Prescribing Controlled Substances Without Examination
Dr. Robert Fields is a dentist in Montgomery. A long-time patient, Mr. Johnson, calls the office complaining of severe tooth pain. Mr. Johnson says he cannot come in because he is caring for his sick wife. Dr. Fields, without seeing Mr. Johnson, calls in a prescription for 30 tablets of hydrocodone 5/325 mg to Mr. Johnson's pharmacy. Dr. Fields does not document the prescription in Mr. Johnson's chart, nor does he check the Alabama Prescription Drug Monitoring Program (PDMP). Two weeks later, Mr. Johnson returns for an extraction. During the visit, Dr. Fields notices that Mr. Johnson seems drowsy and admits to taking more hydrocodone than prescribed. Dr. Fields reviews the PDMP and discovers that Mr. Johnson has received multiple opioid prescriptions from other providers in the past month. Dr. Fields reports the issue to the Board.
1. Did Dr. Fields violate Alabama law or Board rules regarding prescribing controlled substances? Explain.
Read the worked answer
Yes. Alabama law and Board rules require dentists to conduct a proper examination and establish a legitimate medical purpose before prescribing controlled substances. Dr. Fields prescribed hydrocodone without seeing the patient, without documenting the prescription, and without checking the PDMP. The PDMP check is mandatory before prescribing certain controlled substances, including opioids, under Alabama law. Failing to check the PDMP and failing to document the prescription are violations. Additionally, prescribing without an examination may constitute unprofessional conduct and a breach of the standard of care. Even though Dr. Fields later reported the issue, the initial prescribing was improper. He could face Board discipline for these violations.
2. What should Dr. Fields have done before prescribing, and what are his obligations now?
Read the worked answer
Before prescribing, Dr. Fields should have either required an office visit to examine Mr. Johnson or, if a telemedicine exception applied, conducted an appropriate evaluation. He should have checked the PDMP as required by law. He should have documented the prescription, including the drug, dose, quantity, and rationale, in the patient's chart. Now, Dr. Fields has an obligation to address Mr. Johnson's substance misuse. He should discuss the issue with Mr. Johnson, refer him for substance abuse treatment if appropriate, and document the conversation. He should also ensure that future prescribing follows the law. Reporting to the Board was appropriate, but he should cooperate fully with any investigation.