Ohio Admin. Code 4731-11-14 - Prescribing for subacute and chronic pain
(A) Prior to treating, or continuing to treat
subacute or chronic pain with an opioid analgesic, the physician shall first
consider and document non-medication and nonopioid treatment options.
(1) If opioid analgesic medications are
required as determined by a history and physical examination, the physician
shall prescribe for the minimum quantity and potency needed to treat the
expected duration of pain and improve the patient's ability to
function.
(2) The physician shall
comply with the requirements of rule
4731-11-02 of the Administrative
Code.
(B) Before
prescribing an opioid analgesic for subacute or chronic pain, the physician
shall complete or update and document in the patient record assessment
activities to assure the appropriateness and safety of the medication
including:
(1) History and physical
examination including review of previous treatment and response to treatment,
patient's adherence to medication and non-medication treatment, and screening
for substance misuse or substance use disorder;
(2) Laboratory or diagnostic testing or
documented review of any available relevant laboratory or diagnostic test
results. If evidence of substance misuse or substance use disorder exists,
diagnostic testing shall include urine drug screening;
(3) Review the results of an OARRS check in
compliance with rule
4731-11-11 of the Administrative
Code;
(4) A functional pain
assessment which includes the patient's ability to engage in work or other
purposeful activities, the pain intensity and its interference with activities
of daily living, quality of family life and social activities, and the physical
activity of the patient;
(5) A
treatment plan based upon the clinical information obtained, to include all of
the following components:
(a)
Diagnosis;
(b) Objective goals for
treatment;
(c) Rationale for the
medication choice and dosage; and
(d) Planned duration of treatment and steps
for further assessment and followup.
(6) Discussion with the patient or guardian
regarding:
(a) Benefits and risks of the
medication, including potential for addiction and risk of overdose;
and
(b) The patient's
responsibility to safely store and appropriately dispose of the
medication.
(7) The
physician shall offer a prescription for an overdose
reversal drug
naloxone to the patient
receiving an opioid analgesic prescription under any of the following
circumstances:
(a) The patient has a history
of prior opioid overdose;
(b) The
dosage prescribed exceeds a daily average of eighty MED or at lower doses if
the patient is co-prescribed a benzodiazepine, sedative hypnotic drug,
carisprodol, tramadol, or gabapentin; or
(c) The patient has a concurrent substance
use disorder.
(C) Prior to increasing the opioid dosage to
a daily average of fifty MED or greater the physician shall complete and
document the following in the patient's medical record:
(1) The physician shall review and update the
assessment completed in paragraph (B) of this rule, if needed. The physician
may rely on an appropriate assessment completed within a reasonable time if the
physician is satisfied that he or she may rely on that information for purposes
of meeting the further requirements of this chapter of the Administrative
Code;
(2) The physician shall
update or formulate a new treatment plan, if needed;
(3) The physician shall obtain from the
patient or the patient's guardian written informed consent which includes
discussion of all of the following:
(a)
Benefits and risks of the medication, including potential for addiction and
risk of overdose.
(b) The patient's
responsibility to safely store and appropriately dispose of the
medication.
(4) Except
when the patient was prescribed an average daily dosage that exceeded fifty MED
before the effective date of this rule, the physician who is neither a
specialist in the area of the body affected by the pain nor a pain management
specialist shall document consideration of the following:
(a) Consultation with a specialist in the
area of the body affected by the pain;
(b) Consultation with a pain management
specialist;
(c) Obtaining a
medication therapy management review by a pharmacist; and
(d) Consultation with a specialist in
addiction medicine or addiction psychiatry, if aberrant behaviors indicating
medication misuse or substance use disorder are noted.
(5) The physician shall consider offering a
prescription for an overdose reversal drug
naloxone to mitigate risk of
overdose.
(D) Prior to
increasing the opioid dosage to a daily average of eighty MED or greater, the
physician shall complete all of the following:
(1) Enter into a written pain treatment
agreement with the patient that outlines the physician's and patient's
responsibilities during treatment and requires the patient or patient
guardian's agreement to all of the following provisions:
(a) Permission for drug screening and release
to speak with other practitioners concerning the patient's condition or
treatment;
(b) Cooperation with
pill counts or other checks designed to assure compliance with the treatment
plan and to minimize the risk of misuse or diversion;
(c) The understanding that the patient shall
only receive opioid medications from the physician treating the chronic pain
unless there is written agreement among all of the prescribers of opioids
outlining the responsibilities and boundaries of prescribing for the patient;
and
(d) The understanding that the
dosage may be tapered if not effective or if the patient does not abide by the
treatment agreement.
(2)
Offer a prescription for an overdose reversal
drug
naloxone to the patient as
described in paragraph (B) of this rule.
(3) Except when the patient was prescribed an
average daily dosage that exceeded eighty MED before the effective date of this
rule, the physician who is neither a specialist in the area of the body
affected by the pain nor a pain management specialist shall obtain at least one
of the following based upon the patient's clinical presentation:
(a) Consultation with a specialist in the
area of the body affected by the pain;
(b) Consultation with a pain management
specialist;
(c) Obtain a medication
therapy management review; or
(d)
Consultation with a specialist in addiction medicine or addiction psychiatry if
aberrant behavior indicating medication misuse or substance use disorder may be
present.
(E)
The physician shall not prescribe a dosage that exceeds an average of one
hundred twenty MED per day. This prohibition shall not apply in the following
circumstances:
(1) The physician holds board
certification in pain medicine, board certification in hospice and palliative
care, board certification in hematology, or board certification in
oncology;
(2) The physician has
received a written recommendation for a dosage exceeding an average of one
hundred twenty MED per day from a board certified pain medicine physician or
board certified hospice and palliative care physician who based the
recommendation on a face-to-face visit and examination of the patient. The
prescribing physician shall maintain the written recommendation in the
patient's record; or
(3) The
patient was receiving an average daily dose of one hundred twenty MED or more
prior to the effective date of this rule. The physician shall follow the steps
in paragraph (E)(2) of this rule prior to escalating the patient's
dose.
(F) During the
course of treatment with an opioid analgesic at doses below the average of
fifty MED per day, the physician shall provide periodic follow-up assessment
and documentation of the patient's functional status, the patient's progress
toward treatment objectives, indicators of possible addiction, drug abuse or
drug diversion and the notation of any adverse drug effects.
(G) During the course of treatment with an
opioid analgesic at doses at or above the average of fifty MED per day, the
physician shall complete and document in the patient record the following no
less than every three months:
(1) Review of
the course of treatment and the patient's response and adherence to
treatment.
(2) The assessment shall
include a review of any complications or exacerbation of the underlying
condition causing the pain through appropriate interval history, physical
examination, any appropriate diagnostic tests, and specific treatments to
address the findings.
(3) The
assessment of the patient's adherence to treatment including any prescribed
non-pharmacological and non-opioid treatment modalities;
(4) Rationale for continuing opioid treatment
and nature of continued benefit, if present.
(5) The results of an OARRS check in
compliance with rule
4731-11-11 of the Administrative
Code.
(6) Screening for medication
misuse or substance use disorder. Urine drug screen should be obtained based on
clinical assessment of the physician with frequency based upon presence or
absence of aberrant behaviors or other indications of addiction or drug
abuse.
(7) Evaluation of other
forms of treatment and the tapering of opioid medication if continued benefit
cannot be established.
(H) This rule does not apply to the physician
who prescribes an opioid in any of the following situations:
(1) The medication is for a patient in
hospice care.
(2) The patient has
terminal cancer or another terminal condition, as that term is defined in rule
4731-11-01 of the Administrative
Code.
(I) This rule does
not apply to inpatient prescriptions as defined in rule
4729-17-01 of the Administrative
Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 3719.062, 4731.05, 4731.052, 4730.39, 4730.07
Rule Amplifies: 3719.062, 4731.052, 4730.39
Prior Effective Dates: 11/11/1998, 11/30/2008, 08/31/2017, 12/23/2018, 10/31/2020
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