Summary of New Virginia Board of Medicine Regulations for Prescribing Medication for Acute Pain
In response to the opioid epidemic in Virginia, the Virginia General Assembly directed the Board of Medicine to create regulations for the treatment of acute and chronic pain. As emergency physicians who treat acute pain every shift, it is important to be familiar with the new regulations,including how they impact our prescribing patterns and documentation requirements.
The new regulations place limits on opioid prescription quantities, requirements for the prescription of naloxone, and recommendations for checking the Prescription Monitoring Program (PMP). In brief, non-opioid medications should be considered first line for outpatient treatment of acute pain and when opioids are prescribed they should be short acting opioids in the lowest dose possible.
The important regulatory changes include:
-For prescriptions more than 14 days, the prescriber shall query the Prescription Monitoring Program as required by law and conduct an assessment of the patient’s history and risk of substance abuse.
-A prescriber providing treatment for acute painshall not prescribe a controlled substance containing an opioid in a quantity that exceeds a seven-day supply as determined by the manufacturer’s directions for use, unless extenuating circumstances are clearly documented in the medical record.
-The practitioner shall carefully consider and document in the medical recordthe reasons to exceed 50 MME/day (10 tablets of hydrocodone/acetaminophen 5/325 a day or 6 tablets of oxycodone/acetaminophen 5/325 a day)
-Prior to exceeding 120 MME/day (15 tablets of hydromorphone 2mg a day), the practitioner shall document in the medicalrecord the reasonable justification for such doses or refer to or consult with a pain management specialist.
-Naloxone shall be prescribed for any patient that meets any of the following risk factors for overdose:
- prior overdose,
- history of substance abuse,
- doses in excess of 120 MME/day, or
- concomitant benzodiazepine is present.
-Due to a higher risk of fatal overdose when opioids are prescribed with benzodiazepines, sedative hypnotics, carisoprodol, and tramadol, the prescriber shall only co-prescribe these substances when there are extenuating circumstances and shall document in the medical recorda tapering plan to achieve the lowest possible effective doses if these medications are prescribed
In addition to documenting the reason for using the opioid regimen prescribed, providers also need to document the following in the medical record
-a description of the pain,
-a presumptive diagnosis for the origin of the pain,
-an examination appropriate to the complaint,
-a treatment plan and the medication prescribed or administered to include the date, type, dosage, and quantity prescribed or administered