30-Med Ruling


The Board of Nursing recently adopted a new rule that creates a limited exception for APRNs to the general prohibition on prescribing opioid analgesics for the treatment of acute pain in excess of a 30 MED daily average for APRNs. The rule becomes effective January 1, 2018. The rule states that the 30 MED average can be exceeded by an APRN when both of the following apply:

  • The circumstances under which the patient’s treating physician can exceed the 30 MED daily average limit for that patient, set forth in OAC 4731-11-13(A)(3)(c), apply; and
  • The patient’s treating physician has entered a standard care arrangement with the APRN that states the understanding of the physician as to when the APRN may exceed the thirty MED average, and when the APRN must consult with the physician prior to exceeding the thirty MED average. The standard care arrangement in this circumstance must comply with rule 4731-11-13 of the Administrative Code, and the APRN must document in the patient’s record the reason for exceeding the thirty MED average and the reason it is the lowest dose consistent with the patient’s medical condition.

(OAC 4723-9-10(J)(3)(c).) This effectively means that for an APRN to prescribe in excess of 30 MED to treat a patient’s acute pain: 1) the APRN must have an SCA with that patient’s treating physician for the condition causing the acute pain; 2) the treating physician must be able to prescribe in excess of 30 MED for their patient under Medical Board rule 4731-11-13(A)(3)(c); 3) the physician must delegate his or her ability to prescribe in excess of 30 MED for their patient to the APRN; and 4) the physician has to supervise the APRN’s performance and remains singularly responsible for the prescription. Under these circumstances, prescribing in excess of 30 MED for acute pain will likely only be feasible and in compliance with the rules in an institutional setting, like hospital. The physician rule on prescribing in excess of 30 MED at 4731-11-13 is available here for reference: http://codes.ohio.gov/oac/4731-11-13.

Additionally, please note that the 30 MED daily average restriction does not apply 1) To an individual who is a hospice patient or in a hospice care program; 2) To an individual who is receiving palliative care; 3) To an individual who has been diagnosed with a terminal condition; or 4) To an individual who has cancer or a condition associated with the individual’s cancer or history of cancer. (OAC 4723-9-10(K).)

For the most up-to-date details about 30-MED rules, see our latest post.