A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: New Hampshire

New Hampshire Statutes

• AN ACT relative to controlled substances used for pain management.
• Be it Enacted by the Senate and House of Representatives in General Court convened:
• 268:1 Statement of Purpose. The state of New Hampshire recognizes that principles of quality medical practice dictate that the people of the state of New Hampshire have access to appropriate and effective pain relief. The appropriate application of up-to-date knowledge and treatment modalities can serve to improve the quality of life for patients with pain as well as to reduce the morbidity and costs associated with untreated or inappropriately treated pain. The state of New Hampshire encourages physicians to view effective pain management as part of quality medical practice for all patients with pain, acute or chronic. It is especially important for patients who experience pain as a result of terminal illness.
• 268:2 New Paragraph; Professional Use of Controlled Substances. Amend RSA 318-B:10 by inserting after paragraph VIII the following new paragraph:
• IX. If, in the judgment of a physician licensed under RSA 329, appropriate pain management warrants a high dosage of controlled drugs and the benefit of the relief expected outweighs the risk of the high dosage, the licensed physician may administer or cause to be administered such a dosage, even if its use may increase the risk for death, so long as it is not furnished for the purpose of causing, or the purpose of assisting in causing, death for any reason and so long as it falls within rules of the Board of Medicine.

New Hampshire Board of Medicine Administrative Regulation

• When prescribing any controlled substance for use in pain control, licensees shall:
  1. Document prescription for such controlled substances according to Med 501.02(d) and (e);
  2. Use appropriate treatment standards for the treatment of chronic pain; and
  3. Comply with all federal and state controlled substances laws, rules, and regulations.

Med 501.02 Standards of Conduct.

• A licensee shall maintain a complete and accurate medical record of all patient encounters.
• Records shall be entirely legible and include but not be limited to:
  1. A history, an examination, a diagnosis, and a plan appropriate for the licensee's specialty; and
  2. Documentation of all drug prescriptions, including name and dose.

New Hampshire Board of Medicine Dear Physician Letter Regarding Guidelines for Pain Management

Dear Physician:

The New Hampshire Board of Medicine has adopted guidelines for pain management in hopes of fostering the best pain treatment for the citizens of this State. The Board encourages physicians to view effective pain management as a part of quality medical practice for all patients with pain, be it acute or chronic, due to either malignant or benign disease, and particularly when associated with terminal illness. For many physicians, fear of investigation or sanction for dispensing large or prolonged narcotic prescriptions has impeded effective and appropriate treatment. Accordingly, these guidelines have been developed to clarify the Board's position of pain control specifically as related to the use of controlled substances, to alleviate physician uncertainty, and to encourage better pain management. This format was derived from many sources including New Hampshire physicians who specialize in pain management, the New Hampshire State Medical Society, and the Federation of State Medical Boards.

Physicians should not fear disciplinary action from the Board or other state regulatory or enforcement agency for prescribing or administering controlled substances for a legitimate medical purpose and in the usual course of professional practice. The Board has concern in those cases where inadequate pain control results from either lack of current knowledge of pain management or inappropriate fear of investigation for providing narcotics where indicated.

The New Hampshire Board remains obligated under the laws of the State of New Hampshire to protect the public health and safety. The Board recognizes that inappropriate prescribing of controlled substances, including opioid analgesics, may lead to drug diversion and abuse by individuals who seek them for other than legitimate medical use. Improper prescribing or documentation will continue to be investigated.

The guidelines are not rigid rules. They serve as a model for physician practice and to communicate what the Board considers to be within the boundaries of professional practice. Whereas the Board will likely not take disciplinary action against a physician for failing to adhere strictly to the provisions of this protocol, "significant deviation" from the guidelines will likely result in investigation and/or sanction of a physician practice. Key features of the guidelines include accurate documentation, some form of a treatment plan, acceptance of the plan by the patient, and appropriate evaluations and/or consultations. Compliance with all controlled substances laws and regulations is mandatory.

The Board will judge the validity of prescribing based on the physician's treatment of the patient and on available documentation rather than on the quantity and chronicity of prescribing. The goal is to control the patient's pain for its duration while effectively addressing other aspects of the patient's functioning, including physical, psychological, social, and work-related factors. This Board hopes to encourage superior pain management by physicians and to clarify appropriate pain-relieving practice with the institution of these guidelines.

Sincerely,
The New Hampshire Board of Medicine

1. Evaluation of the Patient. An accurate and complete medical history and physical examination must be documented in the medical record. The medical record should document the nature and intensity of the pain and relevant coexisting conditions (including current or past substance abuse.) The results of relevant diagnostic studies, other evaluations, and consults should be part of the record.
2. Treatment Plan. A treatment plan should state objectives that will be used to determine treatment success, such as pain relief and/or improved physical or psychosocial function. The record should indicate whether any further diagnostic evaluations or treatments are planned. Other treatment modalities might include a rehabilitation program, physical therapy, or other treatment plan deemed appropriate for the patient's treatment objectives. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient.
3. Informed Consent and Agreement for Treatment. The physician should discuss the risks and benefits of the use of controlled substances with the patient, appropriate significant other, and/or guardian. The patient should receive prescriptions from one physician and one pharmacy when chronic narcotic use is adopted and should authorize communication between both parties. Frequently, the physician may elect to use a written agreement with the patient, especially where risk for medication abuse is a concern. A written agreement may:
   1. indicate a specific pharmacy and prescribing physician;
   2. give permission for communication between care providers;
   3. detail amount and frequency of medication and prescription refills;
   4. define expected follow-up and participation in any other pain treatment activities;
   5. provide reasons for which opioid therapy may be discontinued;
   6. include an agreement to have urine/serum medication or drug levels/screens when requested; and
   7. document other inclusions appropriate for management of the individual patient.
4. Periodic Review. At reasonable intervals, the physician should review the course of opioid treatment and any new information about the cause and impact of the pain. Continuation or modification of opioid therapy should depend on the physician's evaluation of progress toward stated treatment objectives. If reasonable treatment goals are not being achieved despite medication adjustments, the physician should reevaluate the appropriateness of continued opioid treatment. The physician should monitor patient compliance in medication usage and related treatment plans.
5. Consultation. The physician should refer the patient for additional evaluation and treatment as necessary and reasonable to achieve adequate control of pain and any other treatment objectives. Special attention should be given to those patients with pain who are at risk for misusing their mediations and those whose living arrangement poses a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder requires extra care in structuring, monitoring, and documentation. When indicated and available, consultation with or referral to an expert in the management of chronic pain is advised.
6. Medical Records. The physician should keep accurate and complete records to include documentation of the following:
   1. medical history and physical examination;
   2. relevant diagnostic, therapeutic, and laboratory results;
   3. results of evaluation and consultation;
   4. treatment objectives;
   5. discussion of risks and benefits;
   6. treatments and treatment responses;
   7. medications (including date, type, dosage, refills, and quantity prescribed);
   8. instructions and agreements; and
   9. periodic reviews.

   Records should remain current, be maintained in an accessible manner, and be readily available for review.

7. Compliance With Controlled Substances Laws and Regulations. To prescribe controlled substances in New Hampshire, the physician must be licensed in the state, have a valid controlled substances registration, and comply with federal and state regulation for issuing controlled substances prescriptions. Physicians should refer to federal, state, and local regulatory agencies for guidance by writing to the Board of Medicine, 2 Industrial Park Drive, Concord, NH 03301.

Prescriptions

Ph 704.03 Transmission of Prescription Drug Order by Prescriber.

1. A prescription drug order may be transmitted to a pharmacy by an authorized prescriber or his or her designated agent in writing, orally or electronically.
2. An electronically transmitted prescription drug or device order shall:
   1. Be sent to the pharmacy of the patient's choice;
   2. For a noncontrolled substance prescription drug or device order, include:
   1. The name of the patient;
   2. The name, strength, and quantity of the drug prescribed;
   3. Any directions specified by the prescribing practitioner;
   4. The name and address of the prescribing practitioner which shall be printed or typewritten;
   5. The prescribing practitioner’s phone number for verbal confirmation; and
   6. The date the prescription was ordered.
   3. For a schedule III or IV controlled substance prescription drug order transmitted by facsimile, the order must include:
      1. The name and address of the patient;
      2. The name, strength, and quantity of the drug prescribed;
      3. Any directions specified by the prescribing practitioner;
      4. The full name of the prescribing practitioner, which must be printed, rubber stamped, or typewritten above or below his or her handwritten signature;
      5. The address of the prescribing practitioner;
      6. The federal drug enforcement administration (DEA) number assigned to the prescribing practitioner; and
      7. The date the prescription was ordered.
3. The pharmacist shall exercise professional judgment regarding the accuracy and authenticity of the electronically transmitted prescription drug order, which shall be consistent with existing federal or state laws and rules.
4. For controlled substances in schedules III, IV, or V, as defined in RSA 318-B:1-b, an electronically generated copy of a written, signed prescription transmitted by facsimile directly by the prescribing practitioner or the practitioner's agent to the pharmacy may be used as the original prescription.
5. For controlled substances in schedule II, a pharmacy may receive an electronically transmitted (by facsimile) drug order directly from the prescriber for filling, provided that the original written prescription is presented and verified against the electronic record at the time the substances are actually dispensed and the original document is processed and retained for filing.
6. There shall be 3 exceptions to the requirements stated in (e) above:
   1. A prescription prepared in accordance with RSA 318-B:9, III and IV, and issued for a schedule II substance, as defined in RSA 318-B:1-b, to be compounded for the direct administration to a patient in a private residence, long-term care facility, or hospice setting by parenteral, intravenous, intramuscular, subcutaneous, or intraspinal infusion may be electronically transmitted by facsimile by the practitioner or the practitioner’s designated agent to the dispensing pharmacy. The facsimile shall serve as the original written prescription and shall be maintained in accordance with the provisions of RSA 318-B:9, I;
   2. A prescription prepared in accordance with RSA 318-B:9, III and IV, and issued for a schedule II substance, as defined in RSA 318-B:1-b, for a resident of a long-term care facility may be electronically transmitted by the practitioner or the practitioner's designated agent to the dispensing pharmacy. The facsimile shall serve as the original written prescription and shall be maintained in accordance with the provisions of RSA 318-B:9, I; and
   3. A prescription prepared in accordance with RSA 318-B:9, III and IV, and issued for a schedule II substance, as defined in RSA 318-B:1-b, for a patient enrolled in a hospice care program, may be electronically transmitted by facsimile by the practitioner or the practitioner's designated agent to the dispensing pharmacy. The practitioner or the practitioner's designated agent shall note on the prescription that the patient is a hospice patient. The facsimile shall serve as the original written prescription and shall be maintained in accordance with the provisions of RSA 318-B:9, I.
7. The device used for the receipt of electronically transmitted prescription drug orders shall be located in the prescription department of the pharmacy to protect patient confidentiality and assure security.

[ CLOSE WINDOW ]

Author Information

David Brushwood RPh, JD, Professor, University of Florida College of Pharmacy, Gainesville

Disclosure: David B. Brushwood, RPh, JD, has disclosed no relevant financial relationships.