Washington’s New Rules Battle Prescription Drug Abuse: The Impact on Patients with Acute
Traumatic and Chronic Pain
By Janet L. Thoman, Attorney at Law
Citing a 395% increase in unintentional poisoning from
prescription pain medication between 1995 and 2009[1],
the Washington state legislature passed a law in 2010 (ESHB 2876) requiring
five different medical boards to create new rules for prescription of opioid
medication. The rules are intended to
improve patient safety and provide doctors with guidelines for prescription of
these powerful drugs.
On January 2, 2012, Washington health care providers
who are licensed to prescribe medication became subject to new rules regarding
prescription of widely-used pain drugs.
The regulatory boards for seven types of practitioners developed the
mandated rules[2]. The practitioners covered
by the new rules include physicians and physician assistants, osteopaths and
osteopathic physician assistants, advanced registered nurse practitioners,
dentists, and podiatrists. These rules
affect treatment of patients with chronic pain that is not associated
with cancer or end-of-life pain control.
The Medical Quality Assurance Commission describes the intent of the new
regulations:
The diagnosis and treatment of pain is integral to the
practice of medicine. The commission encourages physicians to view pain
management as a part of quality medical practice for all patients with pain,
acute or chronic, and it is especially urgent for patients who experience pain
as a result of terminal illness. ... This
rule has been developed to clarify the commission's position on pain control,
particularly as related to the use of controlled substances, to alleviate
physician uncertainty and to encourage better pain management.. . .
. . . The commission recognizes that controlled
substances including opiod analgesics may be essential in the treatment of acute pain due to trauma or surgery and
chronic pain, whether due to cancer or noncancer origins. The commission
will refer to current clinical practice guidelines and expert review in
approaching cases involving management of pain. The medical management of
pain should consider current clinical knowledge and scientific research and the
use of pharmacologic and nonpharmacologic modalities according to the judgment
of the physician. Pain should be assessed and treated promptly, and the
quantity and frequency of doses should be adjusted according to the intensity,
duration of the pain, and treatment outcomes. Physicians should recognize
that tolerance and physical dependence are normal consequences of sustained use
of opioid analgesics and are not the same as addiction.
Washington Administrative Code 246-919-850 (Emphasis added).
The new rules apply to drugs known as opioid
analgesics. Opioids are a class of drugs
that affect specific pain receptors in the brain. Natural opioids are derived from a specific
alkaloid in the opium poppy. There are
now many synthetic opioids as well. Common drugs within this class, and covered
by the new rules, include methadone, morphine, codeine, hydrocodone (e.g.,
Vicodin), oxycodone (e.g., OxyContin, Percocet), fentanyl and many others.
The new
rules do not apply to
prescriptions for acute pain, such as a new injury, or for post-surgical
pain. They are intended to provide guidelines
for treating patients who have chronic pain, defined as pain lasting over three
months and not related to treatment for cancer or hospice care.
Physicians will be required to keep thorough records
of a patient's history, potential for drug abuse, and the need for opioid
medication. In certain circumstances,
such as dosage over a set limit, doctors are required to consult a pain
management specialist in one of several ways.
Criteria for exemption from the consultation rule and for qualification
as a pain management specialist are also delineated.
While the new rules are intended to reduce the
incidence of prescription drug abuse and death associated with these drugs, the
range of repercussions will only be known with time. Anticipatory opinions vary from optimism that
the new rules will improve patient care and reduce addiction, to concern that
the rules will intimidate providers into deserting patients and leaving them to
suffer.
If the rules function as intended, many primary care
providers who are called upon to routinely prescribe pain medication will have
clear guidelines to follow. They can
fall back upon the regulations to discourage drug-seeking behavior and
prescription misuse. They can feel
confident that they are within specified parameters that are sanctioned by
their disciplinary boards. Knowing the
threshold at which consultation with a pain specialist is appropriate may
further reduce uncertainty and lead to better pain management for patients.
The regulations do require providers to obtain a
focused history, to thoroughly document the patient’s potential for addiction
and the need for the prescribed medication.
The provider may maintain continuing medical education credits to
qualify as a pain management specialist, but this may be an option only for a
few. Those who do not attain the
necessary level of education will be required to monitor patient care within
specified parameters and consult with a pain management specialist, either
through provider-to-provider contact or by referring the patient to a
specialist. Navigating and interpreting
the rules may be daunting in a busy practice in which multiple standards of
care must be watched at all times. An unforeseen
consequence of the new rule may be providers choosing not to treat chronic pain
patients and avoid the issue entirely.
Chronic pain patients may feel left to the mercy of
rules they do not understand. A change
in the doctor-patient relationship because of the rules may leave patients
feeling deserted and desperate if they are unable to access pain care on which
they depend. The effect on patients will
depend on the approach each provider chooses to take.
Patients who have been treated for chronic pain
arising from injury months or years in the past, and the providers treating
them, may be presented with a new opportunity to reduce or eliminate medication
by taking a new look at alternatives to opioid medication. Once a patient and doctor find an approach
that works "well enough" to improve function and reduce pain, the
treatment is often routinely followed as long as it maintains the status
quo. With a renewed focus on safe,
effective and appropriate pain care, providers can choose to take the
opportunity to reevaluate their approaches to treatment and reevaluate the
needs of chronic pain patients.
Conservative treatments, such as spinal manipulation,
massage, physical therapy and acupuncture, have been shown to be effective in
reducing pain and increasing functionality.
Even approaches still considered “alternative”, such as meditation, have
shown promise for chronic pain populations.[3][4]
Reconsideration and trial of new or previously rejected options for pain care
may prove to be beneficial to some patients.
Whether directly affected by the new rules or not, all
providers have the opportunity to offer care alternatives to a population of
patients who struggle with chronic pain and limitations. Prescribing doctors can integrate new
approaches to management of these challenging cases. Providers who do not prescribe can develop
relationships with prescribing doctors and reach out to patient populations,
educating them on what their specialty has to offer and making themselves
available to provide care where appropriate.
For some, the inability to access necessary medication
may result in reduced functionality, poor quality of life and unnecessary
suffering. For others, the new rules may
provide enough of a barrier to avoid addiction or abuse by patients or
diversion of medication by others around them.
Health care providers of all types, directly subject to the rules or
not, are likely to be called upon to assist patients with chronic pain in
different ways than in the past.
Patients suffering chronic injury as a result of the
negligence of another and who are affected by this type of regulation, or any
other insurance or regulatory barrier, should consult with an attorney
experienced in handling traumatic injuries.
The attorneys of Adler Giersch are available for consultation.
[1] National Institute on Drug
Abuse,
http://www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse,
January 19, 2012.
[2] WAC 246-919-850
(physicians), WAC 246-817-901 (dentists), WAC 246-853-660 (osteopaths), WAC
246-854-240 (osteopathic assistants), WAC 246-918-800 (physicians assistants)
and WAC 246-922-660 (podiatrists)
[3] The Clinical Use of
Mindfulness Meditation for the Self-Regulation of Chronic Pain. J Behav Med
1985 Jun;8(2):163-90.
[4] Teixiera, ME.
Meditation as an intervention for chronic pain: an integrative review. Holist Nurs Pract, 2008 July-Aug;22(4):225-34.
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