Doctor and patient concerns that new state opioid prescribing rules would force chronic pain patients off their medication have not materialized, health officials say.
In 2017, the Legislature mandated that five health-care professional boards and commissions adopt the new rules for prescribing opioids earlier this year. The new rules primarily set limits for short-term prescribing and expand on chronic pain prescribing guidelines set in 2011.
Some doctors and chronic pain patients were concerned the rules would cut off patients from their prescriptions. Although the regulations added some education and Prescription Monitoring Program requirements, they did not set rules limiting doses or requiring chronic pain patients to be weaned off opioids.
The regulations outline prescribing limits for pain lasting up to 12 weeks or for surgeries. Prescribing for acute pain lasting six weeks or less has a limit of seven days of medication, with three days being enough in most cases. The rules institute a 14-day supply limit for pain lasting six to 12 weeks or following surgeries. Pain lasting more than 12 weeks is considered chronic.
Longview doctor Rich Kirkpatrick previously voiced concerns about the rules but said Thursday they left guidelines for treating chronic pain mostly untouched.
“The way I read the rules, it seems like it’s mainly focused on avoiding people getting started on a long-term [opioid] regimen,” Kirkpatrick said. “Most people who deal with chronic pain patients are now very aware or focused on making sure the opioids are necessary and that all other potential treatments have been attempted.”
Kirkpatrick said some of his patients are still nervous they will lose access to their medication.
“These people are worried because they depend on pain medication to do their regular activities,” he said.
Any change in opioid rules or guidelines have important implications for Cowlitz County, which had the state’s highest opioid-related overdose deaths from 2011 to 2015. That number has decreased but is still above the state average. The county rate of patients with chronic opioid prescriptions was 33 percent higher than the state average in 2017, according to the state health department.
In the United States, between 8 percent and 12 percent of patients prescribed opioids for chronic pain become addicted, according to the National Institute on Drug Abuse.
Health officials creating the rules took chronic pain patients’ concerns into account, said Blake Maresh, deputy director for office of health professions at the Department of Health.
“We want to try to accomplish three goals: To make sure patients get the care they need while curbing excessive prescribing that can lead to misuse while not creating disincentives for prescribers to see patients,” he said.
Kaiser Permanente has worked to limit opioid prescriptions, lower doses and course lengths, and help chronic pain patients taper their doses to safer amounts for the last few years, said Jennifer Bard, director of operations for primary care for Clark and Cowlitz counties. However, working with patients to reduce opioid doses is tough and every patient goes through it at a different pace, Bard said.
“As a primary care provider you have to be advocating for patients’ well-being and reassuring them of that is our primary focus,” Bard said. “We have a responsibility to prescribe safely and within legal means, but we’re reassuring them we’ll work together that they’ll get where they need to go.”
PeaceHealth hospitals and clinics have worked to standardize prescribing practices and visits to give patients consistent care and remove some risks associated with opioid prescribing, said Timothy Randall, doctor at the Lakefront clinic in Longview. Along with regulations, Randall said ongoing research helps drive prescribing practices.
The new rules establish some requirements for treating patients with chronic pain, including requiring the doctor to consult with a pain specialist when prescribing over 120 morphine milligram equivalents (Morphine milligram equivalents are used to compare relative potency of different opioids.)
The regulations also require patients to complete a written agreement for treatment and for prescribers to confirm or provide opioid overdose reversal drug naloxone when prescribing opioids to a high-risk patient. Patients who take a high dose of opioids, use other certain medications, have other medical issues, or exhibit aberrant behavior are considered high risk of developing complications, misuse or overdose.
Stephanie McManus, Washington Medical Commission spokeswoman, said doctors have the final say in what they prescribe in all cases. If a patient needs more medication, they can get that as long as the doctor documents why in their medical record, she said.
Confusion around chronic pain prescribing has come from different interpretations of the Centers for Disease Control’s opioid prescribing guidelines, McManus said.
The CDC’s 2016 guidelines on prescribing opioids for chronic pain suggest doctors limit patients to a dose of 90 morphine milligram equivalents per day. Many think this is a national law, rather than just a guideline, McManus said. Part of the commission’s outreach regarding the new state rules has included clearing up those misconceptions, she said.
“We don’t want people who need medication to not get it,” McManus said.
Creating requirements for prescribers to register with the state’s Prescription Monitoring Program and establishing when they should check the database is a big part of the new rules, McManus said.
The program is a database of patient information that allows providers to look for duplicate prescriptions, possible misuse and potentially hazardous drug combinations. Maresh said the program is an educational resource for prescribers that can show them not only their own prescribing habits but what others who are seeing that patient are doing.
The five commissions instituted different requirements for when prescribers should use the program, but most require checks before a refill and when a patient transitions to a different pain phase.
Kaiser’s integrated system previously allowed pharmacists to take the lead on checking the Prescription Monitoring Program, Bard said. The new rules put an “administrative burden” on clinicians, and the group is trying to make the program checks more efficient, she said.
Maresh said although challenges remain, the Department of Health has received a mostly positive response from providers regarding the new rules.
“Opioids and opioid prescribing presents a real challenge to prescribers today,” Maresh said. “A lot of people feel squeezed in terms of their prescribing habits. … We let them know we have not put in place hard barriers or limits. We want clinicians to exercise their professional discretion.”