{"data":{"id":"us-va/18vac90-40-190","jurisdiction":"us-va","citation":"18VAC90-40-190","heading":"Treatment of chronic pain with opioids","body":"A. Nonpharmacologic and non-opioid treatment for pain shall be given consideration prior to treatment with opioids.\n\nB. In initiating opioid treatment for all patients, the practitioner shall:\n\n1. Carefully consider and document in the medical record the reasons to exceed 50 MME per day;\n\n2. Prior to exceeding 120 MME per 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;\n\n3. Prescribe naloxone for any patient when risk factors of prior overdose, substance misuse, doses in excess of 120 MME per day, or concomitant benzodiazepine are present; and\n\n4. Document the rationale to continue opioid therapy every three months.\n\nC.  Buprenorphine mono-product in tablet form shall not be prescribed for chronic pain.\n\nD. Due to a higher risk of fatal overdose when opioids, including buprenorphine, are given with other opioids, benzodiazepines, sedative hypnotics, carisoprodol, and tramadol (an atypical opioid), the prescriber shall only co-prescribe these substances when there are extenuating circumstances and shall document in the medical record a tapering plan to achieve the lowest possible effective doses if these medications are prescribed.\n\nE. The practitioner shall regularly evaluate for opioid use disorder and shall initiate specific treatment for opioid use disorder, consult with an appropriate health care provider, or refer the patient for evaluation for treatment if indicated.","path":["Title 18. Professional And Occupational Licensing","Agency 90. Board of Nursing","Chapter 40. Regulations for Prescriptive Authority for \nAdvanced Practice Registered Nurses","Part VI. Management of Chronic Pain"],"source_url":"https://law.lis.virginia.gov/admincode/title18/agency90/chapter40/section190/","current_through":"2026 Regular Session (effective July 1, 2026)","vintage":"","retrieved_at":"2026-09-14T04:52:53Z","sha256":"c8267138371e0675b18e59b7c84085c5d22def0a8501c099547826e3c7034ca1","source_id":"us-va-vac","stale":false,"prev":"us-va/18vac90-40-180","next":"us-va/18vac90-40-200"},"notice":"GroundRules: Original legal text. Not legal advice."}