Published on Jun 10, 2026
Annette Graham, MS, APRN, ANP-BC, Probable Cause Reviewer/Agency Subordinate, Virginia Board of Nursing
Approximately 20% of Americans suffer from chronic pain, and opioids remain a multimodal treatment option intended to enhance function and quality of life. However, considering the ongoing opioid epidemic, the Virginia Board of Nursing (BON) and Board of Medicine (BOM) have established specific regulations to ensure patient safety. Navigating the complexities of chronic pain management requires a delicate balance between clinical efficacy and regulatory compliance. This article summarizes the Regulations for Prescriptive Authority for APRNs (18 VAC 90-40-10 et seq., revised 11/6/2024). You can access the full text via the "Practitioner Resources" section on the Virginia BON website: Virginia Board of Nursing - Laws Regulations
It is important to note that these specific regulations do not apply to the treatment of cancer-related pain, sickle cell anemia, patients in hospice or palliative care, patients enrolled in clinical trials and inpatient treatment in a facility using a sole pharmacy.
The information provided here is intended to assist APRN’s in applying these regulations in clinical practice.
The Initial Evaluation “Setting the Standard”
Prior to initiating opioid therapy for chronic pain, a comprehensive medical history, physical exam, and mental status examination must be documented. Per 18VAC90-40-180, your documentation should include:
• The nature and intensity of pain (e.g. documented on a 0–10 pain scale)
• Location and quality of pain (sharp, dull, burning)
• Treatment History: All past and current efforts, including non-pharmacological interventions (e.g., ice, rest, massage, distraction).
• Comorbidities: Underlying conditions like arthritis, diabetes, or spinal stenosis.
• Functional Impact: How pain affects the patient’s Quality of Life (QOL), Psychological Function, and Activities of Daily Living (ADLs).
• Risk Assessment: A thorough history of psychiatric illness, addiction, and substance misuse for both the patient and their family. This may involve reviewing prior SUD treatment records, psychiatric records and legal history. The Opioid Risk Tool (ORT) is a brief, self-report screening tool designed for use with adult patients to assess risk for opioid abuse in adults in treatment for chronic pain.
• Baseline Testing: A mandatory urine drug screen (UDS) or serum medication level.
• PMP Query: A formal query of the Prescription Monitoring Program as required by § 54.1-2522.1.
Virginia regulations (18VAC90-40-200) require a documented treatment plan outlining pain relief goals, functional improvements, safety monitoring, and dosage thresholds, with specific requirements to document justifications for exceeding 50 or 120 MME/day. Additionally, 18VAC90-40-210 mandates that APRNs obtain written informed consent covering risks and alternatives, along with a signed treatment agreement detailing compliance monitoring and cessation criteria.
Periodic Review and Specialist Referrals
To remain compliant with Virginia’s regulations, managing chronic pain is not a "set it and forget it" process. The law mandates ongoing oversight to ensure that opioid therapy continues to provide more benefit than harm.
Periodic Review Requirements (18VAC90-40-220)
At least every three months, you must conduct and document a formal review of the patient’s progress. This review must include:
• Functional Assessment: Documentation of whether the treatment is improving the patient’s quality of life and ADLs, not just their pain score.
• PMP Query: A fresh review of the Prescription Monitoring Program to check for "doctor shopping" or undisclosed prescriptions from other providers.
• Medication Adherence: At least once annually, you must order a random urine drug screen (UDS) or serum medication level to verify compliance and screen for illicit substances.
• Dose Justification: If the dose remains above 50 MME/day, you must re-justify why a lower dose or non-opioid alternative is not sufficient.
When to Refer to a Specialist (18VAC90-40-230)
The regulations identify specific "red flags" or clinical thresholds that should trigger a consultation with a pain management specialist. You should consider a referral if:
• High-Dose Therapy: The patient’s daily dose reaches or exceeds 90 MME. At this level, the risk of overdose increases significantly.
• Co-prescribed Benzodiazepines: Mixing opioids and benzodiazepines creates a high risk of respiratory depression. If this combination is clinically necessary, a specialist's input is often required and highly recommended.
• History of SUD: If the patient has a known history of substance use disorder or scores "High Risk" on the ORT, a multidisciplinary approach is safer.
• Stagnant Progress: If the patient is not reaching the functional goals outlined in your treatment plan despite escalating doses.
The "Exit Strategy"
If the periodic review reveals that the patient is not meeting functional goals, is exhibiting aberrant behaviors, or the risks now outweigh the benefits, you must implement the exit strategy discussed during the informed consent phase. This typically involves a gradual taper or transition to medication-assisted treatment (MAT).
This checklist serves as a quick reference to ensure your documentation meets the 18 VAC 90-40 standards for chronic pain management in Virginia.
Virginia APRN Chronic Pain Documentation Checklist
Initial Evaluation
• Pain Assessment: Location, quality, and intensity (0–10 scale).
• History: Treatment history (including non-pharmacological) and comorbidities.
• Impact: Documentation of how pain affects QOL, ADLs, and psychological function.
• Risk Screen: Completed Opioid Risk Tool (ORT) (Score + Risk Category).
• PMP: Query of the Prescription Monitoring Program.
• Baseline Lab: Mandatory urine drug screen (UDS) or serum level.
Treatment Plan & Consent
• Measurable Goals: Clear metrics for pain relief and functional improvement.
• Informed Consent: Signed agreement covering risks, benefits, and "Exit Strategy."
• Patient Counseling: Documented discussion on addiction, overdose, and alcohol/benzodiazepine risks.
• MME Justification: Rationale if starting dose exceeds 50 MME/day.
Periodic Review (Every 3 Months)
• Functional Check: Evidence that treatment is improving ADLs and QOL.
• PMP Query: Re-query the database before every refill or at least every 90 days.
• Medication Check: Verification of current dose and non-opioid alternatives.
Annual & Safety Requirements
• Annual UDS: At least one random drug screen per year.
• Naloxone: Discuss and prescribe for high-risk patients or those >50 MME.
• Specialist Consultation: Documented referral or consultation if dose hits 90 MME.
Clinical Tip: If a patient is stable on a chronic dose, ensure your notes explicitly state why the opioid is still necessary and how it is currently improving their ability to function.
Virginia Board of Nursing