REVIEW
4. Patients in long-term care facilities
5. Any period of disaster or mass casualties
6. A single dose to relieve anxiety, pain or discomfort for a
diagnostic test or procedure
the prescriber is now required to manage the taper:
a. In a manner slow enough to minimize symptoms and signs
of opioid withdrawal
b. In collaboration with other specialists as needed
7. Any Schedule V controlled substance i. To optimize non-opioid pain management and
8. As part of a licensed narcotic treatment program ii. To optimize psychosocial support for anxiety re-
lated to the taper
9. Immediately prior to, during, or within the 14 days following
a major surgery for no longer than 14 days
As a reminder, please note that in all cases (that are not exempt)
the initial prescription of a controlled substance still requires doc-
umentation of:
In a related section of the KBML regulations there is a new
dictum regarding two specific scenarios where the physician must
stop prescribing:
1. An appropriate medical history and a physical examination A physician shall stop prescribing or dispensing any controlled
substance:
2. A KASPER report (REF 4) a. Diverted by or from the patient or
3. A decision (assessment) that a controlled substance is ap-
propriate b. Taken less frequently than once a day
4. Instruction that controlled substances for acute pain are
for a limited time Another if…then passage in the pain regulations now reads like this:
5. How to safely use and dispose of unused controlled sub-
stances
( 4 ) REFERRAL TO ADDICTION MANAGEMENT
The physician shall discontinue controlled substance treatment
or refer the patient to addiction management if:
6. Long-acting or extended-release opioids are not to be used
for acute pain a. There has been no improvement in function and response
to the medical complaint and related symptoms, if improve-
ment is medically expected (or)
The story does not end here. There are more changes to the KBML
regulations that have not been so well publicized as the three-day
limit, but are no less mandatory. Here are some of these additional
regulation changes: b. Controlled substance therapy has produced significant
adverse effects, including instances such as an overdose or
events leading to hospitalization or disability (or)
( 2 ) NONCOMPLIANT PATIENTS c. The patient exhibits inappropriate drug-seeking behavior
or diversion (or)r
If and when any information becomes available indicating the
patient is noncompliant, the physician now must do at least one of
the following: d. The patient is taking a high-risk regimen, such as dosag-
es fifty morphine milligram equivalents/day or opioids with
benzodiazepines, without evidence of benefit
a. Taper and collaborate
b. Stop prescribing (or)
c. Refer the patient to an addiction specialist, mental health
professional, pain management specialist, or drug treatment
program
Granted, the term “noncompliant” can have a wide range of
interpretations. This illustrates one of the problems when objective
prescriber actions are made dependent upon such ill-defined and
subjective conditions, but these are the regulations we have. Regard-
less, it is imperative to document one’s rationale behind choosing
any of the three options listed above.
( 3 ) TAPERING
Suffice it to say that the information below deserves more elucidation
than the brevity of this article allows. Nevertheless, Kentucky physi-
cians must now be aware that when tapering a patient’s medications,
GUIDELINES VS. STANDARDS OF CARE VS. REGU-
LATIONS
The most influential guideline in recent years is the 2016 CDC
Guideline for Prescribing Opioids for Chronic Pain (REF 5). This
guideline is referenced in the first paragraph of Kentucky’s updated
regulations:
… to establish mandatory prescribing and dispensing standards
related to controlled substances, and in accordance with the
Centers for Disease Control and Prevention (CDC) guidelines,
to establish a prohibition on a practitioner issuing a prescription
for a Schedule II controlled substance for more than a three
(3) day supply if intended to treat pain as an acute medical
condition, unless an exception applies.
As regulatory agencies, such as the KBML, continue looking to
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FEBRUARY 2018
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