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

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

3. 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.

4. 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.

5. 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.

6. 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

7. 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.

8. 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)

9. 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

10. 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.

11. 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

13. Informed Consent
Information on potential for:
Misuse
Abuse
Diversion
Addiction

14. 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)

15. Example of Informed Consent for Opioids

16. 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

17. 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.

18. 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.

19. 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.

21. 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
≥ mg/day 12
Morphine
Oxycodone
1.5
Oxymorphone 3

22. 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.

23. 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)

24. 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)

25. 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

26. Vermont Department of Health, Patient Information Sheet
References
Vermont Department of Health, Patient Information Sheet
Vermont Department of Health, Vermont Prescription Monitoring System Rule, effective July 1, 2017.
Centers for Disease Control and Prevention (CDC), Calculating Total Daily Dose of Opioids for Safer Dosage
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).
18 V.S.A. § 4284, Section 2a of Act 173 An act relating to combating opioid abuse in Vermont (2016).