Pregabalin and Gabapentin for Neuropathic Pain and CRPS

Pregabalin and Gabapentin for Neuropathic Pain and CRPS

 
By Brett R. Stacey, MD, and Pamela Campbell, MD
Comprehensive Pain Center, Oregon Health & Science University, Portland, Oregon

Recently, pregabalin (Lyrica®) was approved by the Food and Drug Administration (FDA) for the treatment of post herpetic neuralgia (PHN) and painful diabetic peripheral neuropathy (DPN). Pregabalin has a chemical structure similar to gabapentin (Neurontin®), a medication originally developed to treat seizures that is now widely used to treat many varieties of neuropathic pain including CRPS. Both medications reduce pain by normalizing overactive pain pathways. Pregabalin is the first drug ever approved in the United States for two different neuropathic pain conditions. We believe it will be an important treatment option for many patients with CRPS. 

Gabapentin has been a great advance in treating CRPS and neuropathic pain. In addition to its effectiveness, it is very safe, with no reports of fatal overdose or organ failure. However, it does not work for everyone and sometimes the side effects are very bothersome. Does pregabalin offer an improvement?

There are currently at least six large studies with pregabalin for the treatment of PHN and DPN. In these studies pregabalin shows up to a 50 percent decrease in pain scores. This is better than the roughly 30 to 40 percent reduction in pain scores observed in the trials of gabapentin for the same indications. In addition to pain relief, patients treated with pregabalin report improvements in sleep, mood, and day-to-day function. Because of its longer half-life, pregabalin can be dosed on a twice a day schedule. (Gabapentin is dosed three times a day.) At high doses, much of the gabapentin is never absorbed from the bowel, whereas pregabalin is easily absorbed at all doses, making for more predictable dosing. Data suggest that pregabalin can begin reducing pain as quickly as one day after it has been started. This is quicker than ever reported with gabapentin. Finally, preliminary results from a study of patients with neuropathic pain who had not responded to gabapentin and two other medicines shows that even in those patients, pregabalin can provide significant relief. The majority of patients in this study (who had PHN and DPN) strongly preferred pregabalin to gabapentin.

In addition to neuropathic pain, pregabalin has been shown to be effective in fibromyalgia pain, the pain after spinal cord injury, and anxiety. 

Pregabalin comes in 8 dosage strengths from 25mg up to 300mg. All capsule sizes are the same price Roughly 1,800 mg of pregabalin is approximately $90, while pregabalin twice a day for all doses is around $118.

Gabapentin and pregabalin have similar side effects. The most common are dizziness and sedation. Patients placed on gabapentin usually experience side effects as they titrate slowly up to an effective dose, which is roughly 1,200 to 3,600 mg per day. Conversely, for patients taking pregabalin the typical starting dose of 150 mg per day can be helpful.. The range of effective doses is 150 to 600mg per day. For both medications, side effects tend to decrease over time. Less common side effects include peripheral edema and weight gain especially when taken in combination with oral hypoglycemics.

Pregabalin is categorized by the FDA as a schedule V drug, the lowest level of surveillance from the FDA. This means it is a controlled substance.

The earliest reports of gabapentin's use in treating pain were case reports of a few patients with CRPS who improved with gabapentin. Unfortunately, there have never been larger, controlled studies that definitively prove the benefits of gabapentin. As of yet, there are no studies in CRPS for pregabalin. CRPS and all other nerve pathology other than PHN and DPN are considered off label since studies in nerve pain have only been done in these specific conditions. 

Our clinical experience

Here at Oregon Health & Science University, we have 8 years of research experience with pregabalin and since September of 2005 many of our patients have received it. Almost every patient converted to pregabalin from gabapentin prefers pregabalin either because of improved pain control or fewer side effects. Some patients have pain relief immediately. As everyone reading this knows, treating neuropathic pain is challenging, so pregabalin certainly doesn't work for everyone. Our experience coupled with the extensive research supporting its use in other painful conditions makes us optimistic that pregabalin will prove to be a valuable tool in treating CRPS.

Updated August 14, 2006

 

12http://rsdsa.org/Research_Articles/stacy_campbell_pregabalin_gabapentin.htm 

Q & A About Methadone (RSDSA-Reviewed 10/09/2006)00

                                     Q & A About Methadone

By Lynn R. Webster, MD, FACPM, FASAM
Medical Director, Lifetree Pain Clinic
Medical Director and CEO, Lifetree Clinical Research, Salt Lake City, Utah 

Q. What are methadone's benefits and potential dangers?
Research demonstrates that methadone can be effective in treating some forms of neuropathic pain but also requires specific knowledge to use safely. Several states have recorded increases in accidental overdose deaths, many of them involving methadone. More research is needed into the exact reasons for the deaths, but at last some contribution appears to be tied to methadone prescribed for pain. There is difficulty in analyzing methadone's distinct contribution because lethal blood levels may vary depending on the decedent's degree of opioid tolerance, the severity of chronic pain and the action of polydrug combinations. Levels of methadone typically reported as a cause of death may actually be therapeutic in some chronic pain patients on long-term methadone therapy. Regardless, methadone does present some unique pharmacologic properties that need to be understood to utilize it safely. 

Q. What should a clinician know about methadone before prescribing it for pain? (YES, pain, not "just" addiction, as if that is to be taken any more lightly!!!)

 
Pain experts typically administer opioids in the belief that patients quickly develop near complete tolerance to respiratory depression. Research is beginning to indicate that clinicians may underestimate the risk of respiratory depression, particularly in the initial conversion to methadone. Methadone is eliminated from the body at a slower rate than many other opioids. Its long, variable half-life averages around 48 hours but can be up to 100 hours. Methadone's properties increase its potential for polydrug interactions. 

Also, if patients defy medical direction and escalate methadone doses in an attempt to control their pain, the results can be lethal.

Q. What is methadone's relationship to sleep?

 
Methadone-related deaths may be influenced by a patient's dosing schedule, including time of the last dose of the day in relation to the onset of sleep. In particular, the presence of sleep apnea appears to pose a risk: New research suggests a relationship between doses of methadone and increased incidence of sleep apnea, particularly in combination with benzodiazepines. If patients are at risk for sleep apnea, clinicians are advised to obtain a sleep study to determine whether patients require supplemental oxygen, continuous positive airway pressure (CPAP) or some other support to safely consume methadone for pain.

Q. What is the safe approach to an initial dose of methadone?
Clinicians are advised to start methadone therapy with a low dose and titrate slowly to an analgesic effect. Published conversion tables are inadequate in giving equianalgesic doses of methadone compared to other opioids. Cross tolerance from other opioids to methadone is incomplete, and the tables are designed for a single dose, not for chronic administration. The result may be a recommended starting dose that is too high.

For now, safe practice supports starting methadone with a ceiling dose of no more than 20 mg/day (10 mg/day for elderly or infirm patients). Dose changes should not occur more often than weekly to allow a steady state of methadone to develop and for the peak side effects to become clear. For patients who are being converted from another opioid to methadone, clinicians should slowly titrate downward the other opioid as they slowly titrate methadone upward. This practice will minimize the risk of withdrawal and the risk of overdose involving either methadone or a combination of the two opioids.

These guidelines represent a more conservative recommendation than seen elsewhere. Certainly, some patients are able to tolerate a much more rapid conversion or titration. Nevertheless, given the reports of deaths associated with methadone, these starting guidelines should help clinicians ensure patient safety and give methadone pain therapy a greater chance of success.

Q. How should patients be counseled?

 
Patient counseling must include an emphasis on following all medical instructions to the letter: no escalation of doses and no mixing of methadone with other prescriptions, alcohol or illicit substances. Patients should be warned that any deviation in this regard can be dangerous, even fatal.

Patients should be apprised of the danger of taking anyone else's prescriptions and of the need to lock up all prescription opioids to prevent them being stolen or consumed by others.

References

Center for Substance Abuse Treatment, Methadone-Associated Mortality: Report of a National Assessment, May 8-9, 2003. CSAT Publication No. 28-03. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2004. Available here.

Webster LR. Methadone-related deaths. J Opioid Manage. 2005;1(4):211-217.

Webster, LR, Fakata, K. Sleep Apnea Associated with Methadone and Benzodiazepine Therapy Presented at the American Academy of Pain Medicine 22nd Annual Meeting, February 22-25, 2006, San Diego, CA. Poster 165.

RSDSA Review.

Updated October 9, 2006

http://rsdsa.org/Treatment/webster_methadone.html

Weighing the Results: Patients and specialists share stories about Hyperbaric Oxygenation Therapy

Stories of Hope

Weighing the Results: Patients and specialists share stories about Hyperbaric Oxygenation Therapy By Patricia McAdams   While Hyperbaric Oxygenation Therapy (HBOT) promises relief to many individuals with Reflex Sympathetic Dystrophy (RSD) and Complex Regional Pain Syndrome (CRPS), everyone's experience with this therapy is different. Glenn J. Shamdas, 48, who has had CRPS for seven years, tried HBOT because of a recommendation from a friend after she received a complete remission. He was not helped. "I had a total of 20 sessions in four weeks - which is a commonly prescribed schedule. Unfortunately, in my case, no significant improvement was experienced." Dana Marsolino, 52, who was in two bad car accidents and is still in a lot of daily pain, found no relief either. "I tried the hyperbaric chamber four times and had to quit due to my bad shoulders and neck," she says. "I could not tolerate lying inside [the chamber] for that length of time, no matter how they adjusted the pillows." Laura Rentsch, 45, has a somewhat complicated story. She had 20 sessions over four weeks, but endured considerable side effects. "During the dives I would experience deep pain in my RSD leg that would subside when we got to the final depth. I would also experience vertigo frequently after the treatment." Rentsch said that her swelling calmed down and she had better range of motion in her foot for some time, but she had also been given two Pamidronate treatments prior to the HBOT. Pamidronate helps with constant deep bone pain and she believes this drug did help her. "Ultimately I cannot say the HBOT helped me, but I can't say that I would not recommend it to others. It may very well have helped me, but other contributing factors that lead to less swelling and better range of motion need to be considered. My treatments occurred during the summer and I generally have lower pain levels and better range of motion during warmer weather. And the Pamidronate did reduce the bone pain." Susan Rodriguez, who has been a certified hyperbaric specialist from San Bernardino, Calif., for many years, says that she has not heard of this problem before. Vertigo is an extremely unusual side effect. She suspects it may have been triggered if a patient had an underlying vestibular problem to begin with. It may have been a result of Rentsch's reaction to the Pamidronate. It could also be the result of compression or decompression or other underlying factors. Indeed, Rentsch had a severe reaction to the Pamidronate. It caused sudden hearing loss and extreme tinnitus - a loud roaring motor sound in her ears. Certain powerful medications, particularly those given by IV, as Pamidronate was given to Rentsch, can literally poison the ears of genetically susceptible individuals. Ear poisoning can affect one's hearing or balance, or both. In this case, it is possible that an underlying vestibular problem may have been present. A more common side effect of HBOT is claustrophobia. For some, like Deb Brown, 60, of north central Florida, claustrophobia was too big a hurdle to overcome. One session was quite enough, she says. There were only two very small sections of clear plastic in the particular chamber she was in that she could look out of during the session. "I dare say it felt like it had done some good," says Brown. "Perhaps had I been sedated with an extremely light sedation, I would have handled it better." According to Allan Spiegel, M.D., Palm Harbor, Fl., the claustrophobia problem is minimal for most of his patients, because his chambers are like clear glass. Still, about 10 percent of his patients struggle with this problem, as Brown did. He gives them sedation, however, if they need it. "Mild sedation works wonders," he says. "But one of my patients overcomes the problem by closing her eyes after she lies down on the cot, before being wheeled into the chamber. For some reason that makes a difference," he says. "And then we put some calming music on." There are several kinds of chambers used for HBOT. Spiegel uses Sechrist chambers in his medical center. Rodriguez, however, prefers Gulf Coast chambers, which she says are somewhat larger. Patients can sit in these chambers and they will be very comfortable. These chambers are 13 feet long and five feet around. "No one has ever become claustrophobic in our chambers  because of the large size," she adds. While the effectiveness of this therapy may vary from individual to individual, for some, it has been a Godsend. Tanya Kee, now 33, had a knee injury in 1999, followed by surgery, which made the knee worse. She developed RSD in her leg, which put her into a wheelchair. About three years after her original injury, Kee learned about HBOT and went through 56 sessions with success for her right lower leg and foot. "Probably within a half dozen dives, I noticed a difference," she says. "Even my friends said that I looked amazing," she added, noting that oxygen affects so much of the body. Kee's leg improved slowly, but steadily. "After about two months I went from being in a wheelchair for the most part, to walking and being able to lead a much better life." Unfortunately, she had to stop therapy because she sustained a new injury to her arm at this time that caused her RSD to spread to her arm, neck, back, neck and right side. She said that HBOT increases blood flow in muscles and makes her muscles too painful. "Prior to that, though, it was a great experience," she says. "My leg has not worsened since then. It's still painful, but I don't use my wheelchair unless we go to Disney or places where we do a lot of walking." Elsie Eten, age 57, had suffered with RSD for nine years before she learned about HBOT. Eten, who Spiegel calls his "Poster Child," (See: Hyperbaric Oxygenation Therapy: Can it relieve your pain?) had endured years of medical procedures before she met Spiegel and began treatment. "I was at a point in my life with the RSD and pain that I was ready to try anything, or I was ready to die, because I could not take the pain anymore. "After the first few days I could feel the difference," she says. "I was feeling better, the pain was less, and I was taking less pain medication. "After four weeks, I was pain free for the first time in eight or nine years. I slowly quit taking Oxycontin, Loratab, and Zanax. About two weeks later - six weeks after I began therapy - I was pain free and drug free. I could not believe it! "I wanted to go back to nursing so badly that I think I went back too soon. As soon as I was off my medications I went back to work without getting my body back into shape and strong. After a month at work, my pain started to come back. After three months, I had to quit my job because of my pain. I had to start taking Laratab again too." Eten says she goes for HBOT treatments every five or six months and it still helps. She is unable to work, but she is able to go out with her husband sometimes and see friends. "Even though I am not cured of RSD, I feel like I got some of my old life back. I recommend HBOT for RSD. My doctor told me when you have chronic pain, it takes a lot of different modalities to keep the pain at a manageable level and I believe that." Connie Waltz, director of nursing at the Robert M. Lombard Medical Center in Columbia, Pa., where Eduardo Pace is being treated (See: Beyond Pain: Some hope for healing), has treated a number of individuals with RSD. "Absolutely, I would recommend Hyperbaric Oxygenation Therapy for RSD," she says, adding that the sooner a person starts HBOT after they have been diagnosed, the better. Patients who have had RSD for a long time are tough to treat. The two patients they had, who were newly diagnosed, had especially good results. "One person stopped after 10 treatments, because of financial reasons," says Waltz. "She saw amazing results. She could open her hand and use it. The swelling went down. The natural pink color returned, instead of a dusky blue. "The other person had it in his shoulder," she says. "Within 20 treatments, he had range of motion." Hyperbaric Oxygenation Therapy appears to be one more tool in the toolbox of managing chronic pain for many individuals. Like Spiegel and Waltz, Rodriguez is passionate about the ability of Hyperbaric Oxygenation Therapy to make a difference for patients with RSD. "RSD can shatter your life," she says. "Mothers can't be mothers. Husbands can't support their families. Kids can't lead normal lives. And no one believes you about the pain. "People's lives depend on this therapy," she says. "Integrated with other ongoing therapies, it holds real promise."

Pain Management from your STATE (well, the docs? From my perspective, I have had like one good one...lol, so there you have it! You aren't the only ones getting wet guys.

Pain Management

The legislature passed Engrossed Substitute House Bill 2876 during the 2010 legislative session. This bill directs five boards and commissions to adopt rules concerning management of chronic noncancer pain. These boards and commissions include the Medical Quality Assurance Commission, Nursing Care Quality Assurance Commission, Dental Quality Assurance Commission, Board of Osteopathic Medicine and Surgery, and Podiatric Medical Board.
The professions include:

• Physicians
• Physician Assistants
• Osteopathic Physicians
• Osteopathic Physician Assistants
• Advanced Registered Nurse Practitioners
• Dentists
• Podiatric Physicians

The boards and commissions are committed to protecting and improving the health of people in Washington State. Overdose deaths and hospitalizations involving prescription opioid analgesics are increasing. Washington State has a higher death rate associated with opioids than the national average.
Each board and commission has adopted their final rules and the department has officially filed the adopted rules.
The goal of the new pain management rules is to keep patients safe and give practitioners who prescribe opioids the best practices in pain management. A key component of the rules is to encourage practitioners to become better educated in the safe and effective uses of these powerful drugs. The rules contain specific mandatory elements required by the law, as well as guidance for practitioners who care for patients with chronic noncancer pain.
Some of the key points for the new rules include:

• A dosing threshold trigger for consultation with a pain specialist
• Criteria to be considered a pain specialist
• Elements for a patient evaluation
• Periodic review of a patient’s course of treatment
• Guidance for episodic care practitioners
• Consultation exemptions for special circumstances and for the practitioner
• Continuing education

Please join our interested parties list to receive email notifications about the pain management prescribing rules. If you already belong to a listserv for one of the professions listed above, you do not need to join the pain management listserv. We will send the information to those interested parties lists as well.  

http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement.aspx

Adopted Rules

Medical Quality Assurance Commission

Adopted rules - Effective 1/2/2012

Nursing Care Quality Assurance Commission

Adopted Rules - Effective 7/1/2011

Dental Quality Assurance Commission

Adopted Rules - Effective 7/1/2011

Board of Osteopathic Medicine and Surgery

Adopted Rules - Effective 7/1/2011

Podiatric Medical Board

Adopted Rules - Effective 7/1/2011

http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/AdoptedRules.aspx

Will these rules impact all types of pain management?

No. The rules do not apply to the treatment of chronic cancer pain or acute pain caused by an injury or a surgical procedure. The rules also do not apply to palliative, hospice, and other end of life care.

Why is the state doing rules?

The 2010 legislation requires five boards and commissions that regulate seven professions to adopt new rules related to chronic pain management. Three boards and commissions must also repeal current pain management rules. These boards and commissions have separate disciplining and rulemaking authority. The legislation requires rules for each profession. Rules are enforceable, unlike guidelines that are suggestions.

Why is this important?

Pain management is a dynamic and challenging area of medical care. This care often includes the use of opioids. Overdose deaths and hospitalizations involving prescription pain medicine have increased in Washington State over the past 16 years. In 2009 there were 17 times more deaths and seven times more hospitalizations than in 1995. The legislature is concerned about the health risks of managing chronic, long-term pain, and in 2010 passed Engrossed Substitute House Bill 2876 in response to these concerns.

What professions must comply with the rules?

The legislation specifically names the Medical Quality Assurance Commission (MQAC), Nursing Care Quality Assurance Commission (NCQAC), Board of Osteopathic Medicine and Surgery (BOMS), Dental Quality Assurance Commission (DQAC), and Podiatric Medical Board (PMB).

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When are the rules effective?

The rules for osteopathic physicians, osteopathic physician assistants, dentists, advanced registered nurse practitioners, and podiatrists are effective July 1, 2011. The BOMS, DQAC, NCQAC, and PMB are the boards and commissions that adopted these rules. The rules for physicians and physician assistants are effective January 2, 2012. The MQAC is the commission that adopted these rules.

What about existing rules?

Three boards and commissions (MQAC, BOMS, and PMB) must repeal existing pain management rules. The repeal effective dates for each of the boards and commission are the same as the effective dates for the new rules.

What about other professions who also prescribe?

There are other professions with prescribing or dispensing authority, such as optometrists, veterinarians, and pharmacists. The 2010 legislation did not require those professions to adopt rules on this subject.

What was the process to create these rules?

The five named boards and commissions each appointed two representatives to form a workgroup. The workgroup developed pattern rules for consideration by each of the boards and commissions. The workgroup conducted five open public meetings and provided opportunities for the public to provide comments. Each of the five boards and commissions considered the draft pattern rules and filed proposed rules in January and February 2011. Five public rule hearings were held in March and April 2011. Each board and commission adopted final rules after their hearing.

Why did the workgroup contain just these professions?

The workgroup was comprised of representatives from the five boards and commissions required to adopt rules. The 2010 Legislature did not require other professions to adopt rules on chronic pain management. The workgroup and the department did recognize the very important role that pharmacists and other professions have in this subject matter and input was sought from other professions and stakeholders.

http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/Background.aspx#1

Why is there a requirement to consult a pain specialist?

The law has several requirements for the rules that are built around consultation with a pain specialist. These include a dosage amount that must not be exceeded without consulting a practitioner specializing in pain management, circumstances when this dosage amount may be exceeded without the consultation, and rules regarding consultation with a practitioner specializing in pain management.

Are there practitioner exemptions for the consultation requirement?

Yes. The rules describe the specific criteria to be an exempt practitioner or to be considered a pain specialist. You are encouraged to consult your legal counsel for practice-specific questions.

For my patient who has been on a dosage regimen higher than 120 mg MED, do I have to consult with a pain specialist?

Not necessarily. The rules provide exemptions for exigent and special circumstances. You must document adherence to all standards of practice defined in the rules for your profession and the patient is following a tapering schedule, or requires treatment for acute pain, or you document your reasonable attempts to obtain a consultation, or you document that your patient’s pain and function is stable and the patient is on a nonescalating dosage opioids.

Will I receive a certificate to show that I am an exempt practitioner or a pain specialist?

No. The rules do not require that you submit proof to anyone that you are exempt or a pain specialist. The rules only require that you meet the required criteria. Practitioners should always retain documentation that shows they meet education, training, or CE requirements.

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Who is going to pay for a required consultation with a pain specialist?

The boards and commissions do not have jurisdiction or authority over insurance coverage or who will pay for care. The rules do not address this topic.

Is there a list available of the pain specialists in the state?

No. Licenses are issued by profession and not by specialty. The department does not have a list of pain specialists.

There are not enough pain specialists in the state. How is this going to work?

This is a concern for the boards and commissions. For this reason, the rules contain options and exemptions related to the consultation requirement.

Why aren’t face-to-face consultations required?

The boards and commissions understand the challenges that patients and practitioners in rural areas face when attempting to obtain care. The rules intend to provide for flexibility for patients and practitioners in rural or remote locations. The law requires that the rules minimize the burden on practitioners and patients. Requiring only face-to-face consultations would have placed a greater burden on practitioners and patients.

Why is an advanced registered nurse practitioner (ARNP) listed as a pain specialist; but a physician assistant is not included in the list?

ARNPs are independent practitioners. PAs are not independent practitioners and work under a supervising physician or osteopathic physician. The rules do not restrict PAs from providing pain management care under the supervision of a pain specialist.

Continuing Education

Is there a grace period to obtain the continuing education required to be exempt or a specialist?

 No. The boards and commissions determined that the required continuing education (CE) is attainable within a short period of time.

 Will the continuing education be monitored?

No. But, the disciplinary authorities do conduct random audits on practitioners to ensure the CE requirements are met. You may be asked to provide copies of completed CE and should always retain these records.

If I took continuing education on pain management three years ago, do I have to take it again in the next three to four years?

Yes. The continuing education must be completed within the last two years for physicians, dentists, ARNPs and podiatrists. Osteopathic physicians must complete the CE every three years which is the CE cycle for this profession.

How much continuing education is required and how often?

It depends upon your profession.

• All of the professions included in the rules require 12 hours within the last two years in order to be exempt from the consultation requirement. At least two of these hours dedicated to long acting opioids.
• Osteopathic physicians have a three-year CE cycle. They may complete 18 hours within the last three years.
• The rules suggest a one-time (lifetime) completion of at least four hours of CE related to long-acting opioids or methadone. This is included in the rules because the boards and commissions believe it is important that practitioners who prescribe opioids should be familiar with its risks and use. 

http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PainManagement/FrequentlyAskedQuestionsforPractitioners/ContinuingEducation.aspx

Why do the rules set a morphine equivalent dosage (MED) amount?

The law requires that the rules must contain dosing criteria to include a dosage amount that must not be exceeded unless the practitioner either consults with a practitioner specializing in pain management or the prescriber or patient are exempt. An MED is used because one drug is not necessarily the same as another. One drug may need a higher dosage amount than another to achieve the same result.

What table should I use to determine the daily morphine equivalency dose (MED)?

The rules include a generally accepted definition for MED. The boards and commissions determined to not include a conversion table in the rules. Technology, knowledge, and medication changes occur frequently. Conversion tables could quickly become outdated. The boards and commissions believe practitioners should be able to decide which conversion table to use. The Washington State Agency Medical Director’s Group (AMDG) provides information on dosing guidelines. Please see the pain management webpage for resources like the AMDG.

Is there a separate MED for children?

No. The legislation does not specify any specific patient population. The rules were clarified to indicate that the 120 mg MED is for adults and based on an oral dose. The rules further indicate that great care should be used with prescribing opioids to children and that appropriate referral to a specialist is encouraged.

If I prescribe below 120mg MED for a patient, do I need to consult a pain specialist?

No. The mandatory consultation threshold for adults is 120mg MED. A consultation with a pain specialist is required if the prescribed dosage amount exceeds 120mg MED orally per day, unless the consultation is exempted. The exemptions are listed in the rules.

If a patient has been at 140 mg MED for several years, do I need to consult a pain specialist?

No. For a patient with stable pain and function, on a non-escalating dosage of opioids, the consultation requirement would not be required as long as the practitioner documents these items.

Are there exemptions to the consultation requirement?

Yes. The exemptions are listed in the rules under two sections: Consultation – Exemptions for exigent and special circumstances; and Consultation – Exemptions for the (specific practitioner profession named), for example “dentist”, “physician”, etc.

Other Frequently Asked Questions

Do the rules include a prescription monitoring program (PMP)?

No. The pain management legislation requires the boards and commissions to include guidance on tracking the use of opioids. In 2007 the legislature authorized the Department of Health to develop and implement a PMP when funding is available. The department recently received a grant and is developing a PMP. The rules include references to the use of any available PMP or emergency department-based information exchange.

I would like to have a conversation with someone about these rules. Who can I contact?

We encourage you to review the rules and the FAQs. If you have general questions, please email them to painmanagement@doh.wa.gov. You can also call 360-236-4997. You may also send technical profession questions to us and we will direct them to the appropriate board or commission. For situation specific questions related to your practice, we encourage you to speak with your legal counsel.

Will the state monitor or audit individual practices?

No.

How can I stay informed about implementation of these rules?

We have created a pain management listserv and website to keep people informed. You can join this listserv, or the listserv for one of the named professions, to receive regular emails about the pain management. You may also send questions to painmanagement@doh.wa.gov.

Rule Content - General

Why is “should” used sometimes and “shall” used at other times?

The law requires that the rules contain certain mandatory elements and provide guidance for other elements. For this reason the rules have requirements for some areas and guidance or recommendations for others. “Shall” is used to mean “has a duty to,” that is, to require the performance of the act. “Should” is used to mean a recommendation or guidance for the act.

Is there a grace period before practitioners must comply with the rules?

No. The requirements begin when the rules are effective.

So folks, we are all under heat: the docs are looking at this invasion of their previously respected autonomy.  Respect, and then you get caught in the middle.  And as for me, " my dope, " what makes me well, seems to lie elsewhere.

But to those who are coming into frustrating arenas when pain docs are forced to put previously reliable and nonproblematic patients on "contract" it isn't "always" of their own doing.

I got my medical card because I don't want the State OR Federal Government involved in something they don't give a shit enough about except to throw stuff at that probably long term, likely will cause some serious problems.

To follow, Washington's new FAQ on pain management for patients, a few odds and ends: who said it was a free country: 

Oh, God: sorry folks, a violation-cuz even TRAMADOL (R) falls into this, ketamine, all of it-ONE LIST I INTEND TO STAY THE HECK AWAY FROM ASAP!!! SOON!!!!

Prescription Monitoring Program (PMP)

Legislation in 2007 gave the Department of Health authority to create a Prescription Monitoring Program. The program’s purpose is to improve patient care and stop prescription drug misuse by collecting all the records for Schedule II, III, IV, and V drugs. This information is then made available to medical providers and pharmacists as a tool in patient care. The state law creating the program is RCW 70.225.

The program is a patient safety tool. Practitioners will have access to the information before they prescribe or dispense drugs. This will help to prevent overdoses, prevent misuse, and promote referrals for pain management and for treatment of addiction.

The program rules (WAC 246-470)  became effective on August 27, 2011.

The program started data collection from all dispensers on October 7, 2011.

Providers can now register at http://www.wapmp.org/practitioner/pharmacist/.

PMP Legislative Changes

Substitute Senate Bill 6105 (2012) was signed into law on March 29, 2012. The bill requires the department in collaboration with the veterinary board of governors to establish alternative data reporting requirements for the Prescription Monitoring Program by either electronic or non-electronic methods.

Information about the rulemaking and how to participate is available on the rules page.

Veterinarians are required to report to the Prescription Monitoring Program until June 7, 2012. We encourage continued reporting until the permanent rule is adopted.

Effective June 7, 2012, the bill also clarifies that controlled substances dispensed for one day use do not have to be reported to the PMP.

For more information, please contact Chris Baumgartner, Program Director, at 360-236-4806 or prescriptionmonitoring@doh.wa.gov.

Links Box

• Practitioner Query Site  http://www.doh.wa.gov/PublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP.aspx

Well, I am sorry guys, but if this crap doesn't seal your desire to get off this garbage, then uh, well, I am sticking with smoking legal dope with my friends (not on my property thanks, long story, very and equally stupid.

Do you need some hack watching every trip you make to the drug store....what if you buy Sudafed?  Well, enough of that: you end up watched in my area by police.  Yeah, it's a dangerous world.  I am sticking with what works.  So hang tight.  Lock it all up.  I mean it.  Don't mess around.  If you have to take this, and can't get on and into something like using medical marijuana?  Do yourself a favor...and just well, make sure it has a combo, and a key.  People get very desperate, and having been the type that would help someone out when I began this journey, it was educational.

I knocked off all but the PRN for the winter.  And it sits in it's hiding place, untouched for almost a month...the rest, I dumped.  I don't need the headache and hassle, or what it does to the body and mind over time, necessary or not.  Consume  THC?  Every chance I get.

Just not at home, hmmm. Stupid, eh?

While maybe it doesn't work for FB, maybe, doubtfully, it will here

Of course, I probably wasted my time with that.

Not that they ever pay attention to it.


Well, as long as free speech is still legal....and I remember to cite my sources...

I might settle for being LEFT ALONE except by RSD/CRPS patients who want to learn~or a friend here for a visit....

A Surviveable III? Hmm this RSDer got CASED again...glad I switched to something else

Shockingly, this seems to have had moved into adults now: one anyhow.  Who wanted dope real bad. Sent a list via email of what I took at the time just to see what she would say.  The response all the more inspired me to turn to the magic plant, as my friend {Name withheld, per request} calls it (formerly agoraphobic, poor guy has to go unmedicated for bloody nine months: el zippo, unless he wants prozac shoved down his throat.  I don't think anyone here wants to see what psych meds did to this body. After the RSD developed...

Well, I at I ate as many calories/protein, smothie/shakes until I couldn't anymore: it is what likely saved me from looking worse than now.    But nevertheless, turns out that doctors don't just pray on the sick.  So do people.

 omeone, unnamed, I got the email (to follow in Word format with Id info removed-even though my feelings, privacy, person, etc was completely violated, and lied to for drugs basically, as you will see, since it reads in part (see, she is in bad pain now-cuz I won't "help" and my new phone isn't listed, etc, and well, see for your self.  I formed this because this is one way that I have gotten screwed:  people find out you have a shitty disorder like this: like any of us have: Deb, Kat's and it is so retarded. 

I would rather throw some hash in a bowl, and smoke it amongst friends.  And really, I am finding out who they really are.  They are the ones who, for example: compare who is the first and the last to wish you a Happy Birthday? 

That was my decision just a few months ago, beginning treatment with medical marijuana.  I made the following video, later on, about fourreen days ago; i was locked out for a while folks, so we have some catching up to do!!!!

What order does it come in?
More importantly, what unique waus do they do to say  it???  To some in my life, well, they screwed the pooch.  I am so sorry to say this (not) but I have about had it with doctors! Well, screw it.  This winter ends, I am done.  I hope to have secured (this isn't a joke, and no it's not to "get high."  Call it self preservation and the need to STAY healthy by not going to a doctor.  I went to the damn doctor when RSD full body wrecked my vagus? LOL, funny, you guys watched while I got worse.  HELLO.  I signed out of the damned hospital.  Done.  I wrote that last day in my former apartment that I couldnot wait to get off this crap so people won't case me.  Guess what.  One down.  Weed.  I only want the fine work of Mr Rick Simpson.  Right on!  This is not a joke.    

This is what the Rick Simpson Oil product looks like.  I use a 67% strength.  The following link discusses CRPS in greater context. I am healthier and happier.  I don't want to discuss it anymore.  Anything further for me?  Is unnecessary.  Your dope, whatever that is: ketamine, or combinations to minimalize discomfort...

The way I see if is we have a disease that violates enough of God's laws, and with every treatment being considered experimental?  I am on disability and would rather cut out things like cable tv so this can be possible for me.  Someone I still think is an ass was correct about ONE thing:  You can choose your health.  It's not unreachable to get legal (if you reside in one of the growing number, 17 so far!!!) and in my own opinion, if you are going to be a lab rat, shouldn't you at least have a choice.

Make it all available to every RSD patient in every state-whether MMJ is legal or not, make a damned exception.  The suffering I see amongst friends makes me sick.  But when their 'dope' has to be something that keeps them miserable, depressed, I admire those still hopeful.  But too sad for them to want to hang out on FB long.

I do things like hang out at a friend's.

Starting PT.

So for me?  Who knows, is it "the dope?"  Seens to be, so I hope folks fine something for themselves.   fast and soon.