7.3 Controlled Substances: PDMP Registration & Opioid Prescribing Rules (Den 502–503)

Controlled Substances, the PDMP, and Opioid Prescribing

Authority

• The Board adopts rules on prescribing controlled drugs under RSA 318-B:41 (RSA 317-A:12, XIII).
• Knowingly or willfully violating any federal, state, or local controlled drug law is professional misconduct (RSA 317-A:17, II(j); Den 407.01(l)).

PDMP registration and use — Den 301.02(k) and 502.01

• A licensee with a DEA number for Schedule II–IV drugs must register with the New Hampshire Controlled Drug Prescription Health and Safety Program (PDMP) under RSA 126-A:91. Failing to register within 90 days of initial licensure is misconduct, and no one may prescribe or dispense Schedule II–IV substances without registering.
• Den 502.01(a): dentists have a professional duty to comply with the PDMP statute and the pharmacy board rules adopted under it.
• Den 502.01(b) (implementing RSA 126-A:92, I) makes these acts grounds for disciplinary proceedings:
  1. prescribing or dispensing Schedule II–IV substances after June 30, 2015 without registering;
  2. knowingly disclosing PDMP information in violation of RSA 126-A:92, I or DHHS rules;
  3. using PDMP information for an unauthorized purpose;
  4. permitting an unauthorized person to use or see PDMP information under the dentist's control.
• CE: registrants holding a DEA number complete 3 CEUs in pain management or addiction disorder, or an online exam, for each biennial renewal (Den 406.03(c)).

Scope of the opioid rules — Den 503.01–503.02

Den 503 applies to opioids for non-cancer, non-terminal pain. It does not apply to the supervised administration of opioids in a health care setting.

Den 101 adds a dose unit (one pill, capsule, patch, or liquid dose), a prescription (a verbal, written, fax, or electronic order for self-administered medication), and a treatment plan (written goals, expectations, methods, and time course that reflect the patient's specific opioid risks and benefits).

Acute pain — Den 503.03

If an opioid is indicated for acute pain, the prescriber must:

1. conduct and document an exam of the oral cavity and associated structures and a medical history;
2. consider the risk of misuse and prescribe the lowest effective dose for less than 30 days;
3. document the prescription and rationale;
4. give the patient information on side effects including addiction and overdose death, the risks of keeping unused medication, safe storage and disposal, and the danger of operating vehicles or heavy machinery;
5. comply with all federal and state controlled-substance laws;
6. complete a Board-approved risk assessment tool, such as the SOAPP (Screener and Opioid Assessment for Patients with Pain);
7. document consideration of non-drug and non-opioid options and a pain treatment plan with drug, dose, and duration;
8. use written informed consent covering seven risks: addiction; overdose and death; physical dependence; physical side effects; hyperalgesia; tolerance; and crime victimization;
9. in an emergency department, urgent care setting, or walk-in clinic, prescribe the minimum amount needed. Three or fewer days is usually enough, and never more than 7 days. Exceeding a Board-approved limit requires documenting the condition and clinical rationale;
10. for unresolved acute pain beyond 30 days, work with the patient's primary care physician or a licensed pain management program. The dentist is not obligated to prescribe opioids for more than 30 days.

Chronic pain — Den 503.04

The acute-pain steps apply, plus:

• a documented risk assessment, such as the SOAPP;
• a treatment plan discussed with the patient, covering goals, function, safety, time course, and non-opioid options;
• a written treatment agreement in the record that lists conduct triggering discontinuation or tapering. It must address safe use and storage, obtaining opioids from one prescriber or practice, consent to random drug testing, and the prescriber's availability or clinical coverage;
• documented consideration of a specialist consultation when the patient takes 100 mg MED daily for more than 90 days, is at high risk, or has a co-morbid psychiatric disorder;
• reevaluation at least twice a year;
• urine drug testing at least annually for patients on opioids longer than 90 days;
• 24/7 clinical coverage.

The prescriber may skip the written agreement and drug testing for residents of long-term, non-rehabilitative nursing homes where licensed staff give medications, and for patients with episodic intermittent pain receiving no more than 50 dose units in 3 months.

PDMP query rule — Den 503.05

Before prescribing an initial Schedule II, III, or IV opioid for a patient's pain, the prescriber (or a delegate) queries the PDMP, and then periodically and at least twice per year. Exceptions apply when:

1. medication is administered in a health care setting;
2. the PDMP is inaccessible or not working; or
3. an emergency department's volume is so high that a query would materially delay care.

Exceptions (2) and (3) must be documented in the patient's record.

Medication-assisted treatment — Den 503.06

Prescribers of medication-assisted treatment for opioid addiction (methadone, buprenorphine, or naltrexone, per Den 503.02(d)) follow the ASAM National Practice Guideline (2015).