A Guide to State Opioid Prescribing Policies

Pain Policy and Regulation: Washington

I. Washington Statutes Mandate for Opiate Therapy Guideline

The Secretary of Health shall coordinate and assist the regulatory boards and commissions of the health professions with prescriptive authority in the development of uniform guidelines for addressing opiate therapy for acute pain, chronic pain associated with cancer and other terminal diseases, or other chronic or intractable pain conditions. The purpose of the guidelines is to assure the provision of effective medical treatment in accordance with recognized national standards and consistent with requirements of the public health and safety.

II. Washington Medical Quality Assurance Commission Administrative Regulations

• Purpose
  1. The Medical Quality Assurance Commission recognizes that effective pain management is an essential component of quality medical care and that no single approach to the treatment of pain is exclusively correct.
  2. The Commission wishes to reassure practitioners that they need not fear disciplinary action from the Commission for prescribing, dispensing, or administering opioids when treating pain so long as the care provided is consistent with currently acceptable medical practices. This includes treatment of acute, chronic, and intractable pain.
  3. Although many other medications may be appropriate in the treatment of pain, these regulations specifically address the use of opioids. As used in these regulations, the term opioid means any natural or synthetic medication that has morphine-like activity.
• What specific guidance should a practitioner follow?
  1. The Commission has adopted guidelines for the management of pain to acquaint practitioners with recognized national standards in the field of pain treatment.
  2. These guidelines specifically address the patient evaluation and treatment plan, informed consent, periodic reviews, use of consultations, and the necessity for maintaining accurate and complete medical records.
  3. These guidelines may be revised from time to time to reflect changes in the practice of pain management.
  4. Practitioners who cannot or choose not to treat patients who have complex or chronic pain conditions should offer appropriate referrals for those patients.
• What knowledge should a practitioner possess to treat patients with pain?
  
      Practitioners treating pain should be:
  1. Knowledgeable about the complex nature of pain;
  2. Familiar with the pain treatment terms used in the Commission's pain treatment guidelines; and
  3. Knowledgeable about acceptable pain treatment modalities.
• How will the commission evaluate prescribing for pain?
  1. The practitioner's treatment will be evaluated by a review of the provided care to see whether it is clinically sound and in accordance with currently acceptable medical practice regarding the treatment of pain.
  2. No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed.

III. Washington Medical Quality Assurance Commission Guidelines for Pain Management

• Introduction

  There is widespread concern among patients throughout the state about access to appropriate medical treatment, including opioid therapy, for addressing chronic intractable pain. Similarly, providers express apprehensions about challenges by state disciplinary authorities when prescribing opioid analgesics for indicated medical treatment when serving the legitimate medical needs of patients with pain. The undertreatment of chronic pain because of concerns about addiction and drug diversion affect the public health, safety, and welfare. There is a need for guidance that would encourage appropriate treatment for pain management, reduce providers' fear of injudicious discipline, and protect the public from inappropriate prescribing practices and diversion.

• Purpose Statement

  The Secretary of the Department of Health recommends the uniform adoption, by appropriate state regulatory authorities, of the following guidelines when managing pain. It is not the intent of these guidelines to define complete standards of acceptable medical care in the treatment of patients with pain. These guidelines are not intended to direct clinical practice parameters. Their intent is to give providers confidence that these guidelines are the standard by which opioid usage is evaluated.

• Policy Statement

  Under generally accepted standards of medical practice, opioids may be prescribed for the treatment of acute or chronic pain, including chronic pain associated with cancer and other noncancer pain conditions. Prescribing opioids requires special consideration. It is the position of the Department of Health that opioids may be prescribed, dispensed, or administered without fear of injudicious discipline when there is an indicated medical need.

• Guidelines for Opioid Usage
  • Acute Pain. Opioids are useful for patients with acute pain such as occurs following surgery, burn, or trauma. The goal of such treatment is to provide adequate and timely pain management to the patient. Side effects of opioids that are difficult to treat may occur and must be balanced against the benefits of pain relief. The provider should, for any patient who has a history of alcoholism or other drug addiction, carefully monitor medications and, when available, seek appropriate consultation.

  • Chronic Pain Associated With Cancer Chronic pain associated with cancer may often be successfully managed with opioids. If use of opioids is the primary analgesic strategy, adequate doses should be given frequently enough to keep the patient continuously comfortable. Addiction is rare in patients with cancer pain; tolerance and physical dependency are often unavoidable and should not interfere with opioid prescribing. Not all pain in patients with cancer is responsive to opioids; alternative strategies for managing the pain should also be made available.
  • Other Chronic Pain Conditions. Opioid analgesics can be useful in the treatment of patients with intractable noncancer pain, especially where efforts to remove the cause of pain or to treat it with other modalities have failed or were not fully successful. The pain of such patients may have a number of different causes and may require several modalities. In addition, the extent to which pain is associated with psychological, physical, and social impairment varies greatly. Therefore, the selection for a trial of opioid therapy should be based on a careful assessment of the pain as well as the impairment experienced by the patient. Continuation of opioid therapy should be based on the provider's evaluation of the results of treatment, including the degree of pain relief; changes in psychological, physical, and social functioning; and appropriate utilization of health services. Providers are encouraged to obtain consultation from providers who are knowledgeable in pain management, particularly when managing patients with a history of alcohol abuse or previous chronic opioid use.
• Definitions
  • Addiction is a disease process involving use of psychoactive substances wherein there is loss of control, compulsive use, and continued use despite adverse social, physical, psychological, or spiritual consequences.
  • Physical dependence is a physiologic state of adaptation to a specific psychoactive substance characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by re-administration of the substance. Physical dependence is not necessarily associated with full-blown addiction, and the condition does not always equate with addiction.
  • Psychological dependence is a subjective sense of need for a specific substance, either for its positive effects or to avoid negative effects associated with its abstinence.
  • Tolerance is a state in which an increased dosage of a psychoactive substance is needed to produce a desired effect.

  • Withdrawal syndrome is the onset of a predictable constellation of signs and symptoms following the abrupt discontinuation of, or rapid decrease in, dosage of a psychoactive substance.
  • Acute pain is an essential biologic signal of the potential for or the extent of injury. It is usually short-lived and is associated with hyperactivity of the sympathetic nervous system (eg, tachycardia, increased respiratory rate and blood pressure, diaphoresis, and papillary dilation). The concurrent effect is anxiety.
  • Chronic pain is pain persistent beyond expected healing time and often cannot be ascribed to a specific injury. Chronic pain may not have a well-defined onset and by definition does not respond to treatment directed at its causes.
  • Intractable pain in a patient who does not have cancer is pain in which the cause cannot be removed or otherwise treated and no relief or cure has been found after reasonable efforts.
• Guidelines for Assessment and Documentation in Noncancer Pain
  Alternative strategies for managing pain must be explored. If alternative strategies for managing the pain are unsuccessful, long-term opioid therapy can be added. The goal is not merely to treat the symptoms of pain but to devise pain management strategies that deal effectively with all aspects of the patient's pain syndrome, including psychological, physical, social, and work-related factors. Documentation in the patient's medical record should include:
  1. History and medical examination. A complete physical examination and comprehensive medical history should be part of the active treatment record, including but not limited to, a review of past pain treatment outcomes and any history of addiction risks to establish a diagnosis and treatment plan.
  2. Diagnosis and medical indication. A working diagnosis must be delineated, which includes the presence of a recognized medical indication for the use of any treatment or medication.ed.
  3. Written treatment plan with recorded measurable objectives. The plan should have clearly stated, measurable objectives, indication of further planned diagnostic evaluation, and alternative treatments.
  4. Informed consent. Discussions of risks and benefits should be noted in some format in the patient's record.
  5. Periodic reviews and modifications indicated. At these periodic reviews, the provider should reassess the treatment plan, the patient's clinical course, and outcome goals with particular attention paid to disease progression, side effects, and emergence of new conditions.
  6. Consultation. The treating provider should be knowledgeable and competent in referring patients to the appropriate specialist if needed and noting in the patient's record the treating provider's interpretation of the consultation reports. Additionally, a new patient with evidence of at-risk patterns of opioid usage should be evaluated by a knowledgeable specialist.ed.
  7. Records. The provider should keep accurate and complete records documenting the dates and clinical findings for all evaluations, consultations, treatments, medications, and patient instructions.ed.
  8. Assessment and monitoring. Some patients with chronic pain not associated with cancer may be at risk of developing increasing opioid consumption without objective improvement in functional status. Subjective reports by the patient should be supported by objective observations. Objective measures in the patient's condition are determined by an ongoing assessment of the patient's functional status, including the ability to engage in work or other gainful activities, patient consumption of healthcare resources, positive answers to specific questions about the pain intensity and its interference with activities of daily living, quality of family life and social activities, and physical activity of the patient as observed by the physician. Physical dependence and tolerance are normal physiologic consequences of extended opioid therapy and are not the same as addiction. Addiction is a disease with behavior characterized by psychological dependence and aberrant drug-related behaviors. Addicts compulsively use drugs for nonmedical purposes despite harmful effects; a person who is addicted may also be physically dependent or tolerant. Patients with chronic pain should not be considered addicts merely because they are being treated with opioids. The physician is responsible for monitoring the dosage of the opioid. Monitoring includes ongoing assessment of patient compliance with drug prescriptions and related treatment plans. Communication between healthcare providers is essential. The patient should receive long-term analgesic medications from one physician and where possible one pharmacy. All providers should be particularly cautious with patients who have a history of alcoholism or other drug addiction when prescribing long-term opioids. Consultation with addiction specialists is recommended.
• Patient Responsibilities
  1. It is the patient's responsibility to candidly provide the treatment provider with a complete and accurate treatment history, including past medical records, past pain treatment, and alcohol and other drug addiction history.
  2. The patient should participate as fully as possible in all treatment decisions.
  3. The patient and family members, if available, should inform the prescriber of all drug side effects and concerns regarding prescription drugs.
  4. The patient should not use other psychoactive agents, including alcohol, naturopathic products, or over-the-counter drugs without agreement of the prescriber.
  5. The patient should always use the same name when receiving medical care to assure completeness of the medical record.
  6. The patient should demand respect and expect to be believed.
  7. The patient should keep an open mind and be willing to work with the treatment provider, including:
     1. Negotiate with the provider to arrive at an acceptable plan of treatment;
     2. Be open in trying alternative treatment strategies; and
     3. Follow the treatment provider's instructions precisely.
  8. The patient should, where possible, get all central nervous system medications from one provider. If this is not possible, the patient should inform each provider of all medications he or she is receiving.
  9. The patient should, where possible, have all prescriptions filled at a single pharmacy.
  10. The patient should not horde, share, or sell medications.
  11. The patient should be aware that providers may, by law, share information with other providers about the patient's care.

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Author Information

David B. Brushwood, RPh, JD, Professor, University of Florida College of Pharmacy, Gainesville

Disclosure: David B. Brushwood, RPh, JD, has disclosed no relevant financial relationships.