Prescription of Schedule II Controlled Substances Policy

Policy: Prescription of Schedule II Controlled Substances

Policy Number: 701 Policy Section: Medication Management
Owner: Dr. Mark Willenbring Approved By: Dr. Mark Willenbring
Effective Date: 3/09/2022 Date of Last Review:


SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula.


Policy Statement

In accordance with state and federal laws, this policy seeks to ensure that prescribers follow consistent and reasonable procedures when prescribing Schedule II controlled substances, when appropriate for the treatment of mental health and substance use disorders



This policy applies to team members who are able to prescribe Schedule II Controlled Substances. For purposes of this policy, the Group’s and Rula’s team members include individuals who would be considered part of the workforce such as employees, independent contractors, business team members, and other persons whose work performance is under the direct purview of Rula or the Group’s  business practices. 



Controlled substance: is a drug, substance, or immediate precursor defined by the Controlled Substances Act (CSA). 


Controlled Substance Analog: is a substance that has a similar chemical structure to a controlled substance 


Controlled Substance Act: is a statute that categorizes all substances that are regulated under federal law into schedules. Drugs, substances, and certain chemicals used to make drugs are classified into five (5) distinct categories or schedules depending upon the drug’s acceptable medical use and the drug’s  dependence potential. A Listing of drugs and their schedule are located at Controlled Substance Act (CSA) Scheduling or CSA Scheduling by Alphabetical Order.

Diagnostic and Statistical Manual of Mental Disorders (DSM): is the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In the United States, the DSM serves as the principal authority for the classification of mental disorders. 


Informed Consent: communication between a patient and healthcare provider  that may result in the patient’s agreement or permission to receive care, treatment, or services. 


Prescribers: individuals who provide services to patients and who have a current, active licensure, DEA licensure for that state, and a state controlled substance license (if required) in the state in which they are practicing. Prescribers include medical doctors (MDs), doctor of osteopathic medicine (DOs), Nurse practitioners and physician assistants.


Schedule II Drugs: includes any substance or analog identified in 21 USC 812 as Schedule II. According to the DEA, substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence. Examples of Schedule II narcotics include: hydromorphone (Dilaudid®), methadone (Dolophine®), oxycodone (OxyContin®, Percocet®), and fentanyl (Sublimaze®, Duragesic®, morphine, and hydrocodone. Examples of Schedule II stimulants include: amphetamines (Dexedrine®, Adderall®), methamphetamine (Desoxyn®), and methylphenidate (Ritalin®). Other Schedule II substances include: amobarbital, glutethimide, and pentobarbital.



  1. Prescribers are responsible for evaluating the appropriateness of using Schedule II Drugs for the treatment of mental health and substance use disorders. Before prescribing a Schedule II drug, a non-physician provider will consult with the supervising physician (if applicable). 
  2. The nurse practitioner and the supervising physician will review the appropriate state database on at least a quarterly basis to ensure appropriate practices.
  3. Prior to prescribing a Schedule II Drug, prescribers must complete a full patient evaluation that includes (at a minimum): 
    1. Document chief complaint
    2. Complete full history 
    3. History of substance use/misuse and treatment
    4. Current and past treatments for this and other mental health or substance use disorders.
    5. Diagnosis of underlying or coexisting physical or mental diseases or conditions. The most current published version of the DSM will be used to diagnose mental health conditions. 
    6. Age of symptom onset, effect of symptoms on patient’s physical, psychological, and social function.
  4. An initial trial medication prescription, not to exceed 30 days, with treatment goals and monitoring of medication side effects is required to be documented in the patient’s record. Prescribers will adjust medication to the individual needs of the patient. Documentation of medication adjustments and/or changes will be contained within the patient’s electronic health record. 
  5. Informed Consent and Agreement for Treatment
    1. Prior to prescribing a Schedule II controlled substance, a prescriber will discuss the risks and benefits of the use of the medication with the patient and document that informed consent was verbally obtained. 
    2. Documentation of verbal informed consent must be entered into the medical record prior to distribution of a prescription for a Schedule II controlled substance. 
    3. At reasonable intervals (not to exceed 90 days) treatment goals of long term medication therapy will be assessed. 
    4. If goals are not being met, the appropriateness of continued treatment will be assessed by the prescriber and documented in the patient’s record.
  6. Discharge of Patient when the patient has an active prescription for a Schedule II controlled substance
    1. Patient discharge will follow the Patient Discharge policy.
    2. Upon discharge from services, the patient may be prescribed a maximum of a 30 day prescription of any Schedule II controlled substance medication with no refills. 

Attachments: None.

Was this article helpful?

0 out of 0 found this helpful