Ala. Admin. Code r. 540-X-18-.15 - Risk And Abuse Mitigation Strategies
(1) 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. It is the opinion of the Board that the best practice when
prescribing controlled substances shall include medically appropriate risk and
abuse mitigation strategies, which will vary from patient to patient.
Additional care should be used by practitioners when prescribing medication to
a patient from multiple controlled substance drug classes.
(2) Every practitioner shall provide his or
her patient with risk education prior to initiating controlled substances
therapy and prior to continuing the controlled substances therapy initiated by
another practitioner.
(3) Every
practitioner shall utilize medically appropriate risk and abuse mitigation
strategies when prescribing controlled substances. Examples of risk and abuse
mitigation strategies include, but are not limited to:
(a) Pill counts;
(b) Urine drug screening;
(c) PDMP checks;
(d) Consideration of abuse-deterrent
medications;
(e) Monitoring the
patient for aberrant behavior;
(f)
Using validated risk-assessment tools, examples of which shall be maintained by
the Board; and
(g) Co-prescribing
naloxone to patients receiving opioid prescriptions when determined to be
appropriate in the clinical judgment of the treating practitioner.
(4) The Board recognizes that the
best available research demonstrates that the risk of adverse events occurring
in patients who use controlled substances to treat pain increases as dosage
increases. The Board adopts the "Morphine Milligram Equivalency" ("MME") daily
standard as set out by the Centers for Disease Control and Prevention ("CDC")
for calculating the morphine equivalence of opioid dosages. The Board further
adopts the "Lorazepam Milligram Equivalency" ("LME") daily standard for
calculating sedative dosing when using the Alabama Prescription Drug Monitoring
Program.
(5) For the purpose of
preventing controlled substance diversion, abuse, misuse, addiction, and
doctor-shopping, the Board sets forth the following requirements for the use of
Alabama's Prescription Drug Monitoring Program (PDMP):
(a) For controlled substance prescriptions
totaling less than 30 MME or 3 LME per day, practitioners are expected to use
the PDMP in a manner consistent with good clinical practice.
(b) When prescribing to a patient controlled
substances of more than 30 MME or 3 LME per day, practitioners shall review
that patient's prescribing history through the PDMP at least two (2) times per
year, and each practitioner is responsible for documenting the use of risk and
abuse mitigation strategies in the patient's medical record.
(c) Practitioners shall query the PDMP to
review a patient's prescribing history every time a prescription for more than
90 MME or 5 LME per day is written, on the same day the prescription is
written.
(6)
Exemptions: The Board's PDMP requirements do not apply to practitioners writing
controlled substance prescriptions for:
(a)
Nursing home patients;
(b) Hospice
patients, where the prescription indicates hospice on the physical
prescription;
(c) When treating a
patient for active, malignant pain; or
(d) Intra-operative patient care.
(7) Due to the heightened risk of
adverse events associated with the concurrent use of opioids and
benzodiazepines, practitioners should reconsider a patient's existing
benzodiazepine prescriptions or decline to add one when prescribing an opioid
and consider alternative forms of treatment.
(8) A violation of this rule is grounds for
the assessment of a fine and for the suspension, restriction, or revocation of
a practitioner's Alabama Controlled Substances Certificate or license to
practice medicine.
Notes
Author: Alabama Board of Medical Examiners
Statutory Authority: Code of Ala. 1975, ยงยง 20-2-250, et. seq.
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