Safe Opioid Prescribing

When prescribing opioid medications for patients, the healthcare provider and the patient must be aware of their responsibilities. An opioid treatment agreement between patient and provider will clarify expectations.

What Prescribers Should Do

Take a Medical History and Physical Examination: This includes an assessment of the pain, physical and psychological function, substance abuse history, assessment of underlying or coexisting diseases or conditions, and should also include the presence of a recognized medical indication for the use of a controlled substance.

Screening Brief Intervention and Referral to Treatment (SBIRT): Consider screening all patients annually or upon entry to your practice to assess potential risk for substance abuse. Tools such as the Opioid Risk Tool (ORT) as well as DAST 10 (Drug and Alcohol Screening Tools 10) and several more tools available from Substance Abuse and Mental Health Services Administration (SAMHSA).

Conversation with Patient about the Risks of Opioid Medications: Before prescribing an opioid, prescribers must document in the medical record that a conversation occurred with the patient (or guardian) about the risks of the opioid medication. This is a state law that is required for the second and third prescriptions as well. Patient education can be communicated orally or in writing depending on patient preference. This conversation is an opportunity to thoughtfully consider risks, and must include:

  • Risks of developing dependence or addiction to the prescription opioid and potential of overdose or death;
  • Risks of concurrent use of alcohol or other sedating medications, such as benzodiazepines;
  • Impaired ability to safely operate any motor vehicle;
  • Patient’s responsibility to safeguard all opioid medications in a secure location;
  • Alternative treatments for managing pain (non-opioid medications and/or non-pharmacologic treatments); and
  • Risks of relapse for those who are in recovery from substance dependence.

To fulfill this requirement, before prescribing an opioid medication, clinicians can print and share RIDOH’s supplementary patient education material, Knowing the Risks of Opioid Prescription Pain Medications (spanish). Prescribers should also review recommended conversation starters for use during patient dialogues.

Make a Treatment Plan: The treatment plan should state objectives by which treatment success can be evaluated, such as pain relief and/or improved physical and psychosocial function, and indicate if any further diagnostic evaluations or other treatments are planned. The prescriber should tailor drug therapy to the individual medical needs of each patient. Several treatment modalities or a rehabilitation program may be necessary if the pain has differing etiologies or is associated with physical and psychosocial impairment.

Prescribe Proportionately: Only prescribe the amount of pain medicine reasonably expected to be needed. If you expect 3 days of severe pain prescribe only 3 days worth of medication. Acute Pain (< 5days) can often be managed without opioids.

Documentation of International Classification of Diseases (ICD) 10 Diagnosis Code(s) on Controlled Substance Prescriptions: State law requires prescribers to include ICD-10 diagnosis codes on any controlled substance prescriptions. Electronic Health Records (EHRs) can accommodate this documentation requirement; however, for cases when a clinician might not use an EHR, the ICD-10 code must be entered on the prescription in a visible location for the pharmacist. The visibility of the ICD-10 code will enable pharmacists to appropriately counsel patients based on the prescriber’s diagnosis/diagnoses. comprehensive list of ICD-10 codes

Co-Prescribe Naloxone: Prescribers are required to co-prescribe naloxone in these three different clinical scenarios. If co-prescribing naloxone is not appropriate for the patient, then the prescriber must document the reason(s) in the patient’s medical record.

  1. When prescribing an opioid individually or in aggregate with other medications that is more than or equal to 50 oral Morphine Milligram Equivalents (MMEs) per day.
  2. When prescribing any dose of an opioid when a benzodiazepine has been prescribed in the past 30 days or will be prescribed at the current visit. Prescribers shall note in a patient’s medical record the medical necessity of the co-prescription of the opioid and the benzodiazepine, and explain why the benefit outweighs the risk given the Food and Drug Administration (FDA) black box warning.
  3. When prescribing any dose of an opioid to a patient with a prior history of opioid use disorder or overdose. Prescribers must also document in the patient’s medical record the medical necessity of prescribing an opioid to this high-risk individual and explain why the benefit outweighs the risk given the patient’s previous history.

Prescribers are encouraged to download and print this naxolone script template when co-prescribing naxolone. To learn more about the prescribing and dispensing of naxolone as well as other useful overdose prevention resources, visit PrescribeToPrevent.org.

Start an Opioid Trial: Advise your patient to try the medication for a specified period of time and re-assess. Agree that if are not making reasonable progress, to consider stopping and trying a different approach.

Electronically Prescribe Controlled Substances: Make sure you upgrade your electronic health record system, get 2 identification tokens, and get approval from surescripts®. more

Obtain Informed Consent: The prescriber should discuss the risks and benefits of the use of controlled substances with the patient, guardian or authorized representative. This discussion should be documented and signed by the patient, guardian or authorized representative. sample

Keep Accurate Records: The prescriber should keep accurate and complete records according to items 1-5 above, including the medical history and physical examination, other evaluations and consultations, treatment plan objectives, informed consent, treatments, medications, agreements with the patient, and periodic reviews.

Be Compliant with Controlled Substances Laws and Regulations: To prescribe controlled substances, the prescriber must be licensed appropriately in Rhode Island, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions.

Additional Guidance

When using opioids to treat acute pain

Patients that undergo medical procedures or have injuries, or other sudden pain, may be appropriately managed with medications, or other interventions, that do not include opioids. If the prescriber strongly feels that an opioid is necessary, state law requires that they are only used for a short duration for a patients who have not taken opioids with the previous 30 days. This law intends to limit the risk of addiction for these "opioid naïve patients"

Initial prescriptions of opioids for acute pain management of outpatient adults shall not exceed thirty (30) morphine milligram equivalents (MMEs) total daily dose per day for a maximum total of twenty (20) doses. Acute pain management does not include chronic pain management, pain associated with a cancer diagnosis, palliative or nursing home care, or other exception in accordance with Department of Health regulations.

Check the Prescription Drug Monitoring Program to determine if a patient is opioid naïve prior to prescribing.

Limits on Opioids for Acute Pain in Opioid Naïve Patients
Morphine Equivalent Dosage Converter Table for Commonly Prescribed Opioids

Opioid Brand/Trade Name MME Per Dose Maximum Daily Dose Max Daily Units (1TAB/CAP=1 Unit) Max Units Dispensed Per Prescription
Oxycodone 5mg Roxicodone 7.5mg 20mg 4 20
Oxycodone/APAP 5mg/325mg Percocet 7.5mg 20mg 4 20
Hydrocodone/APAP 5mg/325mg Norco 5mg 30mg 6 20
Hydrocodone/APAP 5mg/300mg Vicodin 5mg 30mg 6 20
Hydrocodone/APAP 7.5mg/500mg Vicodin ES 7.5mg 30mg 4 20
Hydrocodone/Ibuprofen 7.5mg/200mg Vicoprofen 7.5mg 30mg 4 20
APAP/Codeine 30mg Tylenol #3 4.5mg 180mg 6 20
APAP/Codeine 60mg Tylenol #4 9mg 180mg 3 20
Hydromorphone 2mg Dilaudid 8mg 8mg 4 20
Tramadol 50mg Ultram 5mg 300mg 6 20

Based on 30 MME per day.

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When using opioids to treat chronic pain

Enter Into a Prescriber-Patient Agreement: The agreement will help you and your patient share information about medications and comply with controlled substance regulations. Violations of the agreement should be discussed with your patient.

Monitor Your Patients Opioid Utilization: Use the Prescription Monitoring Program before each appointment. Enroll Login Positive Prescription Monitoring Reports should be reviewed with the patient. Additionally, it is important to conduct random urine drug screens as well as have patients bring back pill bottles to monitor supply remaining.

Periodically Review Treatment: The prescriber should periodically review the course of opioid treatment of the patient and any new information about the etiology of the pain. Continuation or modification of opioid therapy depends on the prescriber's evaluation of progress toward treatment objectives. If the patient has not improved, the prescriber should assess the appropriateness of continued opioid treatment or trial of other modalities.

Make Consultations: The prescriber should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. In addition, prescribers should give special attention to those pain patients who are at risk for misusing their medications including those whose living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse requires extra care, monitoring, documentation and consultation with addiction medicine specialists, and may entail the use of agreements between the provider and the patient that specify the rules for medication use and consequences for misuse.

Addiction is a disease, chronic and relapsing. Patients with any chronic disease deserve appropriate treatment. There are many places to find treatment for addiction and substance abuse.

Continuing Education Courses

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In an Emergency Department Setting

Prescriptions for opioid pain medicine given on discharge from the Emergency Department will be for no more than a 3-day supply with no refills.

Patients should not receive opioid pain medications for the same condition from multiple providers. Emergency Department providers, therefore, should not prescribe refills or additional opioid prescriptions for a condition previously treated by another provider unless there are extenuating circumstances.

Emergency providers should not replace lost or stolen prescriptions for opioid pain medications.

Emergency providers should not give refill prescriptions for patients who have run out of chronic opioid pain medication. Refills need to be arranged with the provider who ordinarily prescribed the medication.

Emergency providers should not prescribe long-acting opioid pain medication such as Oxycontin, extended-release opioids, or methadone.

The administration of opioid pain medication injections in the Emergency Department is discouraged for chronic non- cancer pain being treated with chronic opioid pain medications by another provider.

The administration of opioid pain medication injections in the Emergency Department is discouraged for certain medical conditions including chronic back pain; routine dental pain; recurrent migraines; and Gl conditions such as chronic abdominal or pelvic pain, gastroparesis, cyclic vomiting, hyperemesis cannabinoid syndromes.

Patients with suspected substance abuse behavior should be referred to appropriate treatment resources.

Emergency Department providers should access the State of Rhode Island Prescription Monitoring Program. Other electronic resources should also be utilized such as records from prior inpatient and outpatient treatment.

Emergency providers are encouraged to communicate with the patient's regular prescribers or PCP if the patient exhibits concerning behavior related to opioid pain medication use.

Patients should be provided detailed information regarding the addictive nature of these medications, and the potential dangers of misuse. This information may be included in the discharge instructions.

What we do

  • Monitor trends in opioid prescribing more
  • Provide advice and guidelines to healthcare providers to encourage responsible prescribing of pain medications