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Provider Considerations

Therapist talking to patient

Clinician-To-Clinician Substance Use Warmline

A goal of the IHS opioid strategy is to support IHS/Tribal/Urban clinicians in providing patient-centric care for patients with an Opioid Use Disorder diagnosis. IHS is pleased to announce a collaboration that provides a new resource for the provider ‘toolbox’ that also supports sites with increasing access to Medication Assisted Treatment. The Substance Use Warmline (1-855-300-3595) offers on-demand Clinician-To-Clinician support for IHS providers managing alcohol and substance use disorders. The Warmline is available Monday through Friday from 6am to 5pm Pacific Time (PT) for all health care providers in IHS federal, tribal, and urban facilities. Calls are answered by trained clinical support specialists with diverse experience and substantial training in substance use disorder interventions. Please view the Clinical Substance Use Warmline flyer for more details.

Legal Considerations

PRESCRIBING BUPRENORPHINE

Regulatory requirements were eased through updated Clinical Practice Guidelines Exit Disclaimer: You Are Leaving www.ihs.gov  in April 2021. Qualified practitioners are eligible to receive a waiver to administer, dispense, and prescribe buprenorphine for the treatment of Opioid Use Disorders for up to 30 patients annually. Qualified practitioners include physicians, Nurse Practitioners (NPs), Physician Assistants (PAs), Clinical Nurse Specialists (CNSs), Certified Registered Nurse Anesthetist (CRNAs), and Certified Nurse-Midwives (CNMs). These providers can submit an application known as a Notice of Intent Exit Disclaimer: You Are Leaving www.ihs.gov  to access exemptions related to specialized training requirements and capacity to provide counseling and ancillary services. Providers can submit an application to increase patient limits following the initial certification year with proof of successful training completion.

View and complete the online waiver notification form. Exit Disclaimer: You Are Leaving www.ihs.gov 

Access the links below if you want to increase your general knowledge or apply to treat more than 30 patients:

For additional collaboration and training opportunities, consider registering and engaging in Indian Country ECHOs. Exit Disclaimer: You Are Leaving www.ihs.gov 

Training Resources

Methadone

SAMHSA, the Food and Drug Administration (FDA),  and the Drug Enforcement Administration (DEA) constitute a three-tier regulatory system restricting methadone prescribing to oral formulations by registered prescribers in Opioid Treatment Programs (OTP). Individual states determine if mid-level providers are authorized to prescribe methadone.

The Narcotic Addict Treatment Act (NATA) of 1974 Exit Disclaimer: You Are Leaving www.ihs.gov  requires prescribers to register annually with the DEA and establishes recordkeeping requirements including unsupervised take-home prescriptions of methadone.

The Indian Health Service requires that prescribing practitioners have DEA licenses, unless they are prescribing under the auspices of institutions that have DEA licenses or they are members of the Public Health Service. However, even if you’re a prescribing practitioner working under an "umbrella" DEA license, it's recommended that you get your own DEA license.

Revised Policy Regarding the Federal Government Doctor [PDF - 265 KB], FEDDOC Program, DEA Memorandum

Clarification regarding locum tenens registration [PDF - 37 KB], DEA letter

The Indian Health Manual has specific requirements for prescribing controlled substances in Section 3-7.3D(2) of the Manual.

The DEA's Practitioner's Manual states that a prescription for a controlled substance may only be issued by a practitioner who is:

  1. Authorized to prescribe controlled substances by the jurisdiction in which the practitioner is licensed to practice,
  2. Registered with DEA or exempted from registration (that is, Public Health Service, Federal Bureau of Prisons, or military practitioners), or
  3. An agent or employee of a hospital or other institution acting in the normal course of business or employment under the registration of the hospital or other institution that is registered in lieu of the individual practitioner being registered (provided that additional requirements as set forth in the Code of Federal Regulations are met).

Practitioners worried about interference from law enforcement agencies concerning the prescribing of opioids or other controlled substances should note that the Drug Enforcement Administration’s official policy states:

The longstanding requirement … that physicians may prescribe controlled substances only for legitimate medical purposes in the usual course of professional practice should in no way interfere with the legitimate practice of medicine or cause any physician to be reluctant to provide legitimate pain treatment. [emphasis added] (71 Fed. Reg. 52,716)

And, while the Drug Enforcement Administration actively pursues doctors and others it believes are involved in illicit prescribing, the DEA stated the following in testimony to Congress in 2006:

The overwhelming majority of prescribing in America is conducted responsibly. Often these responsible doctors and pharmacists are the first to alert law enforcement to potential prescription problems. However, the small number of physicians who over prescribe controlled substances—carelessly at best, knowingly at worst—help supply America’s second most widespread drug addiction problem. Although the problem exists, the number of physicians and pharmacists responsible for this problem is a very small fraction (less than 1 percent) of those licensed to prescribe and dispense controlled substances in the United States. [emphasis added]

The Drug Enforcement Administration has issued an interim final rule allowing practitioners the option of writing prescriptions for controlled substances (Schedules II through V) electronically and permitting pharmacies to receive, dispense, and archive electronic prescriptions. (21 C.F.R. Parts 1300, 1304, 1306, and 1311) This new regulation modifies existing regulations, which remain in force. The prescribing practitioner must use an electronic health record application (software) that complies with the interim final rule, and a qualified third party must verify the application’s compliance with the rule. For a copy of the interim final rule and for questions and answers about it, visit the Office of Diversion Control Exit Disclaimer: You Are Leaving www.ihs.gov .

Drug Enforcement Administration regulations allow practitioners to provide individual patients with multiple prescriptions, to be filled sequentially, for the same Schedule II controlled substance, with such multiple prescriptions having the combined effect of allowing a patient to receive over time up to a 90-day supply of that controlled substance. (21 C.F.R. Part 1306) Among the requirements are that each prescription issued have a “legitimate medical purpose” and that doctors include written instructions on each prescription. For questions and answers about the multiple prescription rule, visit the Office of Diversion Control. Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 228 KB]

References

Indian Health Service. Office of Management Services. Indian Health Manual. Rockville, MD: US Department of Health and Human Services, 2009.

Drug Enforcement Administration. Office of Diversion Control. Pharmacists's Manual: An Informational Outline of the Controlled Substances Act (2021). mura]$.showExitDisclaimer()

"Dispensing Controlled Substances for the Treatment of Pain; Policy Statement," Exit Disclaimer: You Are Leaving www.ihs.gov  [PDF - 140 KB] Federal Register, Vol. 71, No. 172 (September 6, 2006), pp. 52,716-52,723.

Office of Diversion Control. Exit Disclaimer: You Are Leaving www.ihs.gov  Drug Enforcement Administration.