Whether you’re a Primary Care Physician, Licensed Nurse Practitioner, or a Dentist – the State of Ohio now requires you to follow seven rules when prescribing opioid treatment for your patients’ acute pain. Read the rules below and my recommendations for easily implementing into your daily practice.
(1) No more than seven days of opioids for adults
Research indicates that a majority of acute pain issues resolve within 5-7 days. Limiting the
(2) No more than five days of opioids for minors, plus consent form required
And only after the written consent of the parent or guardian is obtained via a form you must create. It is your responsibility as the prescriber to record the guardian’s consent on a form, which is commonly known as the, “Start Talking!” consent form. The form shall be separate from any other document the prescriber uses to obtain informed consent for other treatment provided to the minor and should contain all of the following:
a) The name and quantity of the opioid analgesic being prescribed and the amount of the initial dose.
b) A statement indicating that a controlled substance is a drug or other substance that the United States Drug Enforcement Administration has identified as having a potential for abuse.
c) A statement certifying that the prescriber discussed with the minor and the minor’s parent, guardian, or another adult authorized to consent to the minor’s medical treatment the matters – this means you’ve reviewed their full medical records and considered any past or current use or abuse of schedule I, II, III, IV, or V opiate narcotics and their derivatives.
d) The number of refills, if any, authorized by the prescription.
e) The signature of the minor’s parent, guardian, or another adult authorized to consent to the minor’s medical treatment and the date of signing. Don’t just get them to sign this form, help them understand the associated risks. Download our Acute Opiate Prescription Minor Consent Form template that we created to eliminate having to create one of your own
(3) Health care providers may prescribe opioids in excess of the day supply limits only if they provide a specific reason in the patient’s medical record.
Here are a couple of examples of patients I’ve encountered:
Patient A is already on long term opioid management for a chronic pain condition and now has postoperative pain after a total knee replacement. These patients due to the long term use of opioids can develop tolerance to pain medication and may take longer to resolve their acute pain episode.
Patient B with new diagnosis of cancer and undergoing active chemotherapy, radiation or surgery may need periods of opioids to help alleviate their symptoms through these treatments that can often take months with the goal of maintaining a quality of life and function.
Patient C acute pain has resulted in complications resulting in pain past the 7 days period requiring
(4) Total morphine equivalent dose (MED) cannot exceed an average of 30 MED per day.
Recent research suggests acute pain due to musculoskeletal injury or even in the post-surgical stage can be treated with non-opioid medications such as NSAIDs, neuropathic agents, and nerve blockers.
Some prescribers resort to oxycodone-acetaminophen (Percocet) to prescribe for acute or post-operative pain. Percocet has an average elimination half-life to 3.5 hours, meaning this is the amount of time it takes for half a dose of Percocet to leaves one’s system. Therefore the patient should have adequate coverage of pain throughout the day based on the known half-life of the medication if dosed every 6 hours. Based on this most acute pain prescriptions should not exceed a 30 MED.
Keep in mind that this is for acute pain. Chronic pain patients are required to follow a different set of MED rules. Read about those here [link our other blog post].
(5) The new limits do not apply to opioids prescribed for cancer, palliative care, end-of-life/hospice care or medication-assisted treatment for addiction.
Many of these conditions are complex requiring ongoing care and treatment and do not fall under the acute care prescribing guidelines. There is often variability in pain levels based type of cancer, stage of disease and treatment protocols allowing prescribers to tailor the pain management regimen based on the specific patient needs.
(6) The rules apply to the first opioid analgesic prescription for the treatment of an episode of acute pain.
The rules apply to opioid naive individuals for the treatment of acute pain. Because many acute pain related conditions can be resolved with non-opioid treatment like using NSAIDs, neuropathic agents, patches, or even injections, these methods should be tried first before resorting to opioid analgesic prescriptions (painkillers). Using alternative treatments and a multidisciplinary approach to acute pain can prevent a potential recurring opioid prescription use and abuse.
(7) The rules do not apply to inpatient prescriptions
Hospitals, convalescent homes, developmental facilities, long term care facilities, nursing homes, psychiatric facilities, rehabilitation facilities, developmental disability facilities, level III sub-acute detoxification facilities certified by the Ohio department of mental health and addiction services, and State or local correctional facilities do not have to adhere to these rules. Prescribers in these facilities should decide the MED on a case by case and consult with pain management specialists. Read more exceptions here.
It’s worth noting that these rules are only in reference to human patients, not animals. Veterinarians should instead reference the resources here.
To speak with a pain management specialist, contact us here[contact page].