1. Barbara Allison-Bryan, MD
Chief Deputy DHP

2. We Are Part of the Problem
In the 1960s 80% of first opioid use=heroin
By the 1990s 80% of first opioid use=Rx drug
The US uses 80% of the world’s opiates for 5% of the world’s population
11% of high school seniors report non-medical use of prescription opioids ( National Institute on Drug Abuse)
Drug OD is the leading cause of death in the US between years of age

3. And it is a huge problem
From DBHDS

4. Regulations May be Part of the Solution
Mandated by 2017 legislation requiring the BOM to promulgate regs
Emergency regulations
Drafted using a Regulatory Advisory Panel January, 2017
Based on guidelines, best practices
Opportunity for comment and amendment
Approved by the BOM and signed by Gov. McAuliffe March, 2017
Permanent regulations required within 18 months; ready now for approval
Acute Pain
Chronic Pain
Buprenorphine use for MAT

5. Regulations: Acute Pain Key Concepts
An appropriate history and physical including an assessment of the patient’s history and risk of substance misuse
Consider non-pharmacologic and non-opioid treatments prior to using opioids
When necessary, a short-acting opioid written in the lowest dose for the fewest possible days, not to exceed 7 days unless the PMP is consulted and extenuating circumstances are fully documented.
New in 2018: the 7day limit is also for post-surgical pain

6. Regulations: Acute Pain Key Concepts
Document the extenuating circumstances for the co- prescribing of benzos and sedative hypnotics. Include a tapering plan to achieve lowest possible effective dose
Consider the MME
Document why the initial dose should exceed 50 MME/day
Prior to exceeding 120 MME/day, document why or consult with or refer to a pain specialist
Prescribe naloxone if >120MME/day, hx prior overdose or abuse, or concomitant benzodiazepine

7. Regulations: Acute Pain Key Concepts
Morphine Milligram Equivalents

8. Regulations: Chronic Pain Key Concepts
Initial evaluation to include history, physical and mental status
Urine drug screen or serum medication level
PMP check
Assessment of risk of substance misuse
Risk/benefit discussion, informed consent and treatment agreement

9. Regulations: Chronic Pain Key Concepts
Consider the MME
Document why the dose should exceed 50 MME/day
Prior to exceeding 120 MME/day, document why or consult with or refer to a pain specialist
Naloxone if >120MME/day, hx prior overdose or abuse, or concomitant benzodiazepine
Co-prescribing of benzos and sedative hypnotics only if extenuating circumstances, with a tapering plan to achieve lowest possible effective dose

10. Regulations: Chronic Pain Key Concepts
Every 3 months:
Review course of treatment, overall state of health
Document rationale for continuing opioids
Check PMP
Urine screen as needed and at least yearly
Regularly evaluate for misuse and refer as needed
Exempt: Terminal Ca, SS, Palliative Care

11. The PMP 24/7 Database of Schedule II – IV Prescriptions
Resource for Prescribers and Pharmacists
Account through VA AWARE
Pharmacies, other dispensers report within 24 hours
PMP interoperable with other states including MD, NC, WV, KY & TN
Pro-active report of outlier prescribing & dispensing for investigation
Pro-active report of doctor shopping behavior to law enforcement

12. How to Access the Virginia PMP:
Navigate to: 
Click the ‘Reset Password’ button on the homepage.
Instructions will be ed to you for resetting your password. 
If the does not appear in your inbox, please check the spam folder.
Once you have reset your password, you will be logged into the system.
If prompted, update demographic information.
To request patient reports, please review the How to Make a Request Guide.

13. Measuring Outcomes
The number of individuals receiving a Rx for an opioid has dropped ~30% since regs took effect
The number of doses of opioid prescribed has decreased ~40% since the initiation of the regs
The number of deaths from opioid overdose continues to increase

14. Regulations: Buprenorphine Prescribing for Addiction Key Concepts
Often diverted substance in SW Virginia
SAMHSA waiver required
NPs, PAs with practice agreement with waivered physician
Provide or refer for counseling
Buprenorphine monoproduct (subutex) only for:
Pregnancy
Conversion from methadone or buprenorphine
Non-tablet form as FDA approved
3% allowance for documented intolerance to naloxone (suboxone)

15. Regulations: Buprenorphine Prescribing for Addiction Key Concepts
Often diverted substance in SW Virginia
SAMHSA waiver required
NPs, PAs with practice agreement with waivered physician
Provide or refer for counseling
Buprenorphine monoproduct (subutex) only for:
Pregnancy
Conversion from methadone or buprenorphine
Non-tablet form as FDA approved
3% allowance for documented intolerance to naloxone (suboxone)

16. v b

17. Contact Information
Department of Health Professions
Board of Medicine