Opioid Prescribing Guidelines

With the support of physicians and other prescribers, Ohio has made some promising progress in key areas in its fight against prescription opioid abuse. In recent years, both the number of opioid doses dispensed to Ohio patients and the number of “doctor shoppers” have decreased, according to data from the Ohio Automated Rx Reporting System (OARRS).

Still, there is more that we must do to save lives. Prescription opioids remain a significant contributor to unintentional drug overdose deaths in Ohio, and the number of overdose deaths increased year to year from 2012 through 2014.

2018 Chronic Pain Prescribing Rules

On May 3, 2018, Governor John Kasich announced that he would implement new chronic pain prescribing rules that he said would help prevent chronic pain patients from becoming addicted to prescription painkillers.

The new rules for chronic pain do not set limits on what can be dispensed but instead are based on the strength of medications. Physicians are required to re-evaluate patients’ opioid use at periodic “safety checkpoints.”

The first checkpoint is at 50 morphine equivalent dose (MED). Prescribers are required to re-evaluate the patient’s underlying condition causing the pain, assess function, look for signs of prescription misuse, consider consultation with a specialist, and obtain written informed consent.

The second checkpoint is at 80 MED. Prescribers must do all of the things done at the 50 MED level plus obtain a written pain agreement and consider a Naloxone prescription.

The final checkpoint is 120 MED.  At this dosage, prescribers are required to have a pain medicine specialist as a prescriber or consultant.

The rules apply to the treatment of patients with sub-acute pain, a type of pain lasting between six and 12 weeks, and long-term pain, lasting 12 weeks or more. The rules do not affect hospice patients, patients being treated in hospitals, or patients already being treated for chronic pain unless their dosages increase.

The State Medical Board of Ohio, the Ohio Board of Nursing, and the Ohio State Dental Board have been charged with writing the rules to implement Gov. Kasich’s initiative.  The rules are expected to take effect in fall 2018.

Opioid Prescribing Guidelines

The Governor’s Cabinet Opiate Action Team (GCOAT) developed opioid prescribing guidelines for emergency departments (EDs) in 2012 and for the management of chronic pain in 2013. These prescribing guidelines are intended to supplement—not replace—clinical judgment.

For Chronic Pain

The Ohio Guidelines for Prescribing Opioids for the Treatment of Chronic, Non-Terminal Pain use 80 mg morphine equivalency dosing (MED) as a “trigger threshold,” as the odds of an overdose are higher above that dose.

Chronic pain is defined as pain that has persisted after reasonable medical efforts have been made to relieve the pain or cure its cause and that has continued, either continuously or episodically, for longer that three continuous months.

Acute Pain Rules

On August 31, 2017, the State of Ohio implemented new rules for prescribing opioid analgesics for the treatment of acute pain. In general, the rules limit the prescribing of opioid analgesics for acute pain as follows:
  1. No more than seven days of opioids can be prescribed adults.
  2. No more than five days of opioids can be prescribed in the initial prescription for minors, and only after the written consent of the parent or guardian is obtained.
  3. Physicians and other licensed health care prescribers may prescribe opioids in excess of the day supply limits only if they provide a specific reason in the patient’s medical record.
  4. Except as provided for in the rules, the total morphine equivalent dose (MED) of a prescription for acute pain cannot exceed an average of 30 MED per day.
  5. These limits do not apply to opioids prescribed for cancer, palliative care, end-of-life/hospice care, or medication-assisted treatment for addiction.
  6. The rules apply to the first opioid analgesic prescription for the treatment of an episode of acute pain.
  7. The rules do not apply to inpatient prescriptions as defined in rule 4729-17-01 of the Ohio Administrative Code.

Acute pain is defined in the rule as pain that normally fades with healing, is related to tissue damage, significantly alters a patient’s typical function and is expected to be time limited.

In addition, the following rules went into effect December 29, 2017:
  • Rule 4729-5-30 requires prescribers to include the first four characters (ex. M16.5) of the diagnosis code (ICD-10) or the full procedure code (Current Dental Terminology – CDT) on opioid prescriptions, which will be entered by the pharmacy into the Ohio Automated Rx  Reporting System (OARRS). Note, this requirement will take effect for all other controlled substance prescriptions on Friday, June 1, 2018.
  • Rule 4729-5-30  requires prescribers to indicate the days’ supply on all controlled substance and gabapentin prescriptions.

To assist prescribers in calculating a patient’s MED, the State of Ohio Board of Pharmacy (SOBP) has developed a conversion chart.

For additional information, please review your licensing board’s respective rules and the SOBP’s manner of issuance rule:

Medical Board – Rules for Physicians and Physician Assistants
  • 4731-11-01 – Definitions (related to controlled substances)
  • 4731-11-02 – General provisions (related to controlled substances)
  • 4731-11-13 – Prescribing of opioid analgesics for acute pain.
Pharmacy Board
  • 4729-5-30 – Manner of issuance of a prescription. (NOTE: This rule went into effect on December 29, 2017. The SOBP has adopted a resolution regarding the diagnosis/procedure code provisions of this rule).

Emergency and Acute Care Facility Guidelines

The Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances Prescribing Guidelines offer clinical guidance for the acute care environment where there is no established patient-doctor relationship.

Parental Informed Consent Form for Prescribing Opioids to Minors

Under provisions of House Bill 314 signed into law by Governor John Kasich on June 17, 2014, all prescribers must obtain written informed consent from a minor’s parent, guardian, or other person responsible for the minor before issuing a controlled substance prescription to the minor. The law, sponsored by Representative Nan Baker (R – Westlake, OH), also establishes penalties for a prescriber’s failure to comply with this requirement.

Effective September 17, 2014, a signed consent form, known as the “Start Talking!” consent form, is required to be completed and maintained in the medical record of a minor for which opioids are prescribed.

The informed consent requirement does not apply under the following circumstances:
  1. The minor’s treatment is associated with or incident to a medical emergency
  2. The minor’s treatment is associated with or incident to surgery, regardless of whether the surgery is performed on an inpatient or outpatient basis
  3. In the prescriber’s professional judgment, fulfilling the bill’s informed consent requirement would be a detriment to the minor’s health or safety
  4. The minor’s treatment is rendered in a hospital, ambulatory surgical facility, nursing home, pediatric respite care program, residential care facility, freestanding rehabilitation facility, or similar institutional facility. This exemption does not apply, however, when the treatment is rendered in a prescriber’s office that is located on the premises of or adjacent to any of the foregoing facilities or locations
  5. The prescription is for a compound that is a controlled substance containing an opioid that the prescriber issues to a minor at the time of discharge from a facility or other location described in No. 4 above.

2017 Law Changed 90-Day Opiate Supply Prescriptions

Effective April 1, 2017, there are new limits in the amount of opiate pills that can be dispensed from a single prescription to a 90-day supply. In addition, opiate prescriptions that are unused after 30 days are invalid. This change was brought about with passage of Senate Bill 319, the mid-biennium review legislation regarding opiates that was passed during the 131st General Assembly and signed into law by Gov. Kasich on January 4, 2017.

Under provisions of the legislation, a pharmacist, pharmacy intern, or terminal distributor of dangerous drugs may dispense or sell the opioid analgesic after more than fourteen days have elapsed since the prescription was issued if all of the following apply:
  • The prescription is one of multiple prescriptions for the drug issued by a single prescriber to the patient on a single day.
  • When combined, the prescriptions do not authorize the patient to receive an amount that exceeds a 90-day supply of the drug, as determined according to the prescriptions’ directions for use of the drug.
  • The prescriber has provided written instructions on the prescription indicating the earliest date on which the prescription may be filled.
  • Not more than 14 days have elapsed since the earliest date on which the prescription may be filled.

Additional information and two other reforms included in the legislation, can be found in the Weekly Family Medicine Update.

Office-Based Treatment of Opioid Addiction Using Buprenorphine Products

To prescribe or dispense buprenorphine, physicians must qualify and apply for a waiver under the Drug Addiction Treatment Act of 2000. Physicians are also required to complete buprenorphine training.

View the State Medical Board’s FAQ on office-based opioid treatment and the Substance Abuse and Mental Health Services Administration’s website for more information.

Medication-Assisted Treatment Rules

Effective April 30, 2019, the following medication-assisted treatment rules went into effect:

Ohio Automated Rx Reporting System

OARRS data is used to assess the impact of the Ohio clinical guidelines. OARRS can help physicians improve patient care, reduce prescription abuse, and prescribe safely. Are you registered for OARRS? If you are not using OARRS, you need to start today!

Additional Resources

Additional Information