May 3, 2017

William L. Harp, M.D.
Executive Director
Board of Medicine
9960 Mayland Drive, Suite 300
Henrico Virginia 23233

RE: Regulations Governing Prescribing of Opioids and Buprenorphine

Dear Dr. Harp:

The Virginia Academy of Family Physicians (VAFP) appreciates the opportunity to provide public comment on the Emergency Regulations Governing the Prescribing of Opioids and Buprenorphine. The practice of medicine is best regulated by the physicians and so the VAFP supports the Board’s evidence based process to develop appropriate regulations concerning the prescribing of opioids and buprenorphine. 

VAFP received a substantial number or responses from its membership in response to the Board’s emergency regulations.  A summary of the comments received by VAFP is included here.  Please note that the summarized comments below do not necessarily reflect the views of the VAFP or its general membership. 

Summary of comments received:

• Need to develop exclusions, reduced visit requirements, or reduced documentation requirements based on patient age (i.e. geriatric patients) or clinical criteria. 
• Need to develop a process for withdrawing patients if a provider decides to stop prescribing opioids in response to these regulations.
• Clarification is needed as to the responsibility of Narcan prescribing; Narcan prescriptions should appear on the PMP.
• Clarification is needed as to whether or not the regulations apply to Tramadol.  Many members expressed a need for confirmation that the regulations do not apply to Tramadol. 
• Clarification is needed as to whether or not the regulations apply to cough syrups including codeine or hydrocodone.
• Many comments requested a definition of “opioid” be included in the regulations.
• Need clarification as to whether Narcan is required to be prescribed in conjunction with sedation medications. 
• Flexibility is needed regarding the 3-month assessment requirement; individualization should be considered to allow for 3-6 month assessments with 3 month assessments reserved for patients at higher morphine equivalent doses.  Frequent office visits may preclude access to primary care for other patients given limited primary care resources. 
• Clarification is needed as to how patients who use opioids intermittently (i.e. opioid for back pain prescribed prn) must be managed under the regulations.
• Responsibilities should be clarified when one physician is prescribing an opioid and another physician is prescribing a benzodiazepine for the same patient.
• Clarification is needed as to how to handle a patients positive drug screen for THC if the THC was lawfully obtained.
• Many members expressed concern that the administrative requirements imposed by the regulations would have the consequence of impeding legitimate patients from accessing necessary medication as providers would be forced to see and prescribe opioids for fewer patients.  Some members reflected to VAFP that they have or will simply stop prescribing opioids entirely to avoid doubt over compliance and due to administrative burdens.

Again, thank you for the opportunity to provide comment on this matter.  VAFP is committed to continuing to work with the Board of Medicine to advance public health and safety through the appropriate regulation of the prescribing of opioids and buprenorphine. 

Respectfully,
Lindsey Vaughn, M.D.
President, VAFP