FREQUENTLY ASKED QUESTIONS ABOUT PRESCRIBING CONTROLLED SUBSTANCES

Transcription

1 FREQUENTLY ASKED QUESTIONS ABOUT PRESCRIBING CONTROLLED SUBSTANCES Hw d I knw if I am eligible t prescribe cntrlled substances? The Bard f Nursing shuld have infrmatin abut the state s laws that determine if yu are eligible t prescribe cntrlled substances (CSs). Alabama and Flrida d nt authrize any Advanced Practice Registered Nurses (APRNs) t prescribe CS. In sme states prescribing CSs may be limited t a certain APRN rle such as a nurse practitiner. In states where there is delegatin f prescriptive authrity r that require cllabratin r supervisin fr APRN prescribing there may be special requirements fr eligibility. What is the prcess fr btaining authrity t prescribe cntrlled substances? First btain prescriptive authrity in yur state. In sme states, prescriptive authrity is part f licensure while in ther states it requires a separate applicatin. If state registratin r a license fr prescribing CSs is required, yu will need t cmplete that prcess befre applying t the Drug Enfrcement Administratin (DEA) fr registratin. DEA registratin is required fr anyne wh prescribes CSs. If a written agreement r ther dcumentatin is required t prescribe CSs that must als be finalized befre yu can prescribe CSs. Hw d I apply fr DEA registratin? Apply fr DEA registratin nline at Yu must have prescriptive authrity fr cntrlled substances and meet all state requirements. Yu must prvide the state registratin r license number fr prescribing cntrlled substances if ne is required. Registratin csts $551 and is valid fr 3 years. Yu will register with yur wrk site and yu will need t change the registratin lcatin fr new emplyment. Yu must register fr each state in which yu practice which requires a new applicatin and fee fr each state. Yu may use a hspital r institutinal registratin rather than btaining an individual registratin if yu are an emplyee r agent f the facility. The requirement f registratin is waived fr any fficial f the U.S. Army, Navy, Marine Crps, Air Frce, Cast Guard, Public Health Service, r Bureau f Prisns wh is authrized t prescribe, dispense, r administer CSs in the curse f his/her fficial duties. What are Schedule I drugs? Substances in Schedule I have n currently accepted medical use in treatment in the United States, a lack f accepted safety fr use under medical supervisin, and a high ptential fr abuse. Sme examples f substances listed in Schedule I are herin; lysergic acid diethylamide (LSD); marijuana (cannabis); peyte; methaqualne; and methylene-dimethxymethamphetamine ("ecstasy"). Schedule I drugs are illegal t prescribe. American Nurses Assciatin Department f Nursing Practice and Plicy Prepared by Luise Kaplan, PhD, ARNP, FNP-BC, FAANP

2 What are Schedule II drugs? Schedule II drugs have a high ptential fr abuse that may lead t severe psychlgical r physical dependence. Examples include: Mrphine, methadne (Dlphine ), meperidine (Demerl ), fentanyl (Duragesic ) Oxycdne (Perccet, Oxycntin ), hydrmrphne (Dilaudid ) Amphetamines (Ritalin, Cncerta ) Ccaine, ambarbital and pentbarbital What are Schedule III drugs? Schedule III drugs have less ptential fr abuse than Schedule II drugs. Abuse may lead t mderate r lw physical dependence but high psychlgical dependence. Examples include: Cmbinatin prducts cntaining less than 15 milligrams f hydrcdne per dsage unit (Vicdin ) Prducts cntaining nt mre than 90 milligrams f cdeine per dsage unit (Tylenl with Cdeine N. 3) Butalbital (Firinal, Firicet ) Teststerne What are Schedule IV drugs? Schedule IV drugs have less ptential fr abuse relative t Schedule III. Abuse leads t less physical r psychlgical dependence relative t Schedule III. Examples include: Benzdiazepines (e.g. Valium, Xanax, Ativan ) Zlpidem (Ambien ) Pentazcine (Talwin ) Temazepam (Restril ) What are Schedule V drugs? Schedule V drugs have a lw ptential fr abuse relative t ther cntrlled substances. Abuse leads t limited physical r psychlgical dependence relative t drugs in Schedule IV. Examples include: Cugh syrup with cdeine (Rbitussin AC ) Diphenxylate preparatins (Lmtil ) American Nurses Assciatin Department f Nursing Practice and Plicy Prepared by Luise Kaplan, PhD, ARNP, FNP-BC, FAANP

3 What is required n the prescriptin fr a CS? Federal requirements fr a prescriptin fr a CS are: Prescriber s name, address, DEA registratin number Patient s name and address Date Drug name, strength, dsage frm, quantity, directins fr use, number f refills, if any, r indicate n refills Manual signature States that require cllabratin r supervisin fr prescribing may require the name f the cllabrating r supervising physician n the prescriptin. Yu shuld als determine if yur state has ther requirements such as yur state cntrlled substances license/registratin number. What date ges n the prescriptin fr a CS? Prescriptins must have the date when written. They cannt be pst-dated. If yu need t write a prescriptin fr future use, enter the date written and then nte D Nt Fill Until... and enter a date. Even thugh the expiratin date fr prescriptins vary by state, if a pharmacist receives a prescriptin that has a date that is nt current, he r she shuld use prfessinal judgment t decide whether t fill a prescriptin r cntact the clinician. Fr example, a prescriptin by an emergency department clinician fr an piid medicatin that is mre than a week ld may need t be verified. What are sme f the legal issues t cnsider when writing a prescriptin fr a CS? A legitimate purpse fr prescribing a CS must exist and there must be a patient-prvider relatinship. Federal law prhibits pre-signed prescriptins. Yu may have an individual prepare a prescriptin fr yur signature hwever yu are legally respnsible if the prescriptin des nt cnfrm t legal requirements. Dcument the prescriptins yu write. Sme states, such as Virginia and Washingtn State, prhibit self-prescribing f CSs. Sme states may als prhibit prescribing CSs fr family members. Even if prescribing a CS fr neself r a family member is permitted under certain circumstances, this may nt be advisable fr prfessinal reasns. What are the plicies when I write a prescriptin fr a Schedule II CS? A prescriptin fr a Schedule II CS must be written with ink, indelible pencil, typed, r generated by an electrnic system and hand signed. Oral prescriptins are nly allwed in an emergency. There are n refills fr a Schedule II CSs hwever there is n limit n the quantity unless specified by state law r health plan plicy. In Pennsylvania APRNs may nly prescribe a 30 day supply f Schedule II CSs while in Kentucky the law limits Schedule II prescribing t a 72 hur supply. In additin, sme health plans may nly cver a 30 day supply. There is n expiratin date fr a Schedule II CS unless specified by state law. In many states all prescriptins expire in ne year hwever this varies. The ptin t prescribe an unlimited amunt f Schedule II drugs needs t be balanced with patient safety. Large quantities f any CS culd lead t veruse, misuse r diversin. The use f future dated prescriptins discussed belw ffers the prescriber an alternative t prescribing large quantities f medicatin. American Nurses Assciatin Department f Nursing Practice and Plicy Prepared by Luise Kaplan, PhD, ARNP, FNP-BC, FAANP

4 What changes can a pharmacist make t a Schedule II prescriptin? The DEA has published rules that have resulted in cnfusin regarding what changes a pharmacist can make t a Schedule II prescriptin. A specific issue is whether a pharmacist can add the prescriber s DEA registratin number t the prescriptin. Until the DEA writes new rules t clarify this situatin, pharmacists have been advised t adhere t state regulatins r plicy regarding changes a pharmacist may make t a Schedule II prescriptin after ral cnsultatin with the prescriber. Under federal law, a pharmacist may never change a patient s name, the cntrlled substance prescribed, r a prescriber s signature. What are the rules fr an emergency ral prescriptin fr a Schedule II drug? In an emergency, a pharmacist may receive an ral prescriptin fr a Schedule II drug if certain cnditins are met. An emergency prescriptin means that there is an immediate need fr the drug t assure prper treatment, n alternative treatment is available, and it is nt pssible fr the prescribing practitiner t prvide a written prescriptin fr the drug at that time. This type f situatin may ccur n a weekend r evening. The pharmacist must create a written frm f the prescriptin. The prvider must then submit a written prescriptin within 7 days n which it is nted: Authrizatin fr Emergency Dispensing. The pharmacist may dispense an amunt apprpriate fr the perid f the emergency. A pharmacist must verify an unknwn prescriber such as by using a callback t business phne. What is the DEA plicy n future dated prescriptins fr Schedule II drugs? While there are n refills fr Schedule II drugs, a prescriber may write multiple prescriptins during a patient encunter fr up t a 90 day supply f medicatin. This is imprtant when state law r health plans limit the quantity prescribed r fr patient safety cnsideratins. One prescriptin is written fr immediate use. The subsequent prescriptins must indicate the earliest date t be filled by writing: D Nt Fill Until... with the date specified. Each prescriptin must have the date it is written. Writing multiple prescriptins shuld be used nly if there is n risk fr diversin r abuse and nly if allwed by state law. The use f multiple prescriptins is nt a mandate r encuragement t issue multiple prescriptins r t see patients nly nce every 90 days if patient safety and quality f care requires therwise. What are the plicies when prescribing a Schedule III-V CS? A prescriptin fr a Schedule III-V CS may be written r ral. The pharmacist must cnvert an ral rder t a written prescriptin. The prescriptin may include up t five refills within a six mnth perid and is nly valid fr 6 mnths. There is n limit n the quantity unless specified by state law r a health plan. Fr example, Oklahma limits APRNs t prescribing a 30 day supply f Schedule III-V CSs. American Nurses Assciatin Department f Nursing Practice and Plicy Prepared by Luise Kaplan, PhD, ARNP, FNP-BC, FAANP

5 What changes may a pharmacist make t a prescriptin written fr a cntrlled substance in Schedules III-V? The pharmacist may add r change the dsage frm, drug strength, drug quantity, directins fr use, r issue date nly after cnsultatin with and the agreement f the prescribing practitiner. A pharmacist may add r change the patient s address and may add the prescriber s DEA registratin number t the prescriptin withut cnsulting the prescriber. The pharmacist shuld nte all cnsultatins and crrespnding changes n the prescriptin. Pharmacists and practitiners must cmply with any state/lcal laws, regulatins, r plicies prhibiting any f these changes t cntrlled substance prescriptins. Am I able t fax prescriptins fr cntrlled substances? Yu may fax a prescriptin fr any Schedule III, IV r V prescriptin. A prescriptin fr a Schedule II CS may be faxed t a pharmacist as an alert that the patient is cming with a written prescriptin. A Schedule II prescriptin may be faxed fr lng term care residents, Medicare certified r state licensed hspice patients, r fr direct administratin t a patient by parenteral, intravenus, intramuscular, subcutaneus r intraspinal infusin rutes. Can I electrnically prescribe prescriptins fr cntrlled substances? N. The DEA authrized electrnic prescribing (erx) f cntrlled substances in 2010 hwever there is n prcess in place fr implementatin f the rules. The implementatin will require that erx r electrnic health recrd systems be reviewed by a qualified third party auditr r certificatin bdy t assure cmpliance with DEA rules. There is als a requirement that prviders underg identity prfing fr secure prescribing. Until the prcess t implement these requirements is finalized there is n electrnic prescribing f CSs at this time. Hw can I avid tampering with prescriptins fr cntrlled substances? There are a variety f strategies yu can use t avid tampering with prescriptins fr CSs. Use tamper resistant pads. They are required fr prescriptins fr Medicaid patients and required by law in sme states. It is imprtant t knw the laws f yur state and Medicaid t assure prescriptin pads meet the requirements. Tamper resistant pads have features such as preventing unauthrized phtcpying f a cmpleted r blank prescriptin; preventing the erasure r mdificatin f a cmpleted prescriptin; preventing cunterfeiting; and use f a watermark r similar feature. There are ther ways t prevent tampering. Write numbers in wrds, e.g. Perccet 5/325 (five/three hundred twenty-five) #30 (thirty). This may be required by state law. Lck up yur supply f prescriptin pads and never leave them in an exam rm. Number the prescriptins n each pad t mnitr whether blanks have been taken. D nt use prescriptin blanks fr ntes t patients. Can pharmacies in ther states accept prescriptins fr cntrlled substances written by an APRN? Laws r plicies allw pharmacists in mst states t accept ut-f-state APRN prescriptins hwever there are sme restrictins. Here are sme examples. Pharmacies in Texas will nt accept prescriptins fr Schedule II CS which Texas APRNs are nt authrized t prescribe. In Kentucky where there are limitatins n the quantity f CSs that can be prescribed, prescriptins frm ut-f-state APRNs must cmply with Kentucky state law fr APRN prescribing. Due t a technical errr in a 2010 law, pharmacists in Washingtn State cannt accept prescriptins fr CSs frm ut-f-state APRNs. American Nurses Assciatin Department f Nursing Practice and Plicy Prepared by Luise Kaplan, PhD, ARNP, FNP-BC, FAANP

6 Can I mnitr prescriptins fr cntrlled substances that patients receive frm multiple prviders? Prescriptin mnitring prgrams (PMPs) allw yu t mnitr prescriptins fr CSs that patients receive frm multiple prviders. In sme states drugs f cncern such as carisprdl are als mnitred. There is a PMP authrized in almst every state hwever they are nt all peratinal. PMPs cllect, analyze and mnitr prescribing and dispensing f cntrlled substances. The schedules cvered vary by state. Fr example, Pennsylvania cllects data nly fr Schedule II while Clrad cllects data fr Schedules II-V. Data is available nly t authrized individuals such as healthcare prfessinals. Mre infrmatin can be btained frm The Alliance f States with Prescriptin Mnitring Prgrams at Can I prescribe drugs used fr treating piate addictin? N. Federal law restricts methadne fr the treatment f dependence t legally authrized Opiid Treatment Prgrams (OTPs). At these sites methadne is administered r dispensed, nt prescribed, t patients. NPs may be part f the OTP team if allwed by state law. Methadne is a Schedule II CS that can be prescribed by APRNs fr pain if authrized by state law. Federal law nly allws physicians t ffer ffice based piid addictin treatment using buprenrphine (Subutex ) and buprenrphine/nalxne (Subxne ). Buprenrphine is a Schedule III CS that can be prescribed by NPs fr pain if legally authrized by the state. What are sme f the requirements fr prescribing cntrlled substances that states may have? As nted abve, there are a variety f requirements r restrictins states may impse n APRNs wh prescribe CSs. Fr example, states may: Require cntrlled drug substances registratin r licensure Require a written agreement between a physician and an APRN Restrict the types f CSs that may be prescribed Limit r prhibit prescribing CS Limit the quantity f a CS prescribed Limit the duratin fr which a CS may be prescribed Have a frmulary fr prescribing CS Have guidelines fr managing patients receiving piids fr nncancer chrnic pain American Nurses Assciatin Department f Nursing Practice and Plicy Prepared by Luise Kaplan, PhD, ARNP, FNP-BC, FAANP