Part III. Prescribing for Pain Management
18VAC60-21-101. Definitions.
The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:
"Acute pain" means pain that occurs within the normal course of a disease or condition or as the result of surgery for which controlled substances may be prescribed for no more than three months.
"Chronic pain" means nonmalignant pain that goes beyond the normal course of a disease or condition for which controlled substances may be prescribed for a period greater than three months.
"Controlled substance" means drugs listed in The Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia) in Schedules II through IV.
"MME" means morphine milligram equivalent.
"Prescription Monitoring Program" means the electronic system within the Department of Health Professions that monitors the dispensing of certain controlled substances.
Statutory Authority
§§ 54.1-2400 and 54.1-2708.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 12, eff. March 6, 2019.
18VAC60-21-102. Evaluation of the patient in prescribing for acute pain.
A. Nonpharmacologic and non-opioid treatment for pain shall be given consideration prior to treatment with opioids. If an opioid is considered necessary for the treatment of acute pain, the dentist shall follow the regulations for prescribing and treating with opioids in 18VAC60-21-103 and 18VAC60-21-104.
B. Prior to initiating treatment with a controlled substance containing an opioid for a complaint of acute pain, the dentist shall perform a health history and physical examination appropriate to the complaint, query the Prescription Monitoring Program as set forth in § 54.1-2522.1 of the Code of Virginia, and conduct an assessment of the patient's history and risk of substance abuse.
Statutory Authority
§§ 54.1-2400 and 54.1-2708.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 12, eff. March 6, 2019.
18VAC60-21-103. Treatment of acute pain with opioids.
A. Initiation of opioid treatment for all patients with acute pain shall include the following:
1. A prescription for an opioid shall be a short-acting opioid in the lowest effective dose for the fewest number of days, not to exceed seven days as determined by the manufacturer's directions for use, unless extenuating circumstances are clearly documented in the patient record.
2. The dentist shall carefully consider and document in the patient record the reasons to exceed 50 MME per day.
3. Prior to exceeding 120 MME per day, the dentist shall refer the patient to or consult with a pain management specialist and document in the patient record the reasonable justification for such dosage.
4. Naloxone shall be prescribed for any patient when there is any risk factor of prior overdose, substance abuse, or doses in excess of 120 MME per day and shall be considered when concomitant use of benzodiazepine is present.
B. If another prescription for an opioid is to be written beyond seven days, the dentist shall:
1. Reevaluate the patient and document in the patient record the continued need for an opioid prescription; and
2. Check the patient's prescription history in the Prescription Monitoring Program.
C. Due to a higher risk of fatal overdose when opioids are prescribed with benzodiazepines, sedative hypnotics, carisoprodol, and tramadol, the dentist shall only co-prescribe these substances when there are extenuating circumstances and shall document in the patient record a tapering plan to achieve the lowest possible effective doses if these medications are prescribed.
Statutory Authority
§§ 54.1-2400 and 54.1-2708.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 12, eff. March 6, 2019.
18VAC60-21-104. Patient recordkeeping requirement in prescribing for acute pain.
The patient record shall include a description of the pain, a presumptive diagnosis for the origin of the pain, an examination appropriate to the complaint, a treatment plan, and the medication prescribed, including date, type, dosage, strength, and quantity prescribed.
Statutory Authority
§§ 54.1-2400 and 54.1-2708.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 12, eff. March 6, 2019.
18VAC60-21-105. Prescribing of opioids for chronic pain.
If a dentist treats a patient for whom an opioid prescription is necessary for chronic pain, the dentist shall either:
1. Refer the patient to a medical doctor who is a pain management specialist; or
2. Comply with regulations of the Board of Medicine, 18VAC85-21-60 through 18VAC85-21-120, if the dentist chooses to manage the chronic pain with an opioid prescription.
Statutory Authority
§§ 54.1-2400 and 54.1-2708.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 12, eff. March 6, 2019.
18VAC60-21-106. Continuing education required for prescribers.
Any dentist who prescribes Schedules II, III, and IV controlled substances shall obtain two hours of continuing education on pain management every two years. Continuing education hours required for prescribing of controlled substances may be included in the 15 hours required for renewal of licensure.
Statutory Authority
§§ 54.1-2400 and 54.1-2708.4 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 12, eff. March 6, 2019; amended, Virginia Register Volume 41, Issue 2, eff. October 24, 2024.
18VAC60-21-107. Waiver for electronic prescribing.
Upon written request, the board may grant a one-time waiver of the requirement of § 54.1-3408.02 of the Code of Virginia for a period not to exceed one year, due to demonstrated economic hardship, technological limitations that are not reasonably within the control of the prescriber, or other exceptional circumstances demonstrated by the prescriber.
Statutory Authority
§§ 54.1-2400 and 54.1-3408.02 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 38, Issue 10, eff. February 2, 2022; amended, Virginia Register Volume 41, Issue 2, eff. October 24, 2024.
18VAC60-21-108. Patient counseling for opioids.
A. Prior to issuing a prescription for an opioid to treat acute or chronic pain, practitioners must provide patient counseling on the following:
1. The risks of addiction and overdose associated with opioid drugs and the dangers of taking opioid drugs with alcohol, benzodiazepines, and other central nervous system depressants;
2. The reasons why the prescription is necessary;
3. Alternative treatments that may be available; and
4. Risks associated with the use of the drugs being prescribed, specifically that opioids are highly addictive, even when taken as prescribed, that there is a risk of developing a physical or psychological dependence on the controlled dangerous substance, and that the risks of taking more opioids than prescribed, or mixing sedatives, benzodiazepines, or alcohol with opioids can result in fatal respiratory depression.
Such patient counseling shall be documented in the patient's medical record.
B. Patient counseling as described in subsection A shall not be a requirement for patients who are (i) in active treatment for cancer, (ii) receiving hospice care from a licensed hospice or palliative care, (iii) residents of a long-term care facility, (iv) being prescribed an opioid in the course of treatment for substance abuse or opioid dependence, or (v) receiving treatment for sickle cell disease.
Statutory Authority
§ 54.1-2400 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 41, Issue 2, eff. October 9, 2024.