If one prescribes an opoid for anticipated acute pain such as after a tooth extraction, what should be documented?  The law states a description of pain and presumptive diagnosis is required but the prescription is given prior to discomfort in order to prevent post operative pain. 

The regulation seems to require the practitioner to reference MME but gives no chart giving the MME of various opioid analgesics.  As a dentist practicing 45 years, I've never heard of MME until now.  It seems to me an undo burden for a general dentist to have to look up and figure out this arcane information in order to prescribe for an acute dental problem.  Perhaps an oral surgeon or perio surgeon would have to be more aware.

Upon my review of the opioid emergency regulations, the requirement to provide a prescription for Naloxone is neither practical nor likely efficatious.  This is intended to give the patient an emergency drug to reverse the additive respiratory depression for patients simultaneouly taking benzodiazopines along with the newly prescribed narcotic analgesic.  It is higly unlikely that it could be used as intended or, for that matter, would be necessary at normal analgesic dosing.  If there occurs an inadvertant overdose, administration of this drug (Naloxone) in untrained hands would be difficult.  Apparently, it can be prepared as a nasal spray, but it does not come this way, and to expect a patient to use it properly and at the appropriate time is unrealistic.  In the hands of a first responder, it can be a lifesaver, but not in this situation.  Please strike this requirement from your emergency regulations.

What are the guidelines for prescribing a one time Benzodiazepine preopratively if patient on pain medication from another provider or using pain medication for acute problem.

There is no question that something needs to be done about the opiod epidemic, as it is costing too many lives in the US ( as well as Canada).  I am a firm believer that much of this epidemic is driven by the unintended consequences of making pain the 5th vital sign, emphasis on patient satisfaction scored (HCAHPS) and their effect on reimbursements.  I bring this up only because I wish to point out some unintended consequences of the current proposed regulatory changes.

1)  Milligram Morphine Equivalencies -  this is a topic that comes from pain medicine and equianalgesic doses.  It has been increasingly emphasized due to the CDC recommendations.  However, the CDC recommendations were meant to be guidelines for consideration by practitioners and not laws.  The CDC was clear on this, and made such recommendations because of the public health crisis posed by the Opioid Epidemic.  Dentists are not trained on this.  I would say few understand that hydrocodone has a 1:1 equivalency with ORAL morphine ( IV morphine is 3 times that of oral morphine due to bioavailability) or Oxycodone is 1:5 : 1.  Codeine shows a major flaw in this equianalgesic / equavalency paradigm, as it is completely dependent on metabolism of a prodrug into active metabolites.  Each individual does so differently.  However, the MME helps to study effects across the plethora of different opioid drugs.

This becomes problematic when a dentist prescribes medications for a 3-5 day period that is typical after dental surgical procedures.  It was long taught that dentists should prescribe Hydrocodone / Acetaminophen 5/325 as 1-2 tabs every 4-6 hrs as needed for pain, perhaps with 16-20 pills.  This allows the patient to adjust their dosing within a safe range depending on pain levels.  A pharmacist will review this Rx as 60 MME daily.  This is regarded as equivalent to an MD prescribing Hydrocodone / Acetaminophen 5/325 2 every 4 hours for 30 days, or 360 pills. Dentists should be encourages to prescribe for less than 7 days (as noted in these changes) for acute pain, not necessary on the basis of MMEs. Most of our crisis is due to misuse, especially of extra supply of medications.

2)  Naloxone requires some training to use.  Dentists being encouraged to prescribe these items to patients and their families will require thorough understanding of respiratory depression secondary to excess narcotics and how to use naloxone.  Intranasal naloxone requires expensive Mucosal atomization devices, and requires high volumes of drug (although there are now more expensive conentrated versions of naloxone), approximately 4 ml.  Intramuscular devices are like epi pens and cost upwards of 600 dollars.  Even the original naloxone formulation has had a price increase of nearly 300% since these rules, going from appoximately 9 dollars to 30 dollars on my most recent order - and it is getting worse.

3) Naloxone with any concomitant use of benzodiazapene - we use benzodiazepenes frequently in dentistry for sedation and anesthesia.  Should we give every patient that gets an opioid prescription Naloxone then?  This would basically mean every patient receiving sedation or anesthesia would need a prescription for Naloxone.  It is true that there can be a synergistic effect of narcotics and benzodiazapenes on respiratory depression, but such a blanket "must" is, in my opinion, a waste of medical resources.

In summary, I would ask you to reconsider the wording of the Naloxone requirements for the reasons above.  I also believe that it is more efficacious for dentists to be encouraged to maximize non-narcotic analgesic techniques first and to limit narcotics to breakthrough pain during the acute phase of recovery (5-7 days maximum) either in addition to or in leui of focussing solely on MMEs.

Having read the previous comments, I agree with each of their points and do not wish to reiterate all those points.  I'll concur that there is an opiod problem which needs to be addressed.  In general, acute dental pain management usually last just a few days.  Therefore, the amount of a particular opiod that we would prescribe is generally 20 pills or under.  The patients to which I would prescribe opiods are absolutely in need of them.  Should their pain persist longer than the usual time period, then the provider should re-examine the patient and re-prescribe as necessary thus avoiding a hefty amount of pills being presribed initially.  How many of these overdoses have been ascribed to dentally related prescriptions?  Not to make an undue burden on our pharmacist collegues, but if there is a requirement for the use of naloxone, doesn't it make sense for the pharmacist to co-distribute the naloxone (along with the detailed instructions on how to use it to family members) as a standard protocol for those dosings in which the MME is much higher or the amount of distributed pill is much greater?

While I support this overall initiative, I would respectfully request reconsideration of the requirement to prescribe naloxone whenever there is concomitant use of a benzodiazepine. I see many patients in our clinics at VCU who may take daily or PRN doses of benzodiazepines, and if I believe a narcotic analgesic is indicated, I routinely consider dose reduction, and I counsel the patient regarding additive effects of the medications. However, to require a naloxone prescription for this entire group of patients is not, in my opinion, indicated.

TDo these regs even speak to people who have already been in treatment for a long time? My husband has Tardive Dyskinesia, a disorder that causes spasms and severe pain in his mouth, jaw, and tongue. It has no cure. The primary treatment is drugs that help control the spasms and pain. A well respected and compassionate oral and maxillo facial surgeon diagnosed this about 14 years ago after my husband had suffered for more than a year. The doctor has been managing his treatment ever since. He literally gave my husband a life! The doctor told us recently that due to the changes in the law, he would not be able to continue caring for my husband and that we should look for a Pain Management doctor. I'm not sure why the doctor believes that to be true. But my husband is a chronic pain patient and the care he receives is palliative in nature. It appears 18VAC60-21-105 may allow him to continue treating my husband as long as he complies with the Board of Medicine regs. I'm not sure because I'm not an attorney. My husband's condition has been worsening recently and the loss of his doctor would be devestating to him. Besides that, I contacted 50-75 Pain Management doctors and all except 2 were anesthesiology pain management and didn't manage medications. Of the 2 exceptions, one said my husband's case was too complex. The other, who had assured me they could handle his case, backed out of that assurance when I called to make an appointment. In addition, I contacted the hospital's physician referral service and placed notifications on social media and on online medical forums. Those resulted in zero success. I just don't know what else I can do at this point. My husband did not ask for the disorder he has. It came about because some doctor failed to warn him of the serious side effects of drugs he prescribed. My husband is in his 60s and he does not abuse or divert the drugs he is prescribed. All he wants is to live his life in some semblance of comfort. If he should be made to suffer because of laws that are promulgated due to the bad acts of others, it would be a real travety.ype over this text and enter your comments here. You are limited to approximately 3000 words.

The number of patients on scheduled or prn benzodiazepines has grown significantly. The requirement to give naloxone is absurd.  Half of my patients would be getting naloxone.  I have called three different pharmacies and none of them even stock the 1mg/1ml SQ dose.  One pharmacy had the nasal dosing at 150.00 dollars.  This regulation needs more thought.  It is unworkable at this time.

I have also read the previous comments and agree with their conclusions.  If indeed this goes through as written I would like to know how to address the patient who is already taking high dose Opioids and concomitent Benzodiazapines prescribes by their physician.  Even if I do not prescribe additional Opioids am I now responsible for prescribing the Naloxone?  Does the Board of Medicine require this as well or just the BOD.  Due to the costs of the nasal spray Naloxone I feel many patients will forgo filling the prescription.  May be we should just review the History and concerns with the patient and family then asked them if they would like the Naloxone RX.  It sounds more like a feel good rule and more thought needs to be done before implimenting it.