Lawriter - OAC - 4715-6-03 Prescribing for subacute and chronic pain.

4715-6-03 Prescribing for subacute and chronic pain.

(A) Definitions

(1) "Acute pain" means pain that normally fades with healing, is related to tissue damage, significantly alters a patient's typical function and is expected to be time limited and not more than six weeks in duration. Acute pain shall be treated in accordance with rule 4715-6-02 of the Administrative Code.

(2) "Medication therapy management" has the same meaning as in rule 4729:5-12-01 of the Administrative Code.

(3) "Subacute pain" means pain that has persisted after reasonable medical efforts have been made to relieve it and continues either episodically or continuously for at least six weeks but less than twelve weeks following initial onset of pain. It may be the result of underlying medical disease or condition, injury, medical or surgical treatment, inflammation, or unknown cause.

(4) "Chronic pain" means pain that has persisted after reasonable medical efforts have been made to relieve it and continues either episodically or continuously for twelve or more weeks following initial onset of pain. It may be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or unknown cause.

(5) Conditions that may require the dentist to treat subacute or chronic pain include:

(a) Chronic neuropathic or neuralgic pain;

(b) Chronic musculoskeletal pain;

(c) Oro-facial pain disorders, including oro-facial pain dysfunction syndrome and atypical oro-facial pain;

(d) Temporomandibular joint dysfunction; or

(e) Myo-facial pain dysfunction or syndrome.

(6) The treatment of subacute or chronic pain requires adequate training and education in appropriate treatment and understanding of the conditions that may cause subacute or chronic pain. Only dentists who are qualified to practice in one of the following areas may prescribe opioid analgesics for the treatment of subacute or chronic pain:

(a) Oral and maxillofacial surgery;

(b) Oral medicine;

(c) Oro-facial pain;

(d) Endodontics;

(e) Periodontics; or

(f) Anesthesia.

(B) Prior to treating, or continuing to treat subacute or chronic pain with an opioid analgesic, the dentist shall first consider and document non-medication and non-opioid treatment options.

(1) If opioid analgesic medications are required as determined by a history and physical examination, the dentist shall prescribe for the minimum quantity and potency needed to treat the expected duration of pain and improve the patient's ability to function.

(2) The dentist shall comply with the requirements of rule 4715-6-01 of the Administrative Code.

(C) Before prescribing an opioid analgesic for subacute or chronic pain, the dentist shall complete (or update) and document in the patient record assessment activities to assure the appropriateness and safety of the medication including:

(1) History and physical examination including review of the previous treatment and response to treatment, patient's adherence to medication and non-medication treatment, and screening for substance misuse or substance use disorder;

(2) Laboratory and/or diagnostic testing or documented review of any available relevant laboratory/diagnostic test results. If evidence of substance misuse or substance use disorder exists, diagnostic testing shall include urine drug screening;

(3) Review the results of an OARRS check in compliance with rule 4715-6-01 of the Administrative Code;

(4) A functional pain assessment which includes the patient's ability to engage in work or other purposeful activities, the pain intensity and its interference with activities of daily living, quality of family life and social activities and the physical activity of the patient;

(5) A treatment plan based upon the clinical information obtained, to include all of the following components:

(a) Diagnosis;

(b) Objective goals for treatment;

(c) Rationale for the medication choice and dosage; and

(d) Planned duration of treatment and steps for further assessment and follow-up;

(6) Discussion with the patient or guardian regarding:

(a) Benefits and risks of the medication, including potential for addiction and risk of overdose; and

(b) The patient's responsibility for safe storage and disposal of the medication;

(7) The dentist shall offer a prescription for naloxone to the patient receiving an opioid analgesic prescription under any of the following circumstances:

(a) The patient has a history of prior opioid overdose;

(b) The dosage prescribed exceeds a daily average of eighty MED or at lower doses if the patient is co-prescribed a benzodiazepine, sedative hypnotic drug, carisprodal, tramadol, or gabapentin; or

(c) The patient has a concurrent substance use disorder.

(D) Prior to increasing the opioid dosage to a daily average of fifty MED or greater the dentist shall complete and document the following in the patient's record:

(1) The dentist shall review and update the assessment completed in paragraph (C) of this rule, if needed. The dentist may rely on an appropriate assessment completed within a reasonable time if the dentist is satisfied that he or she may rely on that information for purposes of meeting the further requirements of this chapter of the Administrative Code;

(2) The dentist shall update or formulate a new treatment plan, if needed;

(3) The dentist shall obtain from the patient or the patient's guardian written informed consent which includes discussion of all of the following:

(a) Benefits and risks of the medication, including potential for addiction and risk of overdose; and

(b) The patient's responsibility during the treatment to safely store the medication and appropriately dispose of the medication;

(4) Except when the patient was prescribed an average daily dosage that exceeded fifty MED before the effective date of this rule, the dentist shall document consideration of the following:

(a) Consultation with a specialist in the area of the body affected by the pain;

(b) Consultation with a pain management specialist;

(c) Obtaining a medication therapy management review by a pharmacist; and

(d) Consultation with a specialist in addiction medicine or addiction psychiatry, if aberrant behaviors indicating medication misuse or substance use disorder are noted.

(E) Prior to increasing the opioid dosage to a daily average of eighty MED or greater the dentist shall complete all of the following:

(1) Enter into written pain treatment agreement with the patient that outlines that dentist's and patient's responsibilities during treatment and requires the patient or patient guardian's agreement to all of the following provisions;

(a) Permission for drug screening and release to speak with other practitioners concerning the patient's condition or treatment;

(b) Cooperation with "pill counts" or other checks designed to assure compliance with the treatment plan and to minimize the risk of misuse or diversion;

(c) The understanding that the patient shall only receive opioid medications from the dentist treating the chronic pain unless there is written agreement among all of the prescribers of opioids outlining the responsibilities and boundaries of prescribing for the patient; and

(d) The understanding that the dosage may be tapered if not effective or if the patient does not abide by the treatment agreement;

(2) Offer a prescription for naloxone to the patient as described in paragraph (C) of this rule;

(3) Except when the patient was prescribed an average daily dosage that exceeded eighty MED before the effective date of this rule, obtain at least one of the following based upon the patient's clinical presentation:

(a) Consultation with a specialist in the area of the body affected by the pain;

(b) Consultation with a pain management specialist;

(c) Obtain a medication therapy management review by a pharmacist; or

(d) Consultation with a specialist in addiction medicine or addiction psychiatry if aberrant behavior indicating medication misuse or substance use disorder may be present.

(F) The dentist shall not prescribe a dosage that exceeds an average of one hundred MED per day. This prohibition shall not apply in the following circumstances:

(1) The dentist has received a written recommendation for a dosage exceeding an average of one hundred MED per day from a board certified pain medicine physician who based the recommendation on a face-to-face visit and examination of the patient. The prescribing dentist shall maintain the written recommendation in the patient's record; or

(2) The patient was receiving an average daily dose of one hundred MED or more prior to the effective date of this rule. The dentist shall follow the steps in paragraph (F)(1) of this rule prior to escalating the patient's dose.

(G) During the course of treatment with an opioid analgesic at doses below the average of fifty MED per day, the dentist shall provide periodic follow-up assessment and documentation of the patient's functional status, the patient's progress toward treatment objectives, indicators of possible addiction, drug abuse or drug diversion and the notation of any adverse drug effects.

(H) During the course of treatment with an opioid analgesic at doses at or above the average of fifty MED per day, the dentist shall complete and document in the patient record the following no less than every three months:

(1) Review of the course of treatment and the patient's response and adherence to treatment;

(2) The assessment shall include a review of any complications or exacerbation of the underlying condition causing the pain through appropriate interval history, physical examination, any appropriate diagnostic tests, and specific treatments to address the findings;

(3) The assessment of the patient's adherence to treatment including any prescribed non-pharmacological and non-opioid treatment modalities;

(4) Rationale for continuing opioid treatment and nature of continued benefit, if present;

(5) The results of an OARRS check in compliance with rule 4715-6-01 of the Administrative Code;

(6) Screening for medication misuse or substance use disorder. Urine drug screen should be obtained based on clinical assessment of the dentist with frequency based upon presence or absence of aberrant behaviors or other indications of addiction or drug abuse; and

(7) Evaluation of other forms of treatment and the tapering of opioid medication if continued benefit cannot be established.

(I) The dentist shall not prescribe an opioid analgesic to a patient to treat pain for more than twenty-four continuous weeks. This prohibition shall not apply in the following circumstances:

(1) Written recommendation from a physician pain management specialist to have dentist continue prescribing opioid analgesics for more than twenty-four weeks. The physician pain management specialist will base recommendation on face-to-face visit and examination of the patient. The prescribing dentist shall maintain the written recommendation in the patient's record:

(a) The dentist shall not exceed any aspect of the written recommendation; and

(b) If the written recommendation does not specify otherwise, the dentist shall refer the patient to obtain an updated written recommendation within eight weeks from the date of the most recent written recommendation.

(2) The patient was prescribed an opioid analgesic to treat pain for more than twenty-four continuous weeks prior to the effective date of this rule. The dentist shall follow all other requirements of this rule.

(J) This rule does not apply to inpatient prescriptions as defined in Chapter 4729. of the Revised Code.



Effective: 12/21/2018
Five Year Review (FYR) Dates: 12/21/2023
Promulgated Under: 119.03
Statutory Authority: 4715.03
Rule Amplifies: 4715.03