How often does the DEA require face-to-face interactions for controlled substances like Adderall (amphetamine/dextroamphetamine), Norco (hydrocodone/acetaminophen), benzodiazepines (benzos), and codeine?

DEA Requirements for Face-to-Face Visits for Controlled Substances

According to CDC guidelines, patients receiving controlled substances such as Adderall, Norco, benzodiazepines, and codeine should be seen in-person at least once per year, with reassessments occurring at least every 3 months (which can be done virtually in appropriate circumstances). 1

General Requirements for All Controlled Substances

Minimum Required Frequency

• Initial evaluation: Must be in-person before first prescription
• Maintenance phase: In-person visits at least once per year
• Regular reassessments: At least every 3 months (can be virtual in appropriate circumstances) 1

Higher Risk Patients Requiring More Frequent Monitoring

Patients with the following factors require more frequent than every 3 month reassessments:

• Mental health conditions (especially depression)
• History of substance use disorder
• Previous overdose
• Taking ≥50 MME/day of opioids
• Taking other CNS depressants concurrently with opioids 1

Medication-Specific Considerations

Stimulants (Adderall)

• Initial titration phase: Weekly contact (can be by telephone) during dose adjustments (typically 2-4 weeks)
• Maintenance phase: Monthly visits until symptoms are stabilized 1
• Follow-up frequency should be based on:
  • Response to treatment
  • Adherence to medication regimen
  • Presence of side effects
  • Need for psychoeducation

Opioids (Norco, Codeine)

• Regular reassessment at least every 3 months
• More frequent monitoring for high-risk patients
• Each visit should assess:
  • Pain control and functional improvement
  • Side effects (constipation, drowsiness, sedation)
  • Warning signs of opioid use disorder
  • Whether benefits continue to outweigh risks 1

Benzodiazepines

• Particularly high risk when combined with opioids
• Should be avoided concurrently with opioids whenever possible 2
• Same minimum monitoring requirements as other controlled substances (at least every 3 months)

Special Circumstances Affecting Visit Requirements

Telemedicine Considerations

• Virtual visits can be appropriate for follow-up assessments when:
  • They are part of standard care
  • Distance or other issues make in-person visits challenging
  • The platform allows clinician to communicate with and observe the patient through video and audio
  • In-person visits still occur at least annually 1

Documentation Requirements

• Each visit should document:
  • Benefits in function and pain control
  • Adverse effects
  • Signs of potential misuse
  • Continued justification for therapy 1

Common Pitfalls to Avoid

1. Inadequate monitoring: Failing to reassess patients at least every 3 months can lead to missed opportunities to identify adverse effects or developing substance use disorders.

2. Relying solely on virtual visits: While convenient, complete absence of in-person evaluation prevents proper assessment of physical signs and may miss important clinical cues.

3. Dismissing patients based on PDMP information: This violates the principle of non-abandonment and undermines the therapeutic relationship. 1

4. Overlooking drug interactions: Many controlled substances have significant interaction potential, particularly when multiple controlled substances are prescribed together. 2

By following these guidelines for face-to-face visits and regular monitoring, clinicians can help ensure the safe and effective use of controlled substances while minimizing risks of misuse, addiction, and adverse effects.