructions?

No. The rule requires a PDMP query every time a prescription for more than 90 MME per day is written, "on the same day the prescription is written." You are not required to perform a PDMP query when the future fill dates arrive. However, it may be appropriate as part of your risk and abuse mitigation strategies to query some patients' prescription histories more frequently.


Concurrent use of opioids and benzodiazepines

The Risk and Abuse Mitigation Strategies rule states the following regarding the concurrent use of opioids and benzodiazepines:

Due to the heightened risk of adverse events associated with the concurrent use of opioids and benzodiazepines, physicians should reconsider a patient's existing benzodiazepine prescriptions or decline to add one when prescribing an opioid and consider alternative forms of treatment.

This is a description of best practices.  You are not required to take all of your patients off of the combination of opioids and benzodiazepines. 

It is the Board's recommendation that you review your existing patients’ benzodiazepine prescriptions, consider whether a reduction in dose, another medication, or alternative treatments would be appropriate, use risk and abuse mitigation strategies and the PDMP as appropriate (and document their use in the medical record), and consider not adding a benzodiazepine when prescribing opiates.


POLYPHARMACY

The Risk and Abuse Mitigation Strategies rule states the following regarding the use of multiple classes of controlled substances:

The Board recognizes that all controlled substances, including but not limited to, opiates, benzodiazepines, stimulants, anticonvulsants, and sedative hypnotics, have a risk of addiction, misuse, and diversion. Physicians are expected to use risk and abuse mitigation strategies when prescribing any controlled substance. Additional care should be used by the physician when prescribing a patient medication from multiple controlled substance drug classes. 

This is an advisement of best practices.  Failure to adhere could be used against the prescriber in the event a patient were harmed.


Exemptions

  • Use of risk and abuse mitigation strategies - applies to all ACSC holders. 
    Some or most of the risk and abuse mitigation strategies may not apply to your practice, but if you prescribe controlled substances of any kind (including non-opioid medications), some of the strategies may be appropriate or necessary.

  • PDMP query - see Querying the PDMP

  • Mandatory CME - applies to all ACSC holders, whether controlled substances are actually written or not


Risk and Abuse Mitigation Strategies rule and mid-level practitioners

QACSC holders must prescribe controlled substances in accordance with the requirements of all Board rules, including the Risk and Abuse Mitigation Strategies rule.  It is a ground for revocation of a QACSC to prescribe controlled substances in violation of a Board rule. 

QACSC holders have a separate CME requirement and should continue to adhere to it.


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