Rhode Island’s regulations for Pain Management, Opioid Use and the Registration of Distributors of Controlled Substances were updated in March 2017 and July 2018. Prescribers and pharmacists can refer to these Frequently Asked Questions (FAQs) to learn more about the updated pain management regulatory requirements.
What Prescribers Should Do
Take a Medical History and Physical Examination: This includes an assessment of the pain, physical and psychological function, substance abuse history, assessment of underlying or coexisting diseases or conditions, and should also include the presence of a recognized medical indication for the use of a controlled substance.
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Screening Brief Intervention and Referral to Treatment (SBIRT): Consider screening all patients annually or upon entry to your practice to assess potential risk for substance abuse. Tools such as the Opioid Risk Tool (ORT) as well as DAST 10 (Drug and Alcohol Screening Tools 10) and several more tools available from Substance Abuse and Mental Health Services Administration (SAMHSA).
Conversation with Patient about the Risks of Opioid Medications: Before prescribing an opioid, prescribers must document in the medical record that a conversation occurred with the patient (or guardian) about the risks of the opioid medication. This is a state law that is required for the second and third prescriptions as well. Patient education can be communicated orally or in writing depending on patient preference. This conversation is an opportunity to thoughtfully consider risks, and must include:
- Risks of developing dependence or addiction to the prescription opioid and potential of overdose or death;
- Risks of concurrent use of alcohol or other sedating medications, such as benzodiazepines;
- Impaired ability to safely operate any motor vehicle;
- Patient’s responsibility to safeguard all opioid medications in a secure location;
- Alternative treatments for managing pain (non-opioid medications and/or non-pharmacologic treatments); and
- Risks of relapse for those who are in recovery from substance dependence.
To fulfill this requirement, before prescribing an opioid medication, clinicians can use the following RIDOH educational resources:
- Recommended Conversation Starters for Use When Prescribing Opioids;
- Knowing the Risks of Opioid Prescription Pain Medications (Spanish) (Portuguese) educational flyers; and
- Knowing the Risks of Opioid Prescription Pain Medications educational video. This video can be played during office visits to introduce patients and/or caregivers to the serious risks of opioid medications and the alternative, non-opioid options for treating pain.
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Make a Treatment Plan: The treatment plan should state objectives by which treatment success can be evaluated, such as pain relief and/or improved physical and psychosocial function, and indicate if any further diagnostic evaluations or other treatments are planned. The prescriber should tailor drug therapy to the individual medical needs of each patient. Several treatment modalities or a rehabilitation program may be necessary if the pain has differing etiologies or is associated with physical and psychosocial impairment.
Prescribe Electronically and Proportionately: Use electronic prescription software that is compliant with federal and state confidentiality and security requirements. more Only prescribe the amount of pain medicine reasonably expected to be needed. If you expect 3 days of severe pain prescribe only 3 days worth of medication. Acute Pain (< 5days) can often be managed without opioids.
Documentation of International Classification of Diseases (ICD) 10 Diagnosis Code(s) on Controlled Substance Prescriptions: State law requires prescribers to include ICD-10 diagnosis codes on any controlled substance prescriptions. Electronic Health Records (EHRs) can accommodate this documentation requirement; however, for cases when a clinician might not use an EHR, the ICD-10 code must be entered on the prescription in a visible location for the pharmacist. The visibility of the ICD-10 code will enable pharmacists to appropriately counsel patients based on the prescriber’s diagnosis/diagnoses. comprehensive list of ICD-10 codes
Co-Prescribe Naloxone: Prescribers are required to co-prescribe naloxone in these three different clinical scenarios. If co-prescribing naloxone is not appropriate for the patient, then the prescriber must document the reason(s) in the patient’s medical record.
- When prescribing an opioid individually or in aggregate with other medications that is more than or equal to 50 oral Morphine Milligram Equivalents (MMEs) per day.
- When prescribing any dose of an opioid when a benzodiazepine has been prescribed in the past 30 days or will be prescribed at the current visit. Prescribers shall note in a patient’s medical record the medical necessity of the co-prescription of the opioid and the benzodiazepine, and explain why the benefit outweighs the risk given the Food and Drug Administration (FDA) black box warning.
- When prescribing any dose of an opioid to a patient with a prior history of opioid use disorder or overdose. Prescribers must also document in the patient’s medical record the medical necessity of prescribing an opioid to this high-risk individual and explain why the benefit outweighs the risk given the patient’s previous history.
Prescribers are encouraged to download and print this naxolone script template when co-prescribing naxolone. To learn more about the prescribing and dispensing of naxolone as well as other useful overdose prevention resources, visit PrescribeToPrevent.org.
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Start an Opioid Trial: Advise your patient to try the medication for a specified period of time and re-assess. Agree that if are not making reasonable progress, to consider stopping and trying a different approach.
Electronically Prescribe Controlled Substances: Make sure you upgrade your electronic health record system, get 2 identification tokens, and get approval from surescripts®. more
Obtain Informed Consent: The prescriber should discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative. This discussion should be documented and signed by the patient, guardian or authorized representative. sample
Keep Accurate Records: The prescriber should keep accurate and complete records according to items 1-5 above, including the medical history and physical examination, other evaluations and consultations, treatment plan objectives, informed consent, treatments, medications, agreements with the patient, and periodic reviews.
Be Compliant with Controlled Substances Laws and Regulations: To prescribe controlled substances, the prescriber must be licensed appropriately in Rhode Island, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions.
Additional Guidance
What we do
- Monitor trends in opioid prescribing more
- Provide advice and guidelines to healthcare providers to encourage responsible prescribing of pain medications
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