Vermont Adopts Opioid Prescribing Rule

The Vermont Department of Health has adopted its permanent opioid prescribing rules. The rules are effective March 1, 2019. The new rules apply to all Schedule II, III or IV opioids prescribed for acute pain in all health care settings, including workers' compensation. The limitations in the rule only apply to initial prescriptions for a given course of treatment and do not apply to renewals or refills. One of the stated goals of the rule is to “provide prescribers with a framework for prescribing opioids in the smallest doses for the shortest periods of time to be effective in the management of pain.”

The Following is a Summary of Some of the Key Provisions of the Rule:

• Prior to prescribing on opioid the patient must be given the Department of Health Opioid Information Sheet and sign an informed consent agreement.
• Depending on the level of pain a patient experiences, different levels of opioids are recommended:
  • For minor pain, no opioids are recommended.
  • For moderate pain, opioids limited to an average daily limit of 24 MME/day for up to 5 days.
  • For severe pain, opioids limited to an average daily limit of 32 MME/day for up to 5 days.
  • For extreme pain, opioids limited to an average daily limit of 50 MME/day for up to 7 days.
• For children 17 years of age or younger, moderate and severe pain is limited to 24 MME/day for up to 3 days.
• Limits indicated are maximums, not therapeutic recommendations.
• Daily MME can be higher and taper to a lower dose as long as the total MME does not exceed the daily average limit.
• Second prescriptions may be written if medically necessary.
• Exceptions include:
  • Pain associated with significant or severe trauma.
  • Pain associated with complex surgical interventions, such as spinal surgery.
  • Pain associated with prolonged inpatient care due to post-operative complications.
  • Medication-assisted treatment for substance use disorders.
  • Patients who are not opioid naive (opioid naive is defined as a patient not using opioids for more than 7 consecutive days in the previous 30 days).
  • Other circumstances as determined by the Commissioner of Health.
• Long-acting opioids are not indicated for acute pain.
• Naloxone should be co-prescribed if opioid dose exceeds 90 MME or if a benzodiazepine is co-prescribed.
• Special rules apply before prescribing extended-release oxycodone or hydrocodone that are not abuse-deterrent formulations.

The rules also address chronic pain (pain lasting longer than 90 consecutive days) and require prescribers to conduct substance abuse risk assessments and to have the patient sign a Controlled Substance Treatment Agreement. In both acute and chronic situations, the rules also encourage the use of non-pharmacological treatments for pain before using opioids.

Complete text of the rules can be found here.

For questions concerning this alert, or for other legislative or regulatory questions, please contact Brian Allen at Brian.Allen@mitchell.com or at 801.903.5754.