Prescribing Opioids in Vermont Alison Eastman, RN Risk Management Specialist Rutland Regional Medical Center Prescribing Opioids in Vermont

Outline Brief History & Statute Review Vermont Department of Health Rules for Prescribing Opioids for Acute Pain Universal Precautions Calculating the Morphine Milligram Equivalent (MME)

Act 75 Adopted pursuant to 18 V.S.A. § 4289 (Standards and Guidelines for Health Care Providers and Dispensers), Section 11 of Act 75- An act relating to strengthening Vermont’s response to opioid addiction an methamphetamine abuse (2013). The standards developed by the licensing authorities shall be consistent with rules adopted by the Department of Health.

Act 173 Adopted pursuant to 18 V.S.A. § 4289, Section 2a of Act 173- An act relating to combating opioid abuse in Vermont (2016). This act addresses appropriate prescriptions of controlled substances to treat acute pain including: Limits on prescriptions, including a maximum number of pills to be prescribed following minor medical procedures. Requires dispensers to query the Vermont Prescription Monitoring System (VPMS) and increases the frequency with which dispensers must report to the VPMS from at least once a week to daily.

Act 173 Continued… This act requires the Department of Health to establish and maintain a statewide unused prescription drug disposal program. Directs BlueCross BlueShield of Vermont to evaluate the evidence supporting the use of acupuncture to treat pain and whether its plans should provide coverage for acupuncture services.

Vermont Department of Health Rules Governing the Prescribing of Opioids Purpose: Provide legal requirements for the appropriate use of opioids in treating pain in order to minimize opportunities for misuse, abuse, and diversion, and optimize prevention of addiction and overdose. Prescription limits for acute pain only apply to the first prescription written for a given course of treatment and do not apply to renewals or refills. This rule only applies to Schedule II, III, or IV Controlled substances. The prescribing limits under this rule do not apply to patients who are receiving palliative care, or end of life care. Dept. of Health wants to see if they can limit exceptions relative to CA patients

Universal Precautions Prior to writing a prescription for an opioid Schedule II, III, or IV Controlled Substance for the first time during a course of treatment to any patient, providers shall adhere to the seven Universal Precautions, unless otherwise exempt.

Upon first prescription prescribers must: Consider Non-Opioid and Non-Pharmacological Treatment. Treatments include, but are not limited to: Nonsteroidal anti-inflammatory drugs (NSAIDs) Acetaminophen Acupuncture Chiropractic Physical Therapy Osteopathic manipulative treatment (OMT)

Vermont Prescription Monitoring System (VPMS) VPMS Query is required either by the prescriber or their delegate (i.e. individual acting on behalf of the provider who is authorized to access the VPMS database) for any of the following circumstances: The first time the provider prescribes an opioid Starting non-palliative long-term pain therapy of 90 days or more Prior to writing a replacement prescription At least annually for patients who are receiving ongoing treatment The first time prescriber prescribes a benzodiazepine (not required to complete Universal Precautions unless prescribed concurrently with an opioid) When a patient requests an opioid or a renewal from an Emergency Department or Urgent Care Center

VPMS Continued… Before the prescriber can prescribe methadone or buprenorphine for the first time or for a replacement prescription Before the prescriber can prescribe buprenorphine that exceeds the dosage threshold approved by the VT Medicaid Drug Utilization Review Board. Prescribers must receive prior approval from the Department of Vermont Health Access.

Chronic pain as a result of cancer or cancer treatment VPMS Query Exemptions The following circumstances are exempt from the VPMS query requirement: Chronic pain as a result of cancer or cancer treatment Palliative care, end-of-life and hospice care Patients in skilled nursing and intermediate care facilities

Informed Consent Information on potential for: Misuse Abuse Diversion Addiction

Informed Consent Continued… Risks of: Respiratory depression Fatal overdose (accidental) Neonatal opioid withdrawal syndrome Potential for fatal overdose when combined with alcohol and/or other psychoactive drugs (benzodiazepines)

Example of Informed Consent for Opioids

Face to Face Discussion of Risks The prescriber will have an in-person discussion with the patient regarding: Side effects Risk of dependence and overdose Alternative treatments Appropriate tapering Safe storage and disposal Co-prescription of naloxone where appropriate

Communication with Primary Care Provider Acute pain in adult patients- Before ending a patient’s treatment for acute pain, a prescriber shall ensure a safe transition of care by making a reasonable effort to communicate with the patient’s Primary Care Provider (PCP) with relevant clinical information. The patient shall be given a clear discharge summary that includes expectations for ongoing pain treatment.

Communication with PCP Continued… Children/Pediatric patients with acute pain- Before prescribing an opioid to a child in the ED or specialty care setting, prescribers will make a reasonable effort to consult with the child’s PCP.

Co-prescribing Naloxone A Co-prescription for naloxone is required for all patients receiving a prescription that exceeds a daily dose of 90 MMEs; or receiving an opioid prescription concurrent with a prescription for a benzodiazepine A prescriber can chose not to supply a naloxone prescription where the prescriber has confirmed that the patient already has a naloxone prescription; or the patient has received information on where to obtain free naloxone and the patient has declined the prescription.

CDC’s Guidelines for Calculating the Daily MME Opioid (mg/day unless otherwise noted) Conversion Factor Codeine 0.15 Fentanyl transdermal (mcg/hr.) 2.4 Hydrocodone 1 Hydromorphone 4 Methadone 1-20 mg/day 21-40 mg/day 8 41-60 mg/day 10 ≥ 61-80 mg/day 12 Morphine Oxycodone 1.5 Oxymorphone 3

Opioid Prescribing Limits for Adults with Acute Pain Opioid prescribing limits apply to Opioid Naïve patients (has not used opioids for more than 7 consecutive days within the last 30 days). Patients receiving their first opioid prescription in a course of treatment. When the medication will not be administered within a healthcare facility. Prescription limits do not inhibit prescriber from writing a second prescription; Framework provides 4 categories with limits- framework is intended to provide for the smallest doses for the shortest period of time.

MME Limits for First Prescription of Opioid Naïve Patient Ages 18+ Pain Average Daily MME (allowing for tapering) Prescription TOTAL MME based on expected duration of pain Common average DAILY pill counts Commonly associated injuries, conditions and surgeries Minor pain No Opioids 0 total MME 0 hydrocodone 0 oxycodone 0 hydromorphone molar removal, sprains, non-specific low back pain, headaches, fibromyalgia, un-diagnosed dental pain Moderate pain 24 MME/day 0-3 days: 72 MME 1-5 days: 120 MME 4 hydrocodone 5mg or 3 oxycodone 5mg or 3 hydromorphone 2mg non-compound bone fractures, most soft tissue surgeries, most outpatient laparoscopic surgeries, shoulder arthroscopy Severe pain 32 MME/day 0-3 days: 96 MME 1-5 days: 160 MME 6 hydrocodone 5mg or 4 oxycodone 5mg or 4 hydromorphone 2mg many non-laparoscopic surgeries, maxillofacial surgery, total joint replacement, compound fracture repair Extreme Pain 50 MME/day 7 day MAX: 350 MME 10 hydrocodone 5mg or 6 oxycodone 5mg or 6 hydromorphone 2mg similar to the severe pain category but with complications or other special circumstances Remind folks that this is for the first prescription only and does not preclude writing a second prescription if needed. For patients with severe pain and extreme circumstance, the provider can make a clinical judgement to prescribe up to 7 days so long as the reason is documented in the medical record. Exemptions: active and aftercare cancer treatment, palliative care, end-of-life and hospice care, patients in skilled and intermediate care nursing facilities, multi-system trauma, complex surgical interventions such as spinal surgery, persons released from an in-patient care setting with uncontrolled pain, patients on medication-assisted treatment for substance use disorder, patients who are not opioid naïve (have had opioids within past 30 days)

MME Limits for First Prescription for Opioid Naïve Patients Ages 0-17 Pain Average Daily MME (allowing for tapering) Prescription TOTAL MME based on expected duration of pain Common average DAILY pill counts Commonly associated injuries, conditions and surgeries Minor pain No Opioids 0 total MME 0 hydrocodone 0 oxycodone 0 hydromorphone molar removal, sprains, non-specific low back pain, headaches, fibromyalgia, un-diagnosed dental pain Moderate to Severe pain 24 MME/day 0-3 days: 72 MME 4 hydrocodone 5mg or 3 oxycodone 5mg or 3 hydromorphone 2mg non-compound bone fractures, most soft tissue surgeries, most outpatient laparoscopic surgeries, shoulder arthroscopy Exemptions: active and aftercare cancer treatment, palliative care, end-of-life and hospice care, patients in skilled and intermediate care nursing facilities, multi-system trauma, complex surgical interventions such as spinal surgery, persons released from an in-patient care setting with uncontrolled pain, patients on medication-assisted treatment for substance use disorder, patients who are not opioid naïve (have had opioids within past 30 days)

Exemptions from Opioid Prescription Limits Palliative care End-of-life and hospice care Patients in skilled and intermediate care nursing facilities Pain associated with significant or severe trauma Pain associated with complex surgery (spinal surgery) Pain associated with prolonged inpatient care due to post-operative complications Medication-assisted treatment for substance use disorders Patients who are not opioid naïve Other circumstances as determined by the Commissioner of Health

Vermont Department of Health, Patient Information Sheet References Vermont Department of Health, Patient Information Sheet http://www.healthvermont.gov/response/alcohol-drugs/information-health-professionals-prescribers Vermont Department of Health, Vermont Prescription Monitoring System Rule, effective July 1, 2017. http://healthvermont.gov/sites/default/files/documents/2016/12/REG_vpms-20170701.pdf Centers for Disease Control and Prevention (CDC), Calculating Total Daily Dose of Opioids for Safer Dosage http://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf 18 V.S.A. § 4289 (e), Section 14 (e) of Act 75 An act relating to strengthening Vermont’s response to opioid addiction an methamphetamine abuse (2013). https://legislature.vermont.gov/assets/Documents/2014/Docs/ACTS/ACT075/ACT075%20As%20Enacted.pdf 18 V.S.A. § 4284, Section 2a of Act 173 An act relating to combating opioid abuse in Vermont (2016). https://legislature.vermont.gov/assets/Documents/2016/Docs/ACTS/ACT173/ACT173%20As%20Enacted.pdf