Prescribing Controlled Substances FAQs
- Board rules governing controlled substances prescribing
- Morphine Milligram Equivalents (MMEs)
- Validated risk-assessment tools
- CME requirement for ACSC/QACSC holders
- Querying the PDMP
- Concurrent use of opioids and benzodiazepines
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
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:
- Epocrates (requires sign in)
- Centers for Medicare & Medicaid Services (.pdf)
- Lexicomp (requires sign in)
- OpioidCalc (free app: Android iTunes)
- Washington State Agency Medical Directors' Group
- CDC Calculating Daily Dose brochure (.pdf)
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.
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.
- BRI - Brief Risk Interview (free download at www.tedjonesresearch.com)
- DIRE - Diagnosis, Intractability, Risk, Efficacy score (link to .pdf copy)
- ORT - Opioid Risk Tool (link to .pdf copy)
- PMQ - Pain Medication Questionnaire (link to download a copy)
- SOAPP - Screener and Opioid Assessment for Patients with Pain (link to a copy; info about use and fees)
- SOAPP-R - Screener and Opioid Assessment for Patients with Pain - Revised (link to a copy; info about use and fees)
- BRQ - Brief Risk Questionnaire (free download at www.tedjonesresearch.com)
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.
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 requrement (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.
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
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
*Active, malignant pain includes cancer 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.
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.
The Risk and Abuse Mitigation Strategies rule states the following regarding the concurrent use of opioids and
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.
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.
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
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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