Barbara AllisonBryan MD Chief Deputy DHP We Are

Barbara Allison-Bryan, MD Chief Deputy DHP

We Are Part of the Problem • In the 1960 s 80% of first opioid use=heroin • By the 1990 s 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 25 -45 years of age

And it is a huge problem From DBHDS

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. Mc. Auliffe March, 2017 Permanent regulations required within 18 months; ready now for approval • Acute Pain • Chronic Pain • Buprenorphine use for MAT

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 7 day limit is also for post-surgical pain

Regulations: Acute Pain Key Concepts • Document the extenuating circumstances for the coprescribing 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 >120 MME/day, hx prior overdose or abuse, or concomitant benzodiazepine

Regulations: Acute Pain Key Concepts Morphine Milligram Equivalents

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

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 >120 MME/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

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

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

• How to Access the Virginia PMP: • Navigate to: https: //virginia. pmpaware. net. • Click the ‘Reset Password’ button on the homepage. • Instructions will be emailed to you for resetting your password. • If the email 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.

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

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)

Contact Information • Department of Health Professions • www. dhp. virginia. gov • Barbara. Allison-Bryan@dhp. virginia. gov • Board of Medicine • www. dhp. virginia. gov/medicine • medbd@dhp. virginia. gov • www. vaaware. com