The Corneal Abrasion and the Expired DEA Registration
Dr. Elias Haddad, OD, removes a metallic foreign body from a 34-year-old patient's cornea and debrides a 3 mm epithelial defect. The patient has severe pain and asks for "something strong." Dr. Haddad's Illinois controlled substance license is active, but his DEA registration expired three weeks ago; a renewal application is pending. He writes a prescription for hydrocodone/acetaminophen 5/325 mg, #30, one to two tablets every six hours as needed, with one refill. He does not check the Illinois Prescription Monitoring Program. The patient fills it, then goes to an urgent care two days later and receives a second opioid prescription from a physician. The pharmacist calls Dr. Haddad because the PMP shows overlapping opioids.
1. Does Dr. Haddad have authority to prescribe this medication? Address the drug schedule, the Illinois controlled substance license, and the DEA registration.
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Drug schedule. Hydrocodone combination products are Schedule II controlled substances. Illinois optometrists do not have authority to prescribe Schedule II controlled substances; their controlled-substance prescribing authority is limited to the schedules the Optometric Practice Act and rules permit, generally Schedules III through V. That alone makes this prescription outside his scope.
Illinois license versus DEA registration. These are separate requirements. The Illinois controlled substance license is issued by the state; the DEA registration is federal. Both must be active for the prescriber to handle controlled substances. An active state license does not authorize prescribing while the DEA registration is expired, and a pending renewal is not the same as an active registration. Prescribing during the gap is a federal and state violation.
Conclusion. The prescription fails on two independent grounds: the drug is outside optometric Schedule II authority, and the DEA registration was not active. Good intentions about pain control do not create authority. The correct path would have been a non-controlled alternative, a referral for pain management, or a prescription within scope after confirming both registrations were active.
2. What obligations did Dr. Haddad have regarding the PMP, quantity, refills, and documentation?
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PMP. Illinois requires prescribers to check the Prescription Monitoring Program in the circumstances the law specifies, particularly before prescribing opioids. A PMP check would have shown whether the patient already had an opioid or other controlled substance from another prescriber. The failure to check is a significant documentation and safety gap, and the pharmacist's call is exactly the kind of overlap the PMP is designed to catch.
Quantity and refills. For acute post-traumatic pain, #30 with a refill is aggressive. A smaller quantity with no refill is generally more defensible, with reassessment if pain persists. Opioid prescriptions should be limited to the expected duration of acute pain.
Documentation. The record should show the indication, the PMP review, the rationale for choosing a controlled substance, the quantity and refill decision, any non-controlled alternatives considered, and the patient education given. "Severe pain" alone is not a sufficient rationale.
Judgment. Even if the drug had been within optometric authority and the DEA registration active, the absence of a PMP check and the excessive quantity/refill would draw scrutiny.
3. What should Dr. Haddad do now, after the pharmacist's call?
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Immediate steps.
- Do not authorize the refill. The prescription is outside his authority and the DEA registration is expired.
- Speak with the pharmacist and document the conversation. The pharmacist is entitled to a clear response about the overlapping prescriptions.
- Contact the patient to explain the situation, assess pain and healing, and coordinate with the urgent care prescriber so the patient is not left without a safe plan. Do not simply abandon the patient.
- Document the corneal findings, the PMP issue, the prescriber contact, and the plan.
- Stop prescribing controlled substances until the DEA registration is active and verified, and do not prescribe Schedule II at all under an optometry license.
- Consult counsel about whether self-reporting to the Department or DEA is required; the expired-registration prescribing and the Schedule II prescription are both serious.
System fix. Institute a pre-prescription check: drug schedule, state license, DEA status, PMP, quantity, and refills. The pharmacist's call should be treated as a safety event, not just an inconvenience.