Controlled Substance and Banned Medications Policy

📚Definitions

Bridge Prescriptions: Temporary prescriptions to ensure uninterrupted treatment while transitioning to another provider or medication.
Controlled Substances: Medications regulated by federal and state laws due to potential for abuse and dependency.
PDMP (Prescription Drug Monitoring Program): A state-level database that tracks controlled substance prescriptions to prevent abuse and diversion.
Prohibited Medications: Specific drugs not permitted for prescription within this organization.
Quantity Restrictions: Limits on the number of pills or doses prescribed at one time.

🗺️ Overview

Background

This facility is committed to providing high-quality healthcare services, including the responsible and safe prescription of controlled substances. This policy ensures that all providers and staff adhere to best practices and regulatory requirements when prescribing, monitoring, and managing controlled substances to prioritize patient safety and high standards of care.

Scope

This policy outlines guidelines for the prescription, monitoring, and management of controlled substances and non-controlled prohibited medications. It applies to all clinicians on the Provider Team involved in prescribing and handling these substances.

🚨 Policy Requirements

Best Practices

PDMP Verification: Providers must check the patient's state PDMP before every controlled substance prescription.
Identity Verification: Providers must verify the patient's identity by reviewing their government-issued identification.
Follow-up Plan: Establish a routinely scheduled appointment for ongoing monitoring.

Informed Consent & Controlled Substance Agreement (CSA)

All patients being prescribed a controlled substance need to have a CSA on file that is updated annually. The following must be reviewed synchronously with the patient and documented:

Clinical Review: Risks, benefits, possible side effects, and alternatives to the prescribed treatment.
Dosing: Dosing strategies and the use of the minimum effective dose of the medication.
Holistic Care: Medication must be part of a comprehensive treatment plan.
Adjustments and Replacements: Early refills, lost medications, and increases in dosage require a video or office visit to assess if replacement or increases are appropriate. These requests cannot be managed via chat.

Procedures & Follow-up Requirements

ADHD Patients: Stable ADHD patients require a monthly follow-up via in-person appointment. Stimulant medications are prescribed one month at a time.
Non-ADHD Controlled Substances: A visit is required for any controlled substance prescription, including treatments for insomnia or anxiety. These medications will be reviewed on an as-needed basis. Cases may be discussed with Dr. Yang
Quantity Limits: For conditions other than ADHD, non-stimulant controlled substances are limited to a 30-day supply, with quantities generally restricted to 12–15 units per 30 days.
Annual Wellness Exam (AWE): A mandatory requirement for patients receiving care for ADHD, depression, or anxiety. A baseline AWE must be on record before prescribing ADHD stimulants.

Blood Pressure / Heart Rate Monitoring

As a primary care practice, we care about the patient as a whole. Though the risks of blood pressure elevations and tachycardia are minimal in young, healthy patients on stimulants, it is not negligible. Furthermore, elevated blood pressure can often be asymptomatic.

Baseline Vitals: Obtaining a baseline set of vital signs (before starting stimulants) is up to the provider’s judgment based on the patient’s personal risk factors, such as weight, health status, and family history.
Ongoing Monitoring: Once a stimulant has been started, it is best to obtain a set of vital signs when the patient’s treatment has stabilized at every appointment. We recommend obtaining updated vital signs at every appointment.

Refills and Renewals

Schedule II Medications: These medications cannot be refilled and can only be filled once. Once a prescription is used, it becomes invalid.

This includes cases where a partial fill was made due to inventory.
A new prescription will be required for the remaining quantity; this is not considered a refill of the original prescription, but rather the provision of a new prescription to complete the original intended therapy.

Schedules III–V: These may have refills as permitted by state law (often limited to five refills in six months).
Refill Determination: The appropriateness of a refill must be determined during the visit and included in the original prescription.
Refill Requests: Refills for controlled substance medications requested via chat features will NOT be granted. Any patients requesting refills via chat will be advised to book an appointment.
Lost or Stolen Medications: No early fills will be given for lost, stolen, or misplaced pills.

Drug Screening

Drug screens (urine, saliva, or blood) are used to monitor adherence and detect potential misuse. While routine screening is not mandatory, providers reserve the right to order a screen if medically necessary, such as for patients with a history of substance use disorder or those requesting frequent early refills.

Bridge Controlled Substance (CS) Prescriptions

Bridge prescriptions are intended only for patients establishing long-term care within this practice.

Intent of Care: If a patient does not plan to utilize this practice for the primary management for their primary care or for specific CS med, DO NOT write for bridge prescriptions.
Existing ADHD Diagnosis: A two-week (14 day) bridge for existing ADHD treatments may be provided only if:

The Annual Wellness Exam (AWE) requirement is met.
A Controlled Substance Agreement (CSA) is signed and on file.
The PDMP confirms a stable, existing treatment regimen.
Medical records have been formally requested. Need Clinical SOAP notes from previous PCP or Psychiatrist

Re-evaluation: If a diagnosis was received from another platform or is over 10 years old without accessible records, the patient must be re-evaluated as a "new diagnosis."

Clinical Suitability & Enrollment Criteria

We are unable to accept patients into the practice for mental health management if they are taking certain medications in a chronic manner. These patients must be referred to a provider outside of this practice for ongoing care.

Not a good fit for mental health management:

Any patient taking chronic daily opioids managed by their PCP (see Special Considerations for patients on chronic opioids managed by a specialist).
Chronic daily benzodiazepines.
Chronic nightly sedative/hypnotics.
Recent opioid prescription filled by urgent care or ER without adequate diagnosis, treatment plan, or follow-up.
Recent inpatient hospitalization for mental health or substance use disorder (within the last 12 months).
On a methadone treatment program (note: methadone dispensed at a clinic may not appear on PDMP).
Patients using Kratom.
Patients actively taking and unwilling to stop or taper off the chronic daily narcotics listed above. (Tapers should occur under the supervision of the original prescribing provider).
Patients who were not forthcoming about previous prescriptions or purposefully not being truthful (damaged therapeutic relationship).

🛑 Exceptions & Prohibited Meds

Exceptions and Primary Care

Buprenorphine: While patients can be on concurrent buprenorphine treatment managed by an outside clinician, they cannot obtain buprenorphine treatment at this practice.
Primary Care Concerns: These patients can still be seen for primary care concerns. Providers must communicate clearly that this practice will not take over prescribing any of the aforementioned medications. Document the specialist’s name and practice info managing their chronic CS medications.

Prohibited Medications

Prescriptions for buprenorphine (Suboxone/Subutex) for opioid use disorder are not issued by this practice. Patients on these treatments must have them managed by an outside specialist.

If you have any questions or would like more information, please reach out to the Delegating Physician.