The continuing opioid crisis across the nation is prompting calls for action and change. In Vermont, new rules outlining how doctors prescribe opioids to patients in need of pain relief are set to take effect on July 1.
The rules were developed by the Vermont Department of Health at the direction the Legislature. This week, the health department has been holding informational sessions so doctors can familiarize themselves with the new rules before they go into effect.
VPR spoke to Shayla Livingston, a public health policy adviser at the Vermont Department of Health, about the new rules.
This transcript has been edited for clarity and brevity. Listen to the full audio above.
There are new "universal precautions" for prescribing opioids.
Livingston: “These are, in fact, rules that were required by Act 173 last year. The universal precautions section is a new section. This is for all new prescriptions for Schedule 2, 3 and 4 controlled substances [such as Percocet, Vicodin, OxyContin and Tramadol]. The idea here is to really ensure that all patients have access to the same information and that we're treating all patients the same way and equally.
“The first is to have the provider talk to the patient about alternatives so that opiates are not the only option on the table. The second is to make sure that the provider queries the VPMS — that’s the Vermont prescription monitoring system.
“[The] next one is to provide patient education and informed consent, and that has a couple of different pieces. We asked that providers have a discussion of the risks with the patient — so that's an in-person discussion face-to-face — that they provide them a patient education sheet that we've developed, and then we'll have patients sign an informed consent to just agree to the risks of having these opioids and using these opioids.
“The risks have not necessarily been fully understood by patients. Often when they are given these [opioids], especially for minor procedures ... they end up often in medicine cabinets unused, or misused in the community.”
The rules are different when it comes to prescribing drugs for acute pain versus chronic pain.
“We have had rules in place for chronic pain now for a couple of years. The acute pain guidelines are what go into effect July 1. Those target first prescriptions for "opiate naive" patients. So, what does that mean? That means that the first time a provider sees a patient who has not had an opioid for the past 30 days, if it's that first prescription, then there are now rules that limit the amount that that prescriber can prescribe in that first prescription. In no way does that mean if the patient continues to experience pain after they're done with that prescription, it does not limit providers from prescribing a second prescription.
“The limits themselves are broken down into a number of different categories: minor, moderate, severe and extreme pain. And then they have what we call a "morphine milligram equivalent limit." That's a way to measure different opioids in a similar fashion. So, one OxyContin is not equal to one Fentanyl is not equal to one Percocet. There's different limits depending on the patient's level of pain [and] the length of duration that’s expected for the pain.
“One of the big pieces here is to make sure that kids are exposed to fewer prescriptions — so anybody under the age of 18, those limits are actually lower than for adults.”
The new rules will be enforced in a variety of ways.
“We doing talks across the state about these rules for providers to do increased education. Different institutions are putting in place their own methods and measures so that providers know what is out there for the rules and what they have to follow.
“Once they go into effect, the medical practice board will be responsible for responding to any complaints. So, we're not going to do what's called ‘proactive enforcement,’ we're not going to go and look for these individuals.
"The health department does use the Vermont Prescription Monitoring System to look for any outliers. So that’s a provider who maybe falls outside of what we would think would be normal.
“They are not going to get in 'trouble,' quote-unquote. They will just receive a notice that says, ‘Hi, it looks like you're an outlier. We'd love to help you out if you're interested in systems or quality improvement.’ They're not going to see any regulatory action, but they will get outreach.”
Vermont's new rules are unique among some of our New England neighbors, and are based on input from providers.
“In developing these rules, one thing that sets Vermont apart from some of our other sister New England states is that these are rules, and they were set by the Department of Health. They were not done through statutes.
[In] Massachusetts and Maine, there are hard cap limits that were simply set. And here we were able to really engage the provider community in the development of these rules. We had over 20 meetings last summer with providers about the rules. So that really allowed us to hear their thoughts and concerns as well as some of their needs. I mean, there are many providers out there who really wanted these rules and want to see a decrease in prescribing.
“The science actually shows that when you set a new default, it doesn't do what we call a 'cooling off,' it doesn't actually make it so that it's harder for patients to access pain medication. And that is definitely not the goal here. The goal here is to ensure that when patients need pain medication they get the right amount for their pain.
By engaging the provider community and making these rules, we're pretty confident that that will not be an issue. We will also definitely be monitoring these rules to make sure that those kind of problems do not crop up in the next couple of years.”