Anesthesiology APPLIED Exam › Ambulatory, non-OR and special populations

Controlled substances: DEA rules, diversion and opioid prescribing

Ambulatory, non-OR and special populations·~5 min read· Physician-reviewed✓ Sourced · 12

Stem

You are the anesthesia department's medical director. Pharmacy surveillance flags a second-year resident: over six weeks he withdrew 2.5 times the departmental median fentanyl per case, documented 100-mcg boluses after his anesthetics had ended, and logged most wastes late in the day with the same cosigner. Two of his patients needed unusually large opioid doses in the PACU. Today he volunteered to cover an extra late room, and he is in OR 6 now.

Question

What do you do?

Ideal answer

HeadlineThis pattern suggests diversion, a danger to his patients and his life. I remove him from patient care today through a planned intervention.

Relieve him from OR 6 now; block his access. Another provider takes the case, pending investigation, because death is often the first sign in anesthesia.¹^,2
Meet privately with the response team, never alone. Program director, pharmacy and human resources; a for-cause drug test; he does not drive home alone.¹
Report as the law requires. Diversion is theft: the hospital, as registrant, notifies DEA in writing within one business day, files Form 106 within 45 days, and reports to the board.³^,1
Refer for evaluation and treatment. Through the physician health program; any return is under a monitored agreement, because relapse risk after a first episode is about 40%.²

Watch for: his safety after the meeting; this is a medical crisis too.

Breaking down the answer

Which flags matter — transactions after the anesthetic ended or away from the point of care identified known diverters; high use and high waste alone did not.² Changes if: the investigation finds charting errors; handoffs and long cases cause documentation discrepancies.²
Waste done right — every waste has an independent witness, preferably licensed, who watches the whole draw and discard; anesthesia waste is randomly assayed.¹ Changes if: the same cosigner recurs; that pattern is reviewed too.
Surveillance as a system — pharmacy reconciles dispensed, administered, wasted and returned doses, reviews cabinet activity against records at least monthly and compares peers.¹ Changes if: a cabinet count is off; resolve by shift end, else pharmacy within 24 to 72 hours.¹
Registration and schedules — I need a registration for each state and principal place where I dispense;⁴ it expires every 36 months.⁵ II: fentanyl; III: ketamine; IV: diazepam; V: pregabalin.⁶ Changes if: a resident; he may work under the hospital's registration.⁷
Cannabinoids — by a final rule effective April 28, 2026, marijuana in FDA-approved products or under a state medical license is Schedule III;⁸ the rest remains Schedule I, broader rescheduling pending.⁹^,10 Changes if: DEA finalizes the broader rule.
The 2023 laws — the X-waiver ended December 29, 2022; the MATE Act requires 8 hours of substance use disorder training, once, attested at the first DEA registration or renewal from June 27, 2023.¹¹ Changes if: I hold addiction medicine certification; that satisfies it.¹¹

Follow-up question

A different patient: a 38-year-old woman on buprenorphine-naloxone 16 mg daily for opioid use disorder, continued through her ankle fracture fixation, is going home today. Her own prescriber is away for two weeks, and the surgeon wants to send oxycodone. Can you write her buprenorphine, and what else do you prescribe?

Follow-up answer

HeadlineYes; no X-waiver exists anymore. I bridge her buprenorphine, check the PDMP, and keep any oxycodone short.

Any prescriber with Schedule III authority can now treat opioid use disorder with buprenorphine, without patient limits.¹¹ I review the state PDMP before the new prescription,¹² write her usual dose until her prescriber returns, and tell both of them. Any oxycodone is no greater quantity than needed for pain severe enough to require it.¹² I offer naloxone because of her substance use history,¹² add scheduled non-opioids, and avoid a benzodiazepine.

Pitfalls that cost points

Cosigning a colleague's waste from across the room "to save time."
Letting him finish the case "to avoid a scene."
Trading his quiet resignation for silence; that protects nobody, least of all his next patients.

Rapid-fire

Q: Who is exempt from the MATE training? A: Addiction medicine or addiction psychiatry diplomates, and graduates within five years of June 27, 2023 whose curriculum had at least 8 hours on substance use disorders.¹¹

Q: When do I offer naloxone with an opioid prescription? A: Particularly after overdose or substance use disorder, with sleep-disordered breathing, at 50 MME/day or more, or with benzodiazepines.¹²

Q: Is detoxification alone acceptable treatment for opioid use disorder? A: No: without medication it raises the risk of returning to use, overdose and overdose death.¹²

Q: Must a loss be quantified before I tell DEA? A: No; notify DEA of unresolved losses or theft even when the amount is unknown.¹

Q: Who should keep a prepared opioid syringe? A: The person who drew it, labeled and under direct control until given.¹

Numbers to know

Item	Value
DEA notice of theft or significant loss	1 business day; Form 106 within 45 days³
DEA registration period	36 months⁵
MATE Act training	8 hours, once, from June 27, 2023¹¹
X-waiver eliminated	December 29, 2022¹¹
Relapse risk after first episode	About 40%²
Naloxone threshold dose	50 MME/day or more¹²

Sources

1.ASHP Guidelines on Preventing Diversion of Controlled Substances · ASHP, 2017 · integratedcare.dc.govHosted copy of the 2017 guideline (Drug Distribution and Control, Guideline 77); ASHP revised the guideline in 2022, and the revision (Clark et al., Am J Health-Syst Pharm 2022;79:2279-2306) could not be opened from this session; its PSNet listing describes strategies across storage, prescribing and waste disposal but not the specific wording used on this page.
2.Prevention of drug diversion and substance use disorders among anesthesiologists: a narrative review · Brazilian Journal of Anesthesiology (Fitzsimons et al.), 2023 · scielo.br
3.21 CFR 1301.76, Other security controls for practitioners · Legal Information Institute (Cornell), Code of Federal Regulations · law.cornell.edu(b): registrant notifies the DEA Field Division Office in writing within one business day of discovery; Form 106 within 45 days.
4.21 CFR 1301.12, Separate registrations for separate locations · Legal Information Institute (Cornell), Code of Federal Regulations · law.cornell.edu
5.21 CFR 1301.13, Application for registration; time for application; expiration date · Legal Information Institute (Cornell), Code of Federal Regulations · law.cornell.edu
6.Drug Scheduling · DEA · dea.govStill lists marijuana in Schedule I without the April 2026 medical-marijuana change.
7.21 CFR 1301.22, Exemption of agents and employees; affiliated practitioners · Legal Information Institute (Cornell), Code of Federal Regulations · law.cornell.edu(c): practitioners employed by a hospital may administer, dispense or prescribe under the hospital's registration.
8.Schedules of Controlled Substances: Rescheduling of certain medical marijuana to Schedule III (final rule, 91 FR 22714) · DEA, Federal Register, 2026 · govinfo.govEffective April 28, 2026.
9.High Time for a Change? Post-DEA Hearing, Broader Marijuana Rescheduling Questions Remain · Morgan Lewis, 2026 · morganlewis.comDEA final rule of April 22, 2026 (published April 28, 2026); broader rescheduling still pending as of September 24, 2026.
10.Initial Certification Content Outline · ABA · theaba.orgSection II.E.4.c.3, understanding laws related to controlled substances, including opioids and cannabinoids; II.E.4.f.4, substance use disorder.
11.Updates to Buprenorphine Prescribing and Substance Use Training from the Consolidated Appropriations Act, 2023 (MAT and MATE Acts) · University of Maryland School of Medicine · medschool.umaryland.edu
12.CDC Clinical Practice Guideline for Prescribing Opioids for Pain, United States, 2022 · CDC (MMWR Recomm Rep 2022;71(3)), 2022 · cdc.gov

Facts on this page were checked against these sources on Oct 25, 2026. Guidelines change; confirm doses against current institutional protocols.