North Carolina’s first-ever limits on opioid prescribing took effect Jan. 1, 2018, as part of the state’s new opioids law, the STOP Act of 2017. The limits apply only to certain prescriptions for postoperative and other types of acute pain, which the law defines as pain that the prescriber expects to last no more than three months.
The STOP Act’s prescribing limits are designed to ensure that patients with acute pain do not receive excessive supplies of opioid pain medication. The law attempts to balance the need for patients to receive adequate pain relief against the desire to prevent situations in which patients are left with large supplies of unused, unneeded pills available for misuse, abuse or diversion.
To help licensees understand and comply with the prescribing limits, the Board has updated and expanded its FAQs on this topic. Brush up on the new limits by reading a sampling of our prescribing limit FAQs below, then
take our short online quiz to test your knowledge.
Q: Does the STOP Act limit prescriptions for chronic pain?
A: No. The Act limits certain prescriptions for acute pain (this includes post-operative pain). Prescriptions for chronic pain are not affected.
Q: How does the STOP Act define “acute pain”?
A: Pain from disease, accident, intentional trauma, or other cause that is expected to last for three months or less. However, NCMB does not consider acute pain stemming from an established chronic condition to be “acute pain” as contemplated by the STOP Act. For example, the Board does not consider a patient with rheumatoid arthritis who experiences an acute flare of the disease to be subject to the Act’s 5-day prescribing limit.
Q: How does the STOP Act limit opioid prescriptions for post-operative pain?
A: Pain medication administered in a health care facility (e.g. hospital or surgery center) is not subject to the STOP Act’s prescribing limits. Upon discharge, initial prescriptions for Schedule II and Schedule III opioids are limited to no more than a 7-day supply for all types of procedures.
Q: How does the STOP Act limit opioid prescriptions for non-surgical acute pain?
A: The Act limits prescriptions for Schedule II and Schedule III opioids to no more than a 5-day supply when the prescription is issued after an initial consultation for acute pain.
Q: What medications are subject to the 5- and 7-day limits imposed by the STOP Act?
A: The limits apply ONLY to Schedule II and Schedule III opioids listed in N.C. Gen. Stat. § 90-90(1), (2) and 90-91(d), only when prescribed for acute pain as described above, and in the Act. Find a complete list of affected drugs at
www.ncmedboard.org/STOP.
Q: Is it the initial prescription for opioids written for acute pain that is limited or is it any opioid prescription written after the initial consultation?
A: The STOP Act states that a prescriber may not prescribe more than a 5- or 7-day supply of opioids following “initial consultation and treatment” of a patient for acute pain. Therefore, the limits apply when a Schedule II or Schedule III opioid is written after an “initial consultation” for acute pain.
Example: A patient presents with severe shoulder pain resulting from a sports injury. After the initial consultation, the clinician recommends ibuprofen, ice and rest. The patient comes back the following week with continued complaints of severe shoulder pain. The clinician recommends treatment with opioids. Because the opioid prescription is issued after a “subsequent consultation for the same pain” the prescriber may lawfully issue a prescription for any amount, consistent with current accepted standards of care. Note: If the clinician in the shoulder pain scenario prescribed opioids after seeing the patient for the first time (e.g. following the initial consultation) then the STOP Act limits would apply and the prescription would be limited to no more than a 5-day supply.
Regardless of whether the STOP Act limits on acute pain prescriptions apply, prescribers are urged to avoid authorizing excessive amounts of opioids for acute pain.
Q: Is it acceptable to prescribe less than a 5- or 7-day supply of opioids for acute pain?
A: Yes, as long as the decision to prescribe less than a 5- or 7-day supply is consistent with good medical practice. The CDC Guideline for Prescribing Opioids for Chronic Pain, for example, recommends prescribing opioids no more than three days for acute pain and five days for post-surgical pain. The Board recognizes that such guidelines may not meet the needs of all patients.
Q: What if the patient is still experiencing severe pain after finishing a 5- or 7-day prescription?
A: The STOP Act states that “upon any subsequent consultation for the same pain” the prescriber may issue “any appropriate renewal, refill or new prescription” for opioids. That is, if the patient is still experiencing pain from the same surgery/accident/injury/illness after finishing an initial 5- or 7-day prescription, the prescriber may provide a refill for any appropriate amount.
Q: Do I need to physically see the patient back in the office in order to renew/refill the prescription or to issue a new prescription for a different amount and/or different drug?
A: Not necessarily. “Follow up consultation” may not require an in-person visit for the same issue before a refill/renewed prescription or before a new prescription may be authorized, depending on the specific circumstances. In some instances (e.g. when symptoms of infection are reported by the patient, or when a patient reports worsening pain or other symptoms that are not indicative of healthy recovery), the prescriber may need to see the patient in person. Prescribers should determine these situations in a manner consistent with current accepted standards of care and good medical practice.
In situations where an in-person consultation is not indicated, a patient might submit a request for a prescription for the same pain via phone or online portal. The patient or patient representative would still need to come to the office to pick up Schedule II prescriptions unless the practice has the capability to e-prescribe controlled substances.
Find an extended set of prescribing limit FAQs and more STOP Act information at
www.ncmedboard.org/STOP.
