Current through April 3, 2024
(1) Opioid Drugs.
Facilities shall develop and implement written policies and procedures for the
prescription of opioid drugs. Any changes to these policies and procedures
shall be done in consultation with the Facility's medical director. These
policies and procedures shall include the following:
(a) Prescribing.
1. The proper initial dose, medication type,
and dosage form shall be based on the clinical judgement of the program
physician who has examined the patient and who has considered all available
relevant patient-specific information including, but not limited to, drug
screens, initial screenings, medication availability and cost, and in
consultation with the patient.
2.
No standardized routines or schedules of increases or decreases of medication
doses may be established or used.
3. A patient dose greater than sixteen
milligrams (16mg), or its equivalent, per day shall be considered a high
dose.
4. A patient dose of
twenty-four milligrams (24mg), or its equivalent, per day shall be considered a
maximum dose. Doses greater than the maximum dose may only be used with prior
written approval from the State Opioid Treatment Authority. Documentation of
this approval shall be kept in the patient's medical chart or otherwise be
readily retrievable upon request or facility inspection.
5. A copy of all prescriptions written for a
patient at the Facility shall be documented in the patient's medical
chart.
6. The prescriber shall
demonstrate to the patient appropriate techniques for administering the
particular prescribed treatment medication.
(b) Dispensing. An office based opiate
treatment facility without dispensing authorization is prohibited from
dispensing buprenorphine-containing products.
(c) Protocols for initiating or switching a
patient to a high dose of the treatment medication used at the facility.
1. The patient's medical chart shall include
documentation of rationale that it is clinically appropriate for the patient to
receive a high dose of the treatment medication.
2. The prescriber shall have a discussion
with the patient and the patient shall provide written consent acknowledging
that the patient will receive a high dose of the treatment medication and
associated risks.
(i) The provider shall
document that this discussion included an assessment of the patient's
administration technique and that the patient is using the appropriate
technique for the prescribed medication.
3. The prescriber shall not establish or use
standardized routines or schedules of increases or decreases of treatment
medication doses for the patient. Decisions about dosing should be
individualized with documentation of reasons for choice of dosing.
(d) Prescriber-Initiated-and-Led
Tapering Discussions
1. Prescribers shall
initiate and lead a discussion with the patient regarding patient readiness to
taper down or taper off treatment medications employed in the patient's
treatment with each patient at any time upon the patient's request but no later
than one (1) year after initiating treatment and then every six (6) months
thereafter.
(i) Documentation of this
discussion shall be placed in the patient's medical chart.
(2) CSMD Check. The
Facility shall check the CSMD upon every visit of the patient with a program
physician. The patient's medical record shall include documentation of the
check of the CSMD and the date upon which it occurred.
(3) Benzodiazepine Use. Benzodiazepines
should only be prescribed to a patient after careful evaluation while utilizing
caution and good judgement. Benzodiazepines may be prescribed to a patient on
buprenorphine or a buprenorphine and naloxone combination under the following
conditions:
(a) Benzodiazepines shall not be
initiated with a patient with opioid use disorder or the disease of addiction
who has never been prescribed these products or has a history of misusing or
abusing these products. Notwithstanding, in rare circumstances:
1. Patients who present with a longstanding
prescription for benzodiazepines for a legitimate medical condition from
another prescriber may be prescribed buprenorphine products by a physician with
a DATA 2000 waiver. Contact should be initiated with the prescriber of the
benzodiazepine to coordinate care and clear documentation should be recorded in
the patient's medical record.
2. A
program physician at an OBOT may assume management of a patient's
benzodiazepine prescribing from another physician if the patient is willing to
initiate a program of tapering.
3.
If a patient presents at an OBOT with a dual diagnosis of opioid use disorder
and a clear history of benzodiazepine use disorder, the duration and extent of
the abuse should be clearly documented in the medical record. A program
physician at an OBOT may prescribe a long acting benzodiazepine, such as
clonazepam or its equivalent, under the following conditions:
(i) A patient may continue on benzodiazepine
therapy as medically indicated as long as there is an ongoing effort to taper
the patient to the lowest effective dose in order to prevent benzodiazepine
withdrawal syndrome and clear documentation of this effort is made in the
patient's medical record.
(I) Prescribing more
than two (2) milligrams of clonazepam or its equivalent daily is considered
"high dose therapy".
(II) Patients
receiving high dose therapy should have justification for the dosing clearly
documented in the patient's record.
(III) Patients receiving high dose therapy
should be tapered as rapidly as possible to two (2) milligrams or less of
clonazepam or its equivalent twice daily, and if the taper is unsuccessful, the
reason(s) shall be clearly documented in the patient's medical
record.
(IV) Patients receiving
high dose therapy for a period of longer than six (6) weeks shall be managed by
a physician who is board certified in addiction medicine or who is board
certified or fellowship trained in addiction psychiatry, or by a physician with
a DATA 2000 waiver who has obtained a formal consult from a physician who is
board certified in addiction medicine or who is board certified or fellowship
trained in addiction psychiatry. The formal consult shall be clearly documented
in the patient's medical record.
(4) The Facility shall develop
guidelines for review of prescriptions from other providers. These shall
include:
(a) Procedures to ensure that a
patient's prescriptions from outside physicians will be reported to the medical
staff and reviewed by the program physician at admission and annually
thereafter;
(b) Procedures
describing the Facility's response when information about prescriptions from
outside physicians is not reported to ensure compliance with this rule;
and,
(c) Documentation of the
Facility's efforts to obtain information about prescriptions from outside
physicians in the patient's record, if a Facility is unable to acquire
information about a patient's prescriptions.
Authority: T.C.A. §§
4-3-1601,
4-4-103,
33-1-302,
33-1-305,
33-1-309,
33-2-301,
33-2-302,
33-2-402,
33-2-403,
33-2-404,
33-2-407,
Chapter 912 of the Public Acts of 2016, and Chapter 978 of the Public Acts of
2018.