How do I document a policy of not prescribing controlled substances (CS), including opioids, benzodiazepines, and stimulants, in patient medical records?

Documentation of Non-Prescribing Policy for Controlled Substances

Document a clear statement in the medical record that you do not prescribe controlled substances (opioids, benzodiazepines, stimulants) as a practice policy, inform patients of this policy at intake, and provide specific referral resources for pain management and psychiatric care when these medications are clinically indicated.

Essential Documentation Components

Initial Patient Notification

• Document the policy discussion during the first visit, including that your practice does not prescribe opioids, benzodiazepines, or stimulants regardless of indication 1.
• Record the patient's acknowledgment and understanding of this policy in the medical record 2.
• Provide written notice (e.g., office policy handout, intake forms) that patients can reference, as written communication reinforces verbal discussions 2.

Medical Record Statement Template

Your documentation should include:

"Practice Policy: This practice does not prescribe controlled substances including opioids, benzodiazepines, or stimulants. Patient informed of this policy on [date]. Patient verbalized understanding. Alternative treatment options and referral resources discussed."

• Include the specific date this policy was communicated 2.
• Document whether the patient had questions and how they were addressed 2.
• Note any current controlled substance use the patient reported, as this informs care coordination needs 1.

Clinical Management Framework

For Patients Requiring Pain Management

• Emphasize nonopioid therapies as the standard of care for subacute and chronic pain, consistent with CDC guidelines that prioritize nonpharmacologic and nonopioid pharmacologic approaches 1.
• Document specific nonopioid alternatives offered: exercise therapy, physical therapy, weight management for joint pain, psychological therapy, acupuncture, or other evidence-based modalities 1.
• Provide referral to pain management specialists or clinicians who prescribe opioids when pain is inadequately controlled with nonopioid approaches 1.
• Document the referral details including provider name, contact information, and appointment scheduling assistance offered 3.

For Patients on Existing Controlled Substances

• Do not abruptly discontinue medications prescribed by other providers, as this creates patient safety risks and may constitute abandonment 1.
• Document: "Patient currently prescribed [medication] by [prescriber]. Will continue to coordinate care with prescribing physician. Patient advised to maintain follow-up with prescriber for medication management" 1.
• Verify the prescribing clinician's contact information and document care coordination efforts 1.
• Check the state Prescription Drug Monitoring Program (PDMP) to understand the patient's controlled substance history, which informs safety monitoring even when you're not prescribing 1.

For Psychiatric Medication Needs

• Provide referral to psychiatry or psychiatric nurse practitioners for benzodiazepine or stimulant prescribing when clinically indicated 1.
• Document evidence-based alternatives you can provide: cognitive behavioral therapy referrals for anxiety, non-benzodiazepine anxiolytics, or antidepressants for anxiety disorders 1.
• Note that concurrent benzodiazepine and opioid use carries significant overdose risk, supporting your policy of not adding to polypharmacy 1, 4, 5.

Legal and Regulatory Considerations

Protecting Your Practice

• This policy is legally defensible as physicians have discretion in their prescribing practices and scope of practice 6.
• Document that the policy applies uniformly to all patients to avoid allegations of discrimination 6.
• Maintain documentation showing you provided appropriate alternative care and referrals rather than simply refusing treatment 1.

Common Pitfalls to Avoid

• Never document judgmental language about patients requesting controlled substances (e.g., "drug-seeking behavior") as this can be stigmatizing and legally problematic 1.
• Do not refuse to see patients who take controlled substances prescribed by others—this constitutes inappropriate patient selection 1.
• Avoid stating you "never" prescribe in emergency situations; instead, specify this is your outpatient practice policy 1.
• Do not fail to document the conversation—verbal notification alone is insufficient for medicolegal protection 2.

Office-Wide Implementation

Standardized Communication

• Post the policy visibly in waiting areas and on intake forms 2.
• Train all staff to communicate the policy consistently during appointment scheduling 2.
• Include the policy on your practice website and new patient information packets 2.

Referral Network Development

• Maintain an updated list of local providers who prescribe controlled substances for appropriate indications 1.
• Include pain management specialists, addiction medicine specialists, and psychiatrists 1.
• Document that you provided specific referral resources, not just general advice to "see someone else" 3.

This approach protects patient safety by ensuring continuity of care, reduces your medicolegal risk through clear documentation, and aligns with evidence-based guidelines prioritizing nonopioid therapies while avoiding the risks of polypharmacy with controlled substances 1, 4, 5.