Title of Regulation: 18VAC60-21. Regulations Governing the Practice of Dentistry (adding 18VAC60-21-101 through 18VAC60-21-106).

Statutory Authority: §§ 54.1-2400 and 54.1-2708.4 of the Code of Virginia.

Public Hearing Information:

July 27, 2018 - 9 a.m. - Department of Health Professions, Perimeter Center, 9960 Mayland Drive, 2nd Floor, Richmond, VA 23233

Public Comment Deadline: September 7, 2018.

Agency Contact: Sandra Reen, Executive Director, Board of Dentistry, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4437, FAX (804) 527-4428, or email sandra.reen@dhp.virginia.gov.

Basis: Regulations are promulgated under the general authority of § 54.1-2400 of the Code of Virginia, which provides the Board of Dentistry the authority to promulgate regulations to administer the regulatory system. In addition, the board has been mandated to adopt regulations related to prescribing of opioids by § 54.1-2708.4 of the Code of Virginia.

Purpose: The purpose of the regulatory action is the establishment of requirements for prescribing of controlled substances containing opioids to address the overdose and addiction crisis in the Commonwealth. The goal is to provide dentists with definitive rules to follow so that they may feel more assured of their ability to treat pain in an appropriate manner to avoid under-prescribing or over-prescribing.

Substance: Regulations for the management of acute pain include requirements for the evaluation of the patient, limitations on quantity and dosage, and recordkeeping. Management of chronic pain requires either referral to a pain management specialist or adherence to regulations of the Board of Medicine. All dentists who prescribe Schedules II through IV drugs are required to take two hours of continuing education on pain management.

Issues: The primary advantage to the public is a reduction in the amount of opioid medication that is available in our communities. A limitation on the quantity of opioids that may be prescribed should result in fewer people becoming addicted to pain medication, which sometimes leads them to turn to heroin and other illicit drugs. Persons who are receiving opioids for chronic pain should be more closely monitored to ensure that the prescribing is appropriate and necessary. There are no disadvantages to the public; dentists prescribing for chronic pain must follow the regulations as those for Board of Medicine. The primary advantage to the Commonwealth is the potential reduction in the number of persons addicted to opioids and deaths from overdoses. There are no disadvantages.

The Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. Pursuant to Chapters 291¹ and 682² of the 2017 Acts of Assembly, the Board of Dentistry (Board) proposes a new regulation for the prescription of opioids in the management of acute and chronic pain. This regulation will replace an emergency regulation that became effective on April 24, 2017, and that is currently set to expire on October 23, 2018.

Result of Analysis. There are insufficient data to accurately compare the magnitude of the benefits versus the costs.

Estimated Economic Impact. The Board reports that this regulation is being proposed to "address the opioid abuse crisis in Virginia." Prior to the legislation enacted by the 2017 General Assembly, no regulations existed for opioid treatment of acute or chronic pain. In March 2017, Chapters 291 and 682 of the 2017 Acts of the Assembly became law. Each Chapter requires the Board of Dentistry to promulgate regulations for prescription of opioids.

Acute and chronic pain are defined in the proposed regulation as follows:

• Acute pain, is "pain that occurs within the normal course of a disease or condition or as the result of surgery for which controlled substances may be prescribed for no more than three months."

• Chronic pain, is "nonmalignant pain that goes beyond the normal course of a disease or condition for which controlled substances may be prescribed for a period of greater than three months."

For the treatment of acute pain, these Chapters require that the Board's regulation include:

"(i) requirements for an appropriate patient history and evaluation, (ii) limitations on dosages or day supply of drugs prescribed, (iii) requirements for appropriate documentation in the patient's health record, and (iv) a requirement that the prescriber request and review information contained in the Prescription Monitoring Program in accordance with § 54.1-2522.1."

For the treatment of chronic pain, the Chapters require the regulations to include the requirements listed above for acute pain treatment, as well as requirements for:

"(i) development of a treatment plan for the patient, (ii) an agreement for treatment signed by the provider and the patient that includes permission to obtain urine drug screens [UDS], and (iii) periodic review of the treatment provided at specific intervals to determine the continued appropriateness of such treatment."

This proposed regulation will apply to all dentists.

Requirements in the Proposed Regulation.

Requirements for Evaluation of the Patient in Prescribing for Acute Pain: For the evaluation of the patient, the regulation (section 102) requires that the dentist: (1) consider nonpharmacologic and non-opioid treatment for pain prior to treatment with opioids, (2) take a health history, (3) perform a physical examination appropriate for the complaint, (4) assess the patient's history and risk of substance abuse, and (5) query the state's Prescription Monitoring Program (PMP) as set forth in § 54.1-2522.1. Section 54.2522.1 requires queries when initiating a new course of treatment in which an opioid prescription is anticipated to last more than seven consecutive days. That section also provides that a prescriber may make additional queries "as may be required by routine prescribing practices."

Requirements for Treatment of Acute Pain with Opioids: The Board proposes to limit opioid prescriptions for all acute care to the lowest effective dose, and for no more than seven days unless extenuating circumstances are clearly documented. The Board also proposes to require that, "practitioners shall carefully consider and document in the medical record the reasons to exceed 50 MME/day"³ if they prescribe opioids in excess of that daily dosage, and to require that, "prior to exceeding 120 MME/day, the practitioner shall document in the medical record the reasonable justification for such doses or refer to or consult with a pain management specialist." Dentists will be required to prescribe naloxone⁴ "when risk factors of prior overdose, substance misuse, doses in excess of 120 MME/day, or concomitant benzodiazepine is present." Finally, dentists will also be required to limit co-prescribing of drugs that may increase the risk of accidental overdose when taken with opioids.

If another prescription for an opioid is to be written beyond seven days, the Board also proposes (in section 103) to require that the patient be re-evaluated and that a check of the PMP be run for the patient's prescription history. The Board proposes to set record-keeping requirements for acute pain to include a description of the pain, a presumptive diagnosis, a treatment plan, and information on medication prescribed or administered

Requirements for the Treatment of Chronic Pain: For treatment of chronic pain, the Board proposes to require that dentists either refer a patient to a medical doctor who is a pain management specialist or comply with the Board of Medicine's regulation, 18VAC85-21-60 through 18VAC85-21-120. Board staff reports that although very few dentists treat chronic pain, oral and maxillofacial surgeons may occasionally treat chronic pain.

Benefits and Costs of the Proposed Regulation. The requirements in the proposed regulation appear to confer a mix of benefits and costs, including those resulting from restrictions on medicine dosages, preferences for non-opioid treatments, and use of the PMP. Except for the estimated costs directly resulting from mandatory drug testing (listed in Board of Medicine rules for treatment of chronic pain), there is insufficient quantitative data to accurately determine, and thus compare, the magnitude of direct benefits versus direct costs. In part this is because the scope and range of potential impacts (cost and benefit) cannot be readily identified. To the extent that the proposed regulation reduces the rate of prescription substance abuse, including drug addiction, savings or cost avoidance could be achieved from reduction in expenditures on the treatment of, and consequences from, substance abuse. However, to the extent that the regulations create a disincentive to obtaining, or limit access to, opioid therapy, any savings or cost avoidance may be offset by direct and indirect costs resulting from untreated pain⁵ or a shift to illicit drugs.⁶

Indirect Benefits and Costs of Prescription Monitoring Program (PMP) Queries: Virginia statute presently requires PMP checks for any prescriptions anticipated to be used for more than seven consecutive days. This regulation proposes to require PMP queries as set forth in § 54.1-2522.1 of the Code of Virginia prior to initiating treatment with opioids and PMP queries "if another prescription for an opioid is to be written beyond seven days." To the extent that the regulation is also interpreted to require PMP checks for all prescriptions, as a "routine prescribing practice" (rather than just prescriptions anticipated to last more than seven continuous days), practitioners may incur additional time costs for running those queries. To the extent that use of the PMP lowers the volume of drugs diverted from licit to illicit uses, the new requirement will provide the benefit of reductions in the costs of illicit drug use in the state.

Indirect Benefits and Costs of Record-Keeping Requirements: The Board's proposed record-keeping requirements for acute pain are likely already common for dental practices; thus licensees are unlikely to incur any costs from that portion of the proposed regulation that covers the treatment of acute pain. Likewise, most of the proposed requirements for taking a patient history and assessing a patient's complaint are likely common practice now and should not cause any additional costs. The proposed requirement that dentists in an acute care setting perform a risk assessment for substance misuse on all patients who may be prescribed opioids may not presently be a part of standard patient care. To the extent that doctors treating acute pain do not currently assess risk of substance abuse, costs would be incurred for their time to perform such assessments.

Indirect Benefits and Costs of Preferences for Alternative Treatments. The proposed regulation's requirements that alternative treatments (both nonpharmacologic and non-opioid) be given consideration prior to prescription of opioids for both acute pain and chronic pain is being proposed to reduce the number of such prescriptions. Board staff state that nonpharmacologic treatments may include physical therapy, chiropractic, and acupuncture.

In addition, non-opioid treatments can include treatment with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as well as selected antidepressants and anticonvulsants. Although these drugs do not have the addiction risks of opioids, they may pose other health risks for certain patients. As noted by the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain,⁷ although NSAIDs are recommended as first-line treatment for osteoarthritis or low back pain they do have risks, including gastrointestinal bleeding or perforation as well as renal and cardiovascular risks. Increasing use of non-opioid treatments like NSAIDs will therefore need to balance the benefits of non-opioid therapy with these and other risks.

Direct Benefits and Costs of Rules for Treating Chronic Pain: Very few dentists will likely treat chronic pain. To the extent that they do, they will be required to follow Board of Medicine rules for such treatment. An analysis of the benefits and costs for the Board of Medicine's rules for chronic pain treatment can be found on the Virginia Regulatory Town Hall.⁸

Businesses and Entities Affected. These proposed regulatory changes will affect all 7,127 dentists currently licensed in the Commonwealth as well as any individuals who will be licensed as dentists in the future. Board staff report that the vast majority of these dentists are small businesses. These proposed regulations will also affect all dental patients who require acute or chronic pain management. Health insurance providers may also be affected.

Localities Particularly Affected. No locality likely will be affected by these proposed regulatory changes.

Projected Impact on Employment. To the extent that these proposed regulatory changes lead to fewer individuals being effectively treated for chronic pain, employee absenteeism may increase, which would tend to depress total productivity. To the extent that this regulation reduces rates of addiction, thereby allowing former addicts to hold employment, productivity may increase.

Effects on the Use and Value of Private Property. There is no apparent impact on the use and value of private property.

Real Estate Development Costs. These proposed regulatory changes are unlikely to affect real estate development costs in the Commonwealth.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. Small business dentists will likely incur increased costs associated with book keeping, staff wages, increased documentation requirements, and new drug testing requirements for chronic pain patients that will be enforced. Alternatively, adherence to the practices required by the regulation may have an unknown impact on liability insurance and associated costs that may result in savings. It is unclear to what extent these costs or savings may be passed on to insurance companies, patients, or other third parties.

Alternative Method that Minimizes Adverse Impact. Allowing dentists the discretion as to whether and how often to use drug testing would likely decrease the costs listed above. As noted above, the CDC only recommends that practitioners "consider" drug testing on an annual basis after the initial screen. For both the initial UDS and subsequent testing, however, it appears that the CDC concludes that practitioners should retain the discretion to determine whether to administer a test. The CDC notes that the recommendation to use drug testing is a Category B recommendation, which is one where "different choices will be appropriate for different patients, so clinicians must help patients arrive at a decision consistent with patient values and preferences, and specific clinical situations."⁹

Adverse Impacts:

Businesses: Dentists who practice independently may incur changes to current business practices related to increased bookkeeping, staff impacts associated with increased documentation requirements, and implementation of new drug testing requirements for chronic pain patients. It is unclear to what extent these costs may be passed on to insurance companies, patients, or other third parties.

Localities: Localities in the Commonwealth are unlikely to see any adverse impacts from these proposed regulatory changes.

Other Entities: To the extent that dentists treat chronic-pain patients, this proposed regulation may lead to those patients, or their insurance companies, incurring increased annual costs on account of drug testing requirements. To the extent that treatment by oral and maxillofacial surgeons is covered by health insurance or dental insurance, the Commonwealth of Virginia may incur increased costs on account of these proposed regulatory changes, including employee health benefits, and the Department of Medical Assistance Services may incur increased costs for Medicaid patients who are in treatment for chronic pain.

References:

Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK91497/pdf
/Bookshelf_NBK91497.pdf.

Krishnamurthy, Partha, Govindaraj Ranganathan, Courtney Williams, Gulshan Doulatram. 2016. "Impact of Urine Drug Screening on No Shows and Dropouts among Chronic Pain Patients: A Propensity-Matched Cohort Study." Pain Physician. 19. 89-100. http://www.painphysicianjournal.com
/current/pdf?article=MjUyNA%3D%3D&journal=94.

Nahin, Richard L. "Estimates of Pain Prevalence and Severity in Adults: United States, 2012." The journal of Pain?: official Journal of the American Pain Society 16.8 (2015): 769–780. PMC. Web. 19 Sept. 2017.

Pollack, Harold, Sheldon Danzinger, Rukmalie Jayakody, Kristen Seefeldt. 2001. Drug Testing Welfare Recipients — False Positives, False Negatives, Unanticipated Opportunities.

Virginia Departments of Forensic Science and Criminal Justice Services. 2016. Drug Cases Submitted to the Virginia Department of Forensic Science Calendar Year 2016. http://www.dfs.virginia.gov/wp-content/uploads/2017/07
/CY16DfsDataReport_Final.pdf.

Virginia Department of Health Office of the Chief Medical Examiner. 2017. Fatal Drug Overdose Quarterly Report First Quarter 2017. Edition 2017.1. http://www.vdh.virginia.gov/content/uploads/sites/18/2016/04/Fatal-Drug-Overdoses-Quarterly-Report-Q1-2017_Updated.pdf.

Dowell Deborah, Tamara M Haegerich, Roger Chou. CDC Guideline for Prescribing Opioids for Chronic Pain. United States. 2016. MMWR Recomm Rep 2016; 65 (No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

___________________________________________

¹http://leg1.state.va.us/cgi-bin/legp504.exe?171+ful+CHAP0291.

²http://leg1.state.va.us/cgi-bin/legp504.exe?171+ful+CHAP0682.

³MME is an abbreviation for morphine milligram equivalent, which provides a standard value for equating the potency of different opioids.

⁴Naloxone, sold under the brand name Narcan among others, is a medication used to block the effects of opioids, especially in overdose.

⁵Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. https://www.ncbi.nlm.nih.gov/books/NBK91497/pdf/Bookshelf_NBK91497.pdf.

⁶Today's fentanyl crisis: Prohibition's Iron Law, revisited, International Journal of Drug Policy 46 (2017) 156–159.

⁷https://www.cdc.gov/drugoverdose/prescribing/guideline.html.

⁸http://townhall.virginia.gov/L/GetFile.cfm?File=C:\TownHall\docroot\26\4760\7981\EIA_DHP_7981_v2.pdf.

⁹CDC Guideline, page 4.

Agency's Response to Economic Impact Analysis: The Board of Dentistry and the Department of Health Professions do not concur with the result of the analysis that "there is insufficient data to accurately compare the magnitude of the benefits versus the costs." We believe it failed to fully analyze the personal and societal costs of opioid addiction. It is the position of the agency that reducing the quantity of opioids in our homes and communities has already been shown to have a cost benefit and will ultimately have a direct benefit in a reduction in opioid misuse and opioid overdose deaths.

1. The agency believes the analysis does not include sufficient data about the current crisis in opioid overdose deaths.

In 2015, there were 811 opioid deaths, and in 2016 there were 1,133 – a 40% increase. In a preliminary report from the Department of Criminal Justice Services (DCJS), the number for 2017 is expected to be 1,181. The result of the 2017 National Drug Threat Assessment notes that controlled prescription drugs (CPDs) have been linked to the largest number of overdose deaths of any illicit drug class since 2001. For each of these deaths, there are immeasurable costs. For the purpose of an economic analysis, medical malpractice carriers and civil litigants can attribute costs in dollars and cents for each year of life lost.

Yearly direct and indirect costs related to prescription opioids have been estimated (based on studies published since 2010) to be $53.4 billion for nonmedical use of prescription opioids; $55.7 billion for abuse, dependence (i.e., opioid use disorder), and misuse of prescription opioids; and $20.4 billion for direct and indirect costs related to opioid-related overdose alone. While we acknowledge that these are national figures, the economic impact analysis (EIA) has used national data to extrapolate the costs of urine drug screens for Virginians. Copious amounts of data exist in national and state reports on the opioid crisis for which these regulations offer a partial solution.

2. The agency believes the analysis does not make the connection between the opioid crisis of fentanyl and heroin to the prescribing of opioid pain medication.

One of the primary purposes of these regulations is to reduce the number of persons who enter the pipeline of addiction through a legitimately prescribed opioid. The National Institute on Drug Abuse reports that a study of young, urban injection drug users interviewed in 2008 and 2009 found that 86% had used opioid pain relievers nonmedically prior to using heroin, and their initiation into nonmedical use was characterized by three main sources of opioids: family, friends, or personal prescriptions. Examining national-level general population heroin data (including those in and not in treatment), nearly 80% of heroin users reported using prescription opioids prior to heroin.

The report from DCJS noted that "data from Department of Forensic Sciences (DFS) and Office of the Chief Medical Examiner (OCME) demonstrate that there are still a large number of individuals using prescription opioids non-medically. These individuals are at risk of overdose death through the prescription drugs they are currently using, but they are also at a higher risk of using heroin in the future. Although only a small percentage of individuals who abuse prescription opioids move on to heroin, a high percentage of heroin users report that their first opioid was a prescription drug (https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-abuse-heroin-use/). Additionally, non-medical users of prescription opioids may seek to acquire those drugs illegally, putting themselves at risk of purchasing and using counterfeit pills made with fentanyl and fentanyl analogs."

Data from OCME indicates that between 2013 and 2016, the number of prescription opioid fatalities involving fentanyl and/or heroin increased 69%. In 2016, 37% of prescription opioid fatalities also involved fentanyl and/or heroin. Although illicit fentanyl cases increased 207% between 2015 and 2016, there were almost four times as many heroin cases and four times as many prescription opioid cases that year.

Data from the Virginia Prescription Monitoring Program shows that since the adoption of emergency regulations there has been a drop in morphine milligram equivalents (MME). MME per day is the amount of morphine an opioid dose is equal to, often used to gauge the abuse and overdose potential of the amount of opioid being prescribed at a particular time. The Centers for Disease Control and Prevention (CDC) indicates that individuals taking greater than 90 MME/day are at a higher risk of overdose and death. The total number of patients prescribed high dosages declined from 169,145 individuals in the fourth quarter of 2016 to 137,618 individuals in the third quarter of 2017, or an 18.6% decline in individuals receiving greater than 100 MME/day. The data is an indicator of the effectiveness of the emergency regulation being replaced with the proposed regulations for which the EIA was prepared.

Numerous reports in the press have made the connection between the overdose death of a person who was prescribed on opioid following an accident or medical procedure. The intent of this regulation is to require prescribers to prescribe fewer quantities for shorter periods of time and to consider nonpharmacological alternatives or non-opioid medications that have the effect of addressing a patient's pain without the potential for addiction and long-term, costly consequences.

3. The agency believes the analysis has not included sufficient data on cost savings relating to a reduction on opioid prescribing.

For example, this agency provided information from the Department of Medical Assistance Services, which experienced a 44% decrease in opioid days-supply and 27% decrease in opioid prescription spending when that agency implemented the CDC guidelines on which these regulations were based, for an annual reduction in drug spending on opioids of approximately $466,000. It is that agency's belief that costs related to an increase in urine drug screens, which have been routinely required by pain management physicians prior to adoption of these regulations, would be more than offset by the decrease in spending on opioid prescriptions, so it would be budget neutral or result in a net cost savings.

Data from the Prescription Monitoring Program show that from the fourth quarter of 2016 to the third quarter of 2017, pain reliever doses declined from 129,797,789 to 77,729,833, which represents a 40.15% decline. It is apparent that the emergency regulations are having a positive effect on the costs of prescription opioids – a cost benefit to consumers and insurers that could be reflected in the EIA.

Summary:

The proposed regulatory action adopts requirements for the prescribing of opioids and products containing buprenorphine pursuant to Chapters 291 and 682 of the 2017 Acts of Assembly. Provisions for the management of acute pain include requirements for the evaluation of the patient, limitations on quantity and dosage, and recordkeeping. A dentist who manages a patient with chronic pain must either refer the patient to a pain management specialist or adhere to the regulations of the Board of Medicine. All dentists who prescribe Schedules II through IV controlled substances are required to complete two hours of continuing education in pain management. The proposed regulations replace emergency regulations currently in effect.

Part III
Prescribing for Pain Management

18VAC60-21-101. Definitions.

The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:

"Acute pain" means pain that occurs within the normal course of a disease or condition or as the result of surgery for which controlled substances may be prescribed for no more than three months.

"Chronic pain" means nonmalignant pain that goes beyond the normal course of a disease or condition for which controlled substances may be prescribed for a period greater than three months.

"Controlled substance" means drugs listed in The Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia) in Schedules II through IV.

"MME" means morphine milligram equivalent.

"Prescription Monitoring Program" means the electronic system within the Department of Health Professions that monitors the dispensing of certain controlled substances.

18VAC60-21-102. Evaluation of the patient in prescribing for acute pain.

A. Nonpharmacologic and non-opioid treatment for pain shall be given consideration prior to treatment with opioids. If an opioid is considered necessary for the treatment of acute pain, the dentist shall follow the regulations for prescribing and treating with opioids in 18VAC60-21-103 and 18VAC60-21-104.

B. Prior to initiating treatment with a controlled substance containing an opioid for a complaint of acute pain, the dentist shall perform a health history and physical examination appropriate to the complaint, query the Prescription Monitoring Program as set forth in § 54.1-2522.1 of the Code of Virginia, and conduct an assessment of the patient's history and risk of substance abuse.

18VAC60-21-103. Treatment of acute pain with opioids.

A. Initiation of opioid treatment for all patients with acute pain shall include the following:

1. A prescription for an opioid shall be a short-acting opioid in the lowest effective dose for the fewest number of days, not to exceed seven days as determined by the manufacturer's directions for use, unless extenuating circumstances are clearly documented in the patient record.

2. The dentist shall carefully consider and document in the patient record the reasons to exceed 50 MME per day.

3. Prior to exceeding 120 MME per day, the dentist shall refer the patient to or consult with a pain management specialist and document in the patient record the reasonable justification for such dosage.

4. Naloxone shall be prescribed for any patient when there is any risk factor of prior overdose, substance abuse, or doses in excess of 120 MME per day, and shall be considered when concomitant use of benzodiazepine is present.

B. If another prescription for an opioid is to be written beyond seven days, the dentist shall:

1. Reevaluate the patient and document in the patient record the continued need for an opioid prescription; and

2. Check the patient's prescription history in the Prescription Monitoring Program.

C. Due to a higher risk of fatal overdose when opioids are prescribed with benzodiazepines, sedative hypnotics, carisoprodol, and tramadol, the dentist shall only co-prescribe these substances when there are extenuating circumstances and shall document in the patient record a tapering plan to achieve the lowest possible effective doses if these medications are prescribed.

18VAC60-21-104. Patient recordkeeping requirement in prescribing for acute pain.

The patient record shall include a description of the pain, a presumptive diagnosis for the origin of the pain, an examination appropriate to the complaint, a treatment plan, and the medication prescribed, including date, type, dosage, strength, and quantity prescribed.

18VAC60-21-105. Prescribing of opioids for chronic pain.

If a dentist treats a patient for whom an opioid prescription is necessary for chronic pain, the dentist shall either:

1. Refer the patient to a medical doctor who is a pain management specialist; or

2. Comply with regulations of the Board of Medicine, 18VAC85-21-60 through 18VAC85-21-120, if the dentist chooses to manage the chronic pain with an opioid prescription.

18VAC60-21-106. Continuing education required for prescribers.

Any dentist who prescribes Schedules II through IV controlled substances after April 24, 2017, shall obtain two hours of continuing education on pain management, which must be taken by March 31, 2019. Thereafter, any dentist who prescribes Schedules II through IV controlled substances shall obtain two hours of continuing education on pain management every two years. Continuing education hours required for prescribing of controlled substances may be included in the 15 hours required for renewal of licensure.