Part V. Management of Acute Pain
18VAC90-40-150. Evaluation of the patient for acute pain.
A. The requirements of this part shall not apply to:
1. The treatment of acute pain related to (i) cancer, (ii) sickle cell, (iii) a patient in hospice care, or (iv) a patient in palliative care;
2. The treatment of acute pain during an inpatient hospital admission or in a nursing home or an assisted living facility that uses a sole source pharmacy; or
3. A patient enrolled in a clinical trial as authorized by state or federal law.
B. 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 practitioner shall give a short-acting opioid in the lowest effective dose for the fewest possible days.
C. Prior to initiating treatment with a controlled substance containing an opioid for a complaint of acute pain, the prescriber shall perform a 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 misuse as a part of the initial evaluation.
Statutory Authority
§§ 54.1-2400 and 54.1-2957 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 21, eff. July 10, 2019.
18VAC90-40-160. Treatment of acute pain with opioids.
A. Initiation of opioid treatment for patients with acute pain shall be with short-acting opioids.
1. A prescriber providing treatment for a patient with acute pain shall not prescribe a controlled substance containing an opioid in a quantity that exceeds a seven-day supply as determined by the manufacturer's directions for use, unless extenuating circumstances are clearly documented in the medical record. This shall also apply to prescriptions of a controlled substance containing an opioid upon discharge from an emergency department.
2. An opioid prescribed as part of treatment for a surgical procedure shall be for no more than 14 consecutive days in accordance with manufacturer's direction and within the immediate perioperative period, unless extenuating circumstances are clearly documented in the medical record.
B. Initiation of opioid treatment for all patients shall include the following:
1. The practitioner shall carefully consider and document in the medical record the reasons to exceed 50 MME per day.
2. Prior to exceeding 120 MME per day, the practitioner shall document in the medical record the reasonable justification for such doses or refer to or consult with a pain management specialist.
3. Naloxone shall be prescribed for any patient when risk factors of prior overdose, substance misuse, doses in excess of 120 MME per day, or concomitant benzodiazepine are present.
C. Due to a higher risk of fatal overdose when opioids are used with benzodiazepines, sedative hypnotics, carisoprodol, and tramadol (an atypical opioid), the prescriber shall only co-prescribe these substances when there are extenuating circumstances and shall document in the medical record a tapering plan to achieve the lowest possible effective doses if these medications are prescribed.
D. Buprenorphine is not indicated for acute pain in the outpatient setting, except when a prescriber who has obtained a SAMHSA waiver is treating pain in a patient whose primary diagnosis is the disease of addiction.
Statutory Authority
§§ 54.1-2400 and 54.1-2957 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 21, eff. July 10, 2019.
18VAC90-40-170. Medical records for acute pain.
The medical 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 or administered to include the date, type, dosage, and quantity prescribed or administered.
Statutory Authority
§§ 54.1-2400 and 54.1-2957 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 35, Issue 21, eff. July 10, 2019.