(c) Prescribing Schedule II narcotics.

1. (1)

   1. (A) The prescribing of excessive amounts of controlled substances to a patient, including the writing of an excessive number of prescriptions for an addicting or potentially harmful drug to a patient.
   2. (B) “Excessive” is defined as the writing of any prescription in any amount without a detailed medical justification for the prescription documented in the patient record.

2. (2) Chronic pain. If there is documented medical justification, “excessive” is defined, pursuant to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain, as prescribing opioids at a level that exceeds greater than or equal to fifty morphine milligram equivalents (50 MME) per day, unless the physician/physician assistant documents each of the following:

   1. (A) Objective findings, which include, but are not limited to:

(i) Imaging studies;

1. (ii) Lab testing and results;

   1. (iii) Nerve conduction testing;

      1. (iv) Biopsy; and
      2. (v) Any other test that would establish pain generating pathology;
   2. (B) Specific reasons for the need to prescribe greater than or equal to fifty morphine milligram equivalents (50 MME) per day;
   3. (C) Documented alternative treatment plans as well as alternative therapies trialed and failed prior to considering chronic opioid therapy;
   4. (D) Documented risk factor assessment detailing that the patient was informed of the risk and the addictive nature of the prescribed drug;
   5. (E) Documented assessment of the potential for abuse and/or diversion of the prescribed drug;
   6. (F) That the Prescription Drug Monitoring Program had been checked prior to issuing the prescription;
   7. (G) A detailed clinical rationale for the prescribing and the patient must be seen in an in-person examination every three (3) months or every ninety (90) days;

   8. (H) The definition of “excessive” as contained in this section shall not apply to prescriptions written for a patient in:

      1. (i) Hospice care;
      2. (ii) Active cancer treatment;
      3. (iii) Palliative care;
      4. (iv) End-of-life care;
      5. (v) A nursing home;
      6. (vi) Assisted living;
      7. (vii) An inpatient setting; or
      8. (viii) An emergency situation;

   9. (I)

      1. (i) Regular urine drug screens should be performed on patients to ensure the patient is taking prescribed medications and is not participating or suspected in participating in diversion or abuse of nonprescribed medications.
      2. (ii) The treatment of chronic pain shall be consistent with the Centers for Disease Control and Prevention guidelines as they relate to baseline drug testing, and at least annual follow-up testing as warranted for treatment; and

   10. (J)

       1. (i) A pain treatment agreement must be signed and reviewed by the patient when initiating chronic opioid therapy.
       2. (ii) This agreement should discuss the following:

(b) (b) Outline the specific expectations between patient and

1. (c) (c) Informed consent for periodic urine drug screenings and random pill counts with urine screening; and

   1. (d) (d) The provisions for termination of opioid therapy.

2. (3) Acute pain.

   1. (A) For treatment of acute pain, “excessive” is further defined as an initial prescription written for more than seven (7) days without detailed, documented medical justification in the medical record.
   2. (B) If the patient requires further prescriptions, they must be evaluated in regular increments with documented medical justification for continued treatment in medical record.

3. (4)

   1. (A) When opioids are started, clinicians should prescribe the lowest effective dosage.
   2. (B) Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than fifty morphine milligram equivalents (50 MME)/day, and should avoid increasing dosage to greater than ninety morphine milligram equivalents (90 MME)/day or carefully justify a decision to titrate dosage to greater than ninety morphine milligram equivalents (90 MME)/day.