The Medical Society of Virginia has new requirements for prescribing Buprenorphine for addiction. These are part of the new Virginia Laws passed in response to the nationwide opioid epidemic and huge uptick in deaths from opioid overdose. Buprenorphine, also prescribed under the brand name Subloxone, is often utilized as a means to treat heroin addiction. While it is a semi-synthetic opioid, and does produce some of the same euphoric effects as heroin and morphine, it is found that at low doses, administration of this drug allows the addict to discontinue heroin or morphine while reducing— and in some cases even eliminating— the severe symptoms of withdrawal that can be so debilitating for addicts.
There are eight steps that physicians should follow before prescribing Buprenorphine:
Step one
Prescriptions should be waivered by the Substance Abuse Mental Health Services Administration (SAMHSA), registered with the Drug Enforcement Agency, and comply with the federal and state laws for prescribing buprenorphine. Nurse practitioners and physician assistants must also be waivered and have a practice agreement with a waivered physician.
Step two
Before buprenorphine can be prescribed for opioid treatment, the physician should conduct and document a patient assessment that covers the following:
- A complete psychiatric and medical history
- A substance abuse history
- A family history review and a review of the patient’s psychological supports
- A physical examination
- A urine drug test
- A pregnancy test for women who are of childbearing age
- Testing for HIV, Hepatitis B, Hepatitis C, and tuberculosis if clinically indicated
Step three
The physician should query (ask for results of a patient search) from the Prescription Monitoring Program before starting any treatment and during treatment.
Step four
Prepare a treatment plan that includes the following:
- The reasons for choosing to use medication assistance
- An education plan for the patient
- A written informed consent from the patient
- How counseling of the patient will be achieved
- A signed agreement that details of both the patient and the physician
Step five
During the induction phase:
Initiate treatment with no more than 8mg of buprenorphine, except when medically indicated if properly documented in the medical record.
The patient should see the doctor once a week
Step six
During the stabilization phase, the prescriber should increase the dosage of buprenorphine in safe and small increments to achieve the lowest dosage without causing intoxication, withdrawal, or significant drug craving.
Step seven
During the course of treatment:
- Ensure that the patient is getting counseling
- Limit the strength of the prescription
- Dosages of more than 16 mg of buprenorphine should be documented in the medical record
- The prescriber should not prescribe more than 24mg of buprenorphine per day
- Require that the patient take urine drug tests and serum medication level tests every three months for the first year of treatment and every six months thereafter
- Incorporate relapse prevention strategies into counseling or make sure they are addressed by a mental health service provider as defined by Virginia Code
- Take steps to reduce the changes of buprenorphine diversion by:
- Using the lowest dosage possible
- Having an appropriate frequency of office visits
- Counting pills
- Checking the Prescription Monitoring Program
Step eight
Make sure the medical record includes the following documentation:
- Records should be legible, timely, accurate, and readily accessible so they can be reviewed
- The informed consent and treatment plan should be in place
- The document should meet the state code confidentiality requirements
- The documentation should comply with the Board of Medicine Regulation
Special Considerations
The prescriber should refer the patient to a mental health service provider as defined by the Virginia Code Section 54-1-2400.1 for counseling or should provide counseling to the patient and document the counseling in the record.
Prescribers should NOT prescribe buprenorphine if the patient is already taking any of the following medications (unless there are extenuating circumstances and a tapering plan to achieve the lowest possible documentation is properly documented):
- Benzodiazepine
- Sedative hypnotics
- Carisoprodol
- Tramadol
Limitations for prescribing buprenorphine mono-products
- Buprenorphine should not be prescribed without Naloxone (also known as Narcan—used to reverse the effects of opioids) unless:
-The patient is pregnant
-The prescriber is converting the patient from methadone to buprenorphine containing naloxone for not more than seven days - Buprenorphine mono-tablets can be prescribed directly to patients in federally approved opioid treatment programs but, with the exception of the above conditions, only the buprenorphine product containing naloxone shall be prescribed or dispensed for use offsite from the program
- If buprenorphine mono-tablets are prescribed, the evidence for prescribing them should be put into the medical record
How to work with the following special treatment populations
- Pregnant women. They should be treated with buprenorphine mono-products that have a dosage level of 16 mg or less each day
- Patients who are less than 16 years of age. Prescribers should not approve the use of buprenorphine for treating addiction unless authorized by the Food and Drug Administration
- Patients with chronic pain. Assess the progress of patients with chronic pain by “reduction of pain and functional objectives which can be identified, quantified, and independently verified.”
- Patients with medical comorbidities. Evaluate by taking a patient history, a complete physical exam, take the right laboratory studies, and be aware of how buprenorphine interacts with other prescription medications
- Patients with psychiatric comorbidities which aren’t stable. Do not undertake buprenorphine treatment. Prescribers should refer the patient for a psychiatric evaluation and treatment before stating any prescription medication treatment program.
Speak with an experienced Virginia workers’ compensation lawyer now
Many workers who are injured are prescribed medications to manage their pain. Attorney Joe Miller works with caring qualified physicians and with the legal community to understand the latest requirements that physicians must follow. He has helped thousands of injured workers get a just recovery. To make an appointment now, please call Joe Miller Esq. by phoning him at (888) 694-1671 or using his contact form.
