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: