Practitioners that prescribe controlled substances to BlueCross BlueShield of Tennessee (BCBST) members are expected to comply with all existing Federal and State laws governing this activity. BCBST adopted standards are listed below and may be monitored through practitioner site reviews and medical records audits of members that receive controlled substances upon request from the Clinical Risk Management Department.

Practitioners non-compliant with these documentation standards are monitored by the Pharmacy and Therapeutics committee, and may be referred to the Clinical Risk Management Committee (CRMC) for further review and action.

Items noted by    are required, and non-compliance will result in immediate referral to CRMC for further review.

•   Medical Records should be legible and maintained in detail consistent with good medical/professional practice, which permits effective internal/external review and/or medical audit and facilitate follow up treatment.
•   Controlled Substances are securely maintained in locked area.
•   A separate log is maintained for controlled substance dispensing.
• There is evidence of established relationship with the member receiving controlled substance in outpatient setting with the prescribing practitioner or call coverage.
• There is a documented medical history, including consideration of presenting complaint that results in a controlled substance prescription.
• There is evidence of a physical examination including an assessment and consideration of the pain, physical and psychological function.
• There is documentation of co-existing diseases and conditions and the presence of a recognized medical indication for use of the controlled substance prescribed.
• There is documentation of a recognized medical indication for the use of the controlled substance(s) prescribed.
• There is documentation of diagnostic, therapeutic and laboratory testing with results.
• There is a documented treatment plan tailored for the individual needs of the patient by which treatment progress and success can be evaluated with stated objectives such as pain relief and/or improved physical and psychosocial function.
• There is documentation regarding other methods of treatment utilized by patient or other practitioners prior to the use of any controlled substance or prior to initial visit .
• There is evidence that the risks and benefits of controlled substances were discussed with the patient or guardian.
• There is evidence of periodic review at reasonable intervals with documentation of progress toward reaching treatment objectives.
• When controlled substances are prescribed there is documentation of the drug name, quantity prescribed, dosage and frequency, and the number of authorized refills.
• There is documentation of illicit/controlled substance abuse history and/or potential for substance abuse.
• There is evidence that members identified as at risk for misuse due to history or environment are monitored more closely, with consultation of appropriate health care practitioners.

• Member/practitioner contracts are documented for identified high-risk members, or those with chronic pain conditions requiring prolonged controlled substance management.

  Symptoms or behaviors that could be considered “red flags” that an individual may be at risk for potential abuse of controlled substances and require additional monitoring or limited access to controlled substances may include, but are not limited to the following:

  • History of substance abuse or identified high-risk environment.
  • Frequent absences from work or school
  • History of frequent injuries or accidental injuries
  • Prescription drug seeking behavior
  • Depression, anxiety, and/or mood swings
  • Labile hypertension
  • Gastrointestinal symptoms such as weight changes, diarrhea, and/or epigastric distress
  • Complaints of sexual dysfunction or sleep disorders
  • Nasal irritation, enlarged liver, mild tremor, hepatitis B, HIV
  • Cutaneous signs of drug abuse such as skin tracks or injection sites

  Please refer to the Web sites below for more information:

  American Society for Addiction Medicine. (2001, February). Red flags for alcohol and drug abuse.
  Retrieved April 20, 2004 from ASAM.org.

  American Academy of Family Physicians. (2000, April). Addition: Part II. Identification and Management of the Drug-Seeking Patient.
  Retrieved April 20, 2004 from AAFP.org.

  American Academy of Family Physicians. (2003, April). Recognition of Alcohol and Substance Abuse.
  Retrieved April 20, 2004 from AAFP.org.