OCCUPATIONS AND PROFESSIONS
CONTROLLED DRUG ACT
Controlled Drug Prescription Health and Safety Program
318-B:41 Rulemaking for Prescribing Controlled Drugs.
I. (a) Before September 1, 2016, the following boards shall submit to the joint legislative committee on administrative rules final proposed rules for prescribing schedule II, III, and IV opioids, for the management or treatment of pain:
(1) The board of medicine, concerning physicians and physician assistants.
(2) The board of dental examiners, concerning dentists.
(3) The board of nursing, concerning advanced practice registered nurses.
(4) The board of registration in optometry, concerning optometrists.
(5) The board of registration in podiatry, concerning podiatrists.
(6) The naturopathic board of examiners, concerning naturopaths.
(b) The rules required under paragraph I shall, at a minimum, contain mandatory standards for the practice components established in paragraph II.
II. The rules shall, at a minimum, contain mandatory standards for the following practice components:
(a) Standards for the use of opioids for the management or treatment of all pain:
(1) Conducting and documenting a detailed history and a physical exam in response to a complaint of pain or anticipated pain.
(2) Completing a board-approved risk assessment tool to determine whether a patient is an appropriate candidate for a schedule II, III, or IV opioid.
(3) Establishing and documenting an appropriate pain treatment plan that includes consideration of nonpharmacological modalities and non-opioid therapy.
(4)(A) Querying the program database when writing an initial schedule II, III, or IV opioid prescription for the management or treatment of a patient's pain or substance use disorder and then periodically, at least twice a year. Such rules shall include exceptions for:
(i) Controlled substances administered to a patient in a health care setting;
(ii) The program is inaccessible or not functioning properly, due to an internal or external electronic issue; or
(iii) An emergency department is experiencing a higher than normal patient volume, and to query the program database would materially delay care.
(B) When a situation falling under exception (A)(ii) or (iii) is applicable, such exception shall be documented in the patient's medical record.
(5) Establishing procedures for informed consent outlining the risks and benefits of opioid use.
(6) Requiring the lowest effective dosage for the fewest number of days with specific dose limits be prescribed for a medical condition or specialty.
(7) Providing for the enforcement of the prescribing rules by specifying that noncompliance with the rules may constitute unprofessional conduct under the board's practice act.
(b) Standards for the use of opioids for the management or treatment of acute pain:
(1) Limiting the amount of days for an opioid prescription issued in an emergency department, urgent care setting, or walk-in clinic. This specific duration limit shall be set by each board no later than August 1, 2016 taking into consideration the recommendation from a majority vote of a policy group consisting of the chief medical officer of the department of health and human services, a physician designated by the New Hampshire chapter of the American College of Emergency Physicians, a physician designated by the New Hampshire Hospital Association, an advanced practice registered nurse designated by the New Hampshire Nurse Practitioner Association, a physician or advanced practice registered nurse designated by the governor, a board certified surgeon designated by the New Hampshire Medical Society, and an oral surgeon designated by the New Hampshire Dental Society. Five members of the policy group shall constitute a quorum. All policy group meetings shall be open to the public and noticed in the house and senate calendars.
(2) In settings where continuity of care is anticipated, each board shall establish finite limits considering dose and duration of opioid prescriptions for treatment of acute pain and appropriate timing of office follow up for persistent, unresolved acute pain.
(c) Standards for the use of opioids for the management or treatment of chronic pain:
(1) Mandatory use of written treatment agreements, such as the agreement developed by the American Academy of Pain Medicine. Treatment agreements shall include conduct that triggers the discontinuation or tapering of opioid prescriptions.
(2) Establishing a requirement for periodic review conducted at reasonable intervals to reevaluate treatment plans and use of opioids.
(3) Establishing a procedure for, and documenting consideration of, consultation with, or referral to a specialist for patients receiving a high morphine equivalent dose for longer than 90 days.
(4) Creating exemptions to the prescribing rules for situations in which an opioid is being prescribed for the management of chronic pain for:
(A) Patients with cancer pain;
(B) Patients with a terminal condition;
(C) Long-term, nonrehabilitative, residents of a nursing home facility.
(d) In addition to the provisions of subparagraph (c), standards for the use of opioids for the management or treatment of chronic pain, which shall include the following:
(1) All decisions regarding the treatment of patients experiencing chronic pain shall be made by the treating practitioner even when the treatment is determined to require the prescribing of opioid analgesics. Treating practitioners shall administer care sufficient to treat a patient's chronic pain based on ongoing, objective evaluations of the patient without fear of reprimand or discipline.
(2) Ordering, prescribing, dispensing, administering, or paying for controlled substances, including opioid analgesics, shall not in any way be pre-determined by specific Morphine Milligram Equivalent (MME) guidelines.
(3) Ongoing treatment of those patients who experience chronic pain can be determined, managed, and administered by:
(A) A pain management practitioner who specializes in the treatment of chronic pain; or
(B) A practitioner who specializes in the illness or injury from which the patient suffers; or
(C) The patient's primary care practitioner who shall document the consideration of a consultation with a practitioner who specializes in the treatment of the patient's specific illness or injury or a pain management practitioner.
(4) For the patient who experiences chronic illness or injury and resulting chronic pain, documentation of the health issue must be provided and held in the patient's file.
(5) When treating a patient who experiences chronic illness or injury and resulting chronic pain, the prescribing of opioid analgesics shall be done in a measured and monitored manner and administered in the lowest amount necessary to control pain.
(6) Once an opioid analgesic is prescribed to treat chronic illness or injury and resulting chronic pain, the prescription shall be monitored closely by the prescriber and titrated as ongoing, objective evaluations of said patient's injury or illness requires for ongoing, successful treatment.
(7) For those patients who experience chronic illness or injury and resulting chronic pain who are on a managed and monitored regimen of opioid analgesic treatment and have increased functionality and quality of life as a result of said treatment, treatment shall be continued if there remains no indication of misuse or diversion.
(8) Proper documentation from the practitioner related to the filling of a prescription under this subparagraph shall be provided to the pharmacist upon the initial filling of the prescription, or upon request of the pharmacist.
(9) The rules necessary to effectuate the provisions of this subparagraph governing pain management associated with chronic pain shall:
(A) Take into consideration the individualized needs of patients covered by this subparagraph;
(B) Make provisions for practitioners, acting in good faith, and in the course of their profession, and managing chronic pain associated with their patients' illness to use their best judgment notwithstanding any statute or rule to the contrary; and
(C) Ensure that patients covered by this section are treated with dignity and not unduly denied the medications needed to treat their conditions.
V. At a minimum, each board's Internet website shall include online links to board approved:
(a) Continuing education on the prescribing of opioids.
(b) Screening tools.
(c) Treatment agreements.
(d) Risks and benefits of opioid use.
(e) Proper storage of opioids.
(f) Proper disposal of unused opioids.
Source. 2016, 213:1, eff. June 7, 2016 except for RSA 318-B:41, pars. II(a)(4) and IV(a)(4) eff. Jan. 1, 2017. 2017, 128:4, eff. Aug. 15, 2017. 2019, 28:1, eff. July 14, 2019. 2020, 39:19, eff. July 29, 2020.