§ 21-28-3.20. Authority of practitioner to prescribe, administer, and dispense. (a)(1) A practitioner, in good faith and in the course of his or her professional practice only, may prescribe, administer, and dispense controlled substances, or he or she may cause the controlled substances to be administered by a nurse or intern under his or her direction and supervision.

(2) When issuing an initial prescription for an opiate to an adult patient, a practitioner shall not exceed the maximum daily dose requirements established by the department of health.

(3) Except as provided in subsection (a)(4) of this section, a practitioner shall not issue an opiate prescription to a minor for more than twenty (20) doses at any time. Prior to issuing an opiate prescription to a minor, a practitioner shall discuss with the parent or guardian of the minor the risks associated with opiate use and the reasons why the prescription is necessary. The practitioner shall document his or her discussion with the parent or guardian in the medical record.

(4) Notwithstanding the limitations referenced in subsection (a)(3) of this section, if, in the professional medical judgment of a practitioner, a greater dosage or supply of an opiate is required to treat the minor patient's acute medical condition or is necessary for the treatment of chronic pain management, sickle cell related pain, intractable pain treatment as defined in chapter 37.4 of title 5, pain associated with a cancer diagnosis, or for palliative care, then the practitioner may issue a prescription for the quantity needed to treat the acute medical condition, chronic pain, sickle cell related pain, intractable pain, pain associated with a cancer diagnosis, or pain experienced while the patient is in palliative care, provided that this dosage shall not exceed the maximum daily dosage permitted for the treatment of this pain as set forth in the department of health regulations. The condition triggering the prescription of an opiate shall be documented in the minor patient's medical record, and the practitioner shall indicate that a non-opiate alternative was not appropriate to address the medical condition.

(5) Notwithstanding subsections (a)(2) and (a)(3) of this section, this section shall not apply to medications designed for the treatment of substance abuse or opioid dependence.

(b) The prescription-monitoring program shall be reviewed prior to starting any opioid. A prescribing practitioner, or designee as authorized by § 21-28-3.32(a)(3), shall review the prescription-monitoring program prior to refilling or initiating opioid therapy with an intrathecal pump. For patients the prescribing practitioner is maintaining on continuous opioid therapy for pain for three (3) months or longer, the prescribing practitioner shall review information from the prescription-monitoring program at least every three (3) months. Documentation of that review shall be noted in the patient's medical record.

(c) The director of health shall develop regulations for prescribing practitioners on appropriate limits of opioid use in acute pain management. Initial prescriptions of opioids for acute pain management of outpatient adults shall not exceed thirty (30) morphine milligram equivalents (MMEs) total daily dose per day for a maximum total of twenty (20) doses, and, for pediatric patients, the appropriate opioid dosage maximum per the department of health.

(d) For the purposes of this section, acute pain management shall not include chronic pain management, pain associated with a cancer diagnosis, palliative or nursing home care, or other exception in accordance with department of health regulations.

(e) Subsection (c) shall not apply to medications designed for the treatment of substance abuse or opioid dependence.

(f) On or before September 1, 2018, the director of health shall develop, and make available to healthcare practitioners, information on best practices for co-prescribing opioid antagonists to patients. The best practices information shall identify situations in which co-prescribing an opioid antagonist may be appropriate, including, but not limited to:

(1) In conjunction with a prescription for an opioid medication, under circumstances in which the healthcare practitioner determines the patient is at an elevated risk for an opioid drug overdose;

(2) In conjunction with medications prescribed pursuant to a course of medication therapy management for the treatment of a substance use disorder involving opioids; or

(3) Under any other circumstances in which a healthcare practitioner identifies a patient as being at an elevated risk for an opioid drug overdose.

(g) The best practices information developed pursuant to subsection (f) of this section shall include guidelines for determining when a patient is at an elevated risk for an opioid drug overdose, including, but not limited to, situations in which the patient:

(1) Meets the criteria provided in the opioid overdose toolkit published by the federal substance abuse and mental health service administration;

(2) Is receiving high-dose, extended-release, or long-acting opioid medications;

(3) Has a documented history of an alcohol or substance use disorder, or a mental health disorder;

(4) Has a respiratory ailment or other co-morbidity that may be exacerbated by the use of opioid medications;

(5) Has a known history of intravenous drug use or misuse of prescription opioids;

(6) Has received emergency medical care or been hospitalized for an opioid overdose; or

(7) Uses opioids with antidepressants, benzodiazepines, alcohol, or other drugs.

(h) On or before September 1, 2018, the director of health and the secretary of the executive office of health and human services shall develop strategies that include:

(1) Allowing practitioners in non-pharmacy settings to prescribe and dispense opioid antagonists; and

(2) Ensuring that opioid antagonists that are distributed in a non-pharmacy setting are eligible for reimbursement from any health insurance carrier, as defined under chapters 18, 19, 20, and 41 of title 27, and the Rhode Island medical assistance program, as defined under chapter 7.2 of title 42.

History of Section. (P.L. 1974, ch. 183, § 2; P.L. 1992, ch. 434, § 1; P.L. 1999, ch. 83, § 43; P.L. 1999, ch. 130, § 43; P.L. 2005, ch. 93, § 1; P.L. 2005, ch. 104, § 1; P.L. 2016, ch. 180, § 1; P.L. 2016, ch. 199, § 1; P.L. 2018, ch. 183, § 2; P.L. 2018, ch. 277, § 2; P.L. 2019, ch. 105, § 1; P.L. 2019, ch. 154, § 1.)