Understanding the new opioid prescribing rules

A week can’t go by without hearing or reading something about the prescription drug and opioid abuse crisis in Ohio. A recent national study by the Henry Kaiser Family Foundation found that Ohio leads the nation in opioid overdose deaths. According to the Ohio Department of Health, unintentional drug overdoses caused the deaths of 4,050 Ohio residents in 2016, as compared to 3,050 in 2015. This is the highest number of deaths on record from drug overdoses and reflects a 32.8 percent increase compared to 2015.

Making matters worse is that Ohio is now seeing an increase in non-prescription drug overdoses as well. Ohio has the highest number of deaths from synthetic opioids such as fentanyl and carfentanil and from heroin.

The causes and responsibilities related to this crisis go far and wide. Accordingly, it will take a multi-pronged approach to combating the crisis involving many different players including law enforcement, the criminal justice system, treatment providers, community leaders, churches and other community institutions, and state and federal officials.

The prescribing community has also been identified as a group that can help the state make progress in fighting this crisis. As some of you know first-hand, changes to Ohio’s laws and rules related to the prescribing community’s use of the OARRS database have helped dentists identify patients who may be doctor-shopping or otherwise abusing prescription drugs.

Now, new rules have been developed to limit the duration and strength of opioid prescriptions in Ohio. Effective on Aug. 31, 2017, the following limits apply to all prescribers when prescribing opioids for acute pain:

For adults, not more than a seven day supply with no refills
For minors, not more than a five-day supply with no refills and only after the written consent of the parent or guardian is obtained

The Ohio State Dental Board’s rules permit the seven-day limit for adults and the five-day limit for minors to be exceeded only “for pain that is expected to persist for longer than seven days based on the pathology causing the pain.” In this circumstance, “the reason that the limits are being exceeded and the reason that a non-opioid medication was not appropriate to treat the patient’s condition shall be documented in the patient’s record.”

The OSDB’s rules further state that the “total morphine equivalent dose (MED) of a prescription for opioid analgesics for treatment of acute pain shall not exceed an average of thirty MED per day.” The Ohio State Board of Pharmacy has posted a calculator on its website to assist prescribers in calculating the MED equivalent for opioid prescriptions, which can be found at ohiopmp.gov/MED_Calculator.aspx

The rules permit a dentist to exceed the 30 MED limit only where all of the following apply:

(1) The patient has significant and prolonged acute pain related to one of the following conditions:

(a) Traumatic oro-facial tissue injury with major mandibular/maxillary surgical procedures,

(b) Severe cellulitis of facial planes, or

(2) The dentist determines that, for the 72 hour period following the procedure, it is absolutely necessary to exceed the 30 MED daily limit based on the patient’s needs but may not exceed 90 MED per day; and

(3) The dentist has documented the reason for exceeding the 30 MED average in the patient record and why it is the lowest dose consistent with the patient’s medical condition.

Conclusion

In light of the current crisis, the Ohio State Dental Board and the Ohio State Board of Pharmacy have made clear that the rules related to the seven-day limit for adults and the five-day limit for minors and the 30 MED limit for opioid prescriptions will be closely monitored and enforced. If you prescribe opioids, you simply must follow the rules described above to avoid the potential for regulatory action against your dental license.