Most healthcare providers are already aware of Virginia’s opioid abuse problem. By some accounts, abuse of opioids claims life of two Virginians daily. As a result, state and federal agencies, including the Virginia Board of Medicine and the DEA continue to focus on opioid prescribing.
The Virginia Board of Medicine has established regulations governing opioid and buprenorphine/Suboxone prescribing. Generally, short-acting opioids to treat acute pain should be prescribed for no more than seven days and post-surgical opioid pain management should not exceed 14 days. If there are extenuating circumstances, they should be well documented in the medical record. The Board also presumes that opioids should be started at 50 morphine milligram equivalent/day or less and a provider should carefully consider and document any deviation from that practice. For more than 120 MME/day, a provider must document the reasonable justification for the dose or refer/consult with a pain management specialist. As many primary care physicians know, obtaining a consult with a pain management specialist can be challenging. Benzodiazepines, sedative hypnotics, carisoprodol or tramadol should only be prescribed along with opioids under extenuating circumstances. Additionally, the provider must document a tapering plan to achieve the lowest possible effective doses. In most of the cases I review, there has been no such tapering plan documented. Naloxone must be prescribed in certain circumstances and Buprenorphine is typically not permitted for treating acute pain.
The Board also set forth what the medical record for management of acute pain should include: a description of the pain; presumptive diagnosis for the pain’s origin; and the presence or absence of any indicators for medication misuse or diversion and appropriate actions taken. (Addressing indications for misuse or diversion is also absent in many of the cases I see). The medical record must also contain a detailed written consent agreement. While many healthcare providers have such agreements, they are often outdated, incomplete, unsigned, unused or not followed. They should regularly be reviewed and updated.
During chronic pain management with opioids, the practitioner must do a prescribed review at least every three months on the course of the pain treatment, new information about the etiology of the patient’s pain, the patient’s health, and a review of the Prescription Monitoring Program. Providers must also evaluate and document the continued benefit of the prescribing and assess the appropriateness of continuing, based on progress.
The regulations do not apply to certain patients including those with sickle cell, cancer, or on palliative care or hospice.
Given the opioid epidemic, and the focus of state and federal agencies on addressing it, physicians should carefully review the Board’s guidelines and their own practices to ensure they comply with the regulations.