What are the guidelines for opioid (narcotic pain medication) refills without patient contact?

Guidelines for Opioid Refills Without Patient Contact

Opioid refills without direct patient contact are permissible under specific circumstances, but safe prescribing procedures including assessment of response, adverse events, aberrant behaviors, function, and quality of life improvements must still be performed via telemedicine or telephone communication. 1

Core Principle: No Automatic Refills

Repeat and refill prescriptions of opioids should be avoided entirely, as each additional refill increases the risk of opioid misuse by 40%, with each additional week of opioid use raising misuse risk by 20%. 1 Any request for more opioids must trigger a patient review rather than an automated repeat prescription. 1

When Refills Without In-Person Contact Are Acceptable

Temporary Policy Allowances

During exceptional circumstances (such as public health emergencies), temporary allowances permit:

• Pharmacists extending prescriptions for limited time periods 1
• Verbal orders by physicians for controlled substance refills 1
• Prescribing opioids without in-person evaluation when necessary conditions are met 1

Mandatory Requirements for Remote Refills

Even when prescribing without direct in-person evaluation, you must perform the following via video communication or telephone: 1

Assessment Components:

• Adequate pain response and functional improvement using validated tools like the PEG scale (Pain average, interference with Enjoyment, interference with General activity) 1
• Adverse events monitoring, specifically sedation, slurred speech, constipation, and drowsiness 1
• Aberrant behaviors screening, including craving, taking opioids in greater quantities than prescribed, difficulty controlling use, or work/family problems related to opioid use 1
• Quality of life improvements and progress toward functional goals 1
• Pill counts can be performed via video communication 1

Follow-Up Frequency Requirements

For patients on chronic opioid therapy (≥90 days), reassessment must occur at least every 3 months, with more frequent monitoring for high-risk patients. 1

Higher-risk patients requiring more frequent than quarterly assessment include those with: 1

• Depression or other mental health conditions
• History of substance use disorder
• History of overdose
• Taking ≥50 morphine milligram equivalents (MME) per day
• Concurrent use of benzodiazepines or other CNS depressants

Initial opioid therapy requires follow-up within 1-4 weeks of starting or dose escalation, with shorter intervals (within 3 days) strongly recommended when starting or increasing methadone. 1

Absolute Contraindications to Refills Without Contact

Any significant, sustained increase in opioid dose requires an in-person evaluation. 1 This is critical because psychological stress may drive increased opioid requirements, and patients may use prescribed opioids for non-pain conditions like anxiety, depression, or insomnia. 1

Patients still requiring opioids 90 days after surgery or beyond the normal healing period must be referred to pain specialists rather than receiving continued refills. 1

Specific Refill Duration Limits

For postoperative patients, prescribe 5 days and no more than 7 days of opioids at discharge, with explicit documentation that these are NOT to become repeat prescriptions. 1

The discharge letter must explicitly state: 1

• Recommended opioid dose
• Amount supplied
• Planned duration of use
• That this is an acute (not repeat) prescription

Essential Safety Measures During Remote Refills

Prescription Drug Monitoring Program (PDMP) Review

Check PDMP data before any refill to identify doctor shopping or multiple prescribers. 1

Urine Drug Testing

Continue adherence monitoring via UDT to identify non-compliance, prescription drug abuse, or illicit drug use. 1

Patient Education Requirements

During remote contact, reinforce: 1

• Risks and benefits of continued opioid use
• Naloxone prescription and overdose reversal training when appropriate
• Dangers of concurrent benzodiazepines, alcohol, or other CNS depressants
• Safe storage in locked locations
• Safe disposal methods for unused medications
• Driving and machinery operation risks

Informed Consent

Obtain or reaffirm informed consent via video communication for continued therapy. 1

Critical Pitfall to Avoid

The most dangerous practice is allowing opioid prescriptions to migrate from acute to repeat prescription templates in electronic medical records. 1 Postoperative or acute opioids must only ever be documented as acute medications and reviewed at each issue by the prescriber. 1

When Remote Refills Are Insufficient

If patients demonstrate any of the following, in-person evaluation is mandatory: 1

• Lack of sustained improvement in pain and function
• High-risk regimens (≥50 MME/day or opioids combined with benzodiazepines) without evidence of benefit
• Request for dosage increase
• Overdose or serious adverse events
• Warning signs of serious adverse events (sedation, slurred speech)

Virtual visits through video/audio platforms can substitute for some in-person visits in remote areas, but at least one in-person visit per year is required for patients on chronic opioid therapy. 1