Citing a 395% increase in unintentional poisoning from prescription pain medication between 1995 and 20091, 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 rules2. 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 opioid 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.