28 Pa. Code § 26.4 – Procedures.

(a) Prescriber requirements. Except as specified in subsection (c), before issuing an individual the first prescription in a single course of treatment for chronic pain with a controlled substance containing an opioid, regardless of whether the dosage is modified during that course of treatment, a prescriber shall:
1. (1) Assess whether the individual has taken or is currently taking a prescription drug for treatment of a substance use disorder.
2. (2) Discuss with the individual:
  1. (i) The risks of addiction and overdose associated with the controlled substance containing an opioid.
  2. (ii) The increased risk of addiction to a controlled substance if the individual suffers from a mental disorder or substance use disorder.
  3. (iii) The dangers of taking a controlled substance containing an opioid with benzodiazepines, alcohol or other central nervous system depressants.
  4. (iv) Other information deemed appropriate by the prescriber under 21 CFR 201.57(c)(18) (relating to specific requirements on content and format of labeling for human prescription drug and biological products described in § 201.56(b)(1)).
  5. (v) The nonopioid treatment options available for treating chronic noncancer pain, if applicable, that are consistent with the best practices per the Pennsylvania Opioid Prescribing Guidelines.
3. (3) Review and sign a treatment agreement form that includes:
  1. (i) The goals of the treatment.
  2. (ii) The consent of the individual to a targeted test in a circumstance where the physician or prescriber determines that a targeted test is medically necessary. The treatment of chronic pain shall be consistent with the Pennsylvania Opioid Prescribing Guidelines.
  3. (iii) The prescription drug prescribing policies of the prescriber, which policies include:
    1. (A) A requirement that the individual take the medication as prescribed.
    2. (B) A prohibition on sharing the prescribed medication with other individuals.
  4. (iv) A requirement that the individual inform the prescriber about any other controlled substances prescribed or taken by the individual.
  5. (v) Any reason why the opioid therapy may be changed or discontinued by the prescriber.
  6. (vi) Appropriate disposal methods for opioids that are no longer being used by the individual as specified in a consultation with the prescriber.
  7. (vii) The brand name or generic name, quantity and initial dose of the controlled substance containing an opioid being prescribed.
  8. (viii) A statement indicating that a controlled substance is a drug or other substance that the United States Drug Enforcement Administration has identified as having a potential for abuse.
  9. (ix) A statement certifying that the prescriber engaged in the discussion under subsection (a)(2).
  10. (x) The signature of the individual and the date of signing. The prescriber may utilize electronic methods to obtain the signature of the individual and the date of signing.
4. (4) Obtain written consent for the prescription from the individual. The prescriber may utilize electronic methods to obtain the written consent of the individual.
5. (5) Record the consent under subsection (a)(4) on the treatment agreement form in subsection (a)(3).
(b) The treatment agreement form under subsection (a)(3) shall be maintained by the prescriber in the medical record of the individual.
(c) Urine drug testing.
1. (1) A baseline test, periodic test or targeted test shall be used to establish a general assessment for an individual new to treatment for chronic pain and in monitoring adherence to an existing individual treatment plan, as well as to detect the use of a nonprescribed drug.
2. (2) A baseline test shall be required prior to the issuance of the initial prescription for chronic pain and shall include confirmatory or quantitative testing of presumptive positive drug test results.
3. (3) An individual who is treated for addiction or an individual who is considered moderate or high risk by the prescriber shall be tested at least once annually or as frequently as necessary to ensure therapeutic adherence.
(d) Exception. Subsection (c) shall not apply if the treatment of an individual with a controlled substance containing an opioid is associated with or incident to:
1. (1) A medical emergency documented in the medical record of the individual.
2. (2) The management of pain associated with cancer.
3. (3) The use in palliative or hospice care.
4. (4) The professional judgment of the prescriber under subsections (a)(1) and (2).
(e) Documentation of exception. If subsection (d) applies, the prescriber shall document in the individual’s medical record the factor under subsection (d) that the prescriber believes applies to the individual.
(f) A prescriber may terminate the treatment agreement form under subsection (a)(3) if the prescriber has reasonable belief, based on standards of professional practice, that the treatment agreement is no longer necessary.
(g) If a prescriber terminates a treatment agreement under subsection (f), the prescriber shall:
1. (1) Document the reason for the termination of the treatment agreement in the individual’s medical record.
2. (2) Inform the individual of the termination of the treatment agreement.
3. (3) If necessary, work with the individual, to the fullest extent possible, to ensure continuity of care as outlined under 49 Pa. Code § 16.61(a)(17) (relating to unprofessional and immoral conduct).
(h) Urine testing exception. If, because of a medical necessity, an individual is unable to produce urine for the urine drug testing required herein, a different type of drug test may be used that is at least equivalent in accuracy to a urine drug test approved by the Food and Drug Administration. Alternative drug tests may not be substituted for urine drug tests under any other circumstances.