Documenting controlled substances prescriptions during session confirmation

The Drug Enforcement Agency (DEA) has been increasing scrutiny of the prescribing of controlled substances through telehealth.

What's changing and why

To help you prepare for a tighter regulatory environment and better protect you, your clients, and Headway as a network, you’ll be asked about any controlled substances prescribed to a patient when you confirm session details.

How it works

Each time you confirm a session, you’ll be asked the following question in the Progress Note section: Did you prescribe a controlled substance for the client? This is a yes or no question. 

If you select No

No further action is required. You won’t need to fill out any additional information, and can confirm the session as normal, filling out all other required fields.

If you select Yes, I prescribed a new/updated dosage or maintained an existing one

You’ll need to fill out a few more fields, and answer a few additional questions, before confirming the session.

These fields include:

• Which substance(s)?
• Did you prescribe any controlled substance with a higher dose per day than the amount listed above?
• Frequency, dosage, and any other relevant notes for each substance

Once these fields, along with all other required fields, are completed you can proceed to confirm the session.

Please note: The details collected will be stored securely and are for internal use only. They will not be shared with health plans or other audiences.

Frequently asked questions

Why is Headway asking if I prescribed a controlled substance for a client?

To help protect you, your patients, and Headway as a network, collecting this information aims to support your compliance with prescribing practices. It also helps us to identify potential increased risk of scrutiny so that we can provide the guidance and feedback needed to support you prescribing in a safe and ethical manner.

What does Headway do with the information collected under the controlled substance section?

This information will only be used internally at Headway. We’ll use these details to help identify opportunities for feedback on prescribing patterns so that we can work with you to help protect you, your clients, and Headway as a network.

In the event that we have individualized feedback to share, we’ll offer support and resources to ensure prescribing is done within the established standards.

How are you determining maximum dosage amounts?

Dosage amounts shown are based on clinical review of existing FDA approved maximum daily dosages and expert consensus recommendations for management of neuropsychiatric conditions. Prescribing above the dosages indicated may increase risk of adverse events and should be done with caution with clinical reasoning and informed consent appropriately documented.

What if I am prescribing a controlled substance that is not listed?

Please select the Other option from the drop down, and list all additional controlled substances you are prescribing and the corresponding dosages.

We will use initial data collected to get a sense of prescribing patterns in order to understand if other substances should be added to our list.

How does Headway define a controlled substance?

In the United States, a controlled substance refers to a drug or chemical whose manufacture, possession, and use are regulated by the government under the Controlled Substances Act (CSA). This law categorizes substances into five schedules based on their potential for abuse, medical use, and safety or dependence risk:

• Schedule I: Substances with no currently accepted medical use and a high potential for abuse (e.g., heroin, LSD, ecstasy).
• Schedule II: Substances with a high potential for abuse, with use potentially leading to severe psychological or physical dependence (e.g., cocaine, methamphetamine, oxycodone).
• Schedule III: Substances with a moderate to low potential for physical and psychological dependence (e.g., anabolic steroids, codeine with aspirin).
• Schedule IV: Substances with a low potential for abuse and low risk of dependence (e.g., Xanax, Valium).
• Schedule V: Substances with the lowest potential for abuse, often containing limited quantities of certain narcotics (e.g., cough preparations with less than 200 milligrams of codeine per 100 milliliters).

These schedules determine how substances are prescribed, distributed, and monitored to prevent abuse and illegal distribution.