Evidence status: CURRENT HIGH-DOSE AND OVERDOSE-PREVENTION FRAMEWORK. Vermont’s opioid rule adds enhanced documentation and overdose-prevention requirements at higher doses and in opioid-benzodiazepine combinations.
Enhanced review above 90 MME
Before prescribing a dose or combination of opioids exceeding 90 morphine milligram equivalents per day, the prescriber must document a reevaluation of treatment effectiveness and safety, adherence, non-opioid alternatives, a functional examination, and review of the patient’s Controlled Substance Treatment Agreement and informed consent.
Agreement review at higher dose
The rule specifically directs the prescriber to review and make any necessary revisions to the agreement and informed consent, including pill counts and directly observed urine testing when used to monitor adherence and other substance use.
Required risk discussion
Before prescribing an average dose of 90 MME or more, the prescriber must have an in-person discussion with the patient or legal representative about increased risk of fatal and nonfatal overdose and appropriate precautions.
Naloxone requirement
The prescriber must co-prescribe an FDA-approved opioid antagonist, or document that the patient already has a valid prescription for or possession of one, when:
- One or more opioid prescriptions total 90 MME per day or more.
- An opioid prescription results in concurrent opioid and benzodiazepine use.
Special rule for certain extended-release products
When prescribing extended-release hydrocodone or oxycodone that is not manufactured in an abuse-deterrent formulation, Vermont imposes additional agreement requirements, including urine testing at least annually, more frequent VPMS checks at specified doses, and follow-up at least every 90 days.
Primary source
Reviewed: October 4, 2026.
Evidence boundary: These additional safeguards apply only when the rule’s dose or medication conditions are met. They should not be generalized into universal agreement terms for every chronic-pain patient.