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Opioid Clinical Guidance

Physicians see firsthand the toll the opioid epidemic is taking on patients, families and communities, and have led efforts in Washington state to reduce prescription opioid-related overdose and death.

Those efforts have paid off, with a 44 percent decline in the number of unintentional prescription opioid deaths since 2008, making Washington a leader among states in addressing the prescribing contribution to the opioid epidemic. While this trend prompts cautious optimism, additional opportunities remain for reducing the number of people who may become addicted to opioids and improving pain treatment.

Learn more about WSMA's efforts to end the opioid epidemic, including a new overdose notification system (due in 2019) and our data-driven safe prescribing initiative Better Prescribing, Better Treatment. Also, on this page you'll find information on new state rules regulating opioid prescribing; state and federal prescribing guidelines; the state's prescription monitoring program; the WSMA/WSHA joint opioid task force; and pain management and addiction medicine resources.

Leveraging data to understand prescribing patterns and improve treatment

House Bill 1427, passed by the Legislature in 2017, and other efforts permit the state to provide physicians and providers prescribing information to support patient care and drive quality improvement. The WSMA and the Washington State Hospital Association have a key role in this strategy,

To ensure success and improve prescribing, we need the support of group practice and health system leaders. Specifically, we need your facilities' provider information. With this information the WSMA and WSHA can enroll your providers in the:

To enroll in these programs, contact Trish Anderson, WSHA staff at 206.216.2524 or trisha@wsha.org, or Jeb Shepard, WSMA staff at 360.352.4848 or jeb@wsma.org.

Better Prescribing, Better Treatment

Leveraging data to encourage better prescribing of opioids while protecting patients from highly addictive medications.

Designed by physicians, Better Prescribing, Better Treatment is a peer-to-peer, non-punitive initiative aimed at ensuring physicians and other prescribers who see Medicaid patients in Washington state are not overprescribing addictive medications while keeping appropriate pain treatments accessible for patients who need them. The initiative was developed in partnership with the Washington State Health Care Authority, the agency responsible for administering the state’s Medicaid program (Apple Health), and the Washington State Hospital Association. Better Prescribing, Better Treatment is a component of the state opioid response plan.

Better Prescribing, Better Treatment takes a three-pronged approach to safe prescribing:

  • Apple Health prescribing policy. The initiative established a new opioid prescribing policy for Washington’s Apple Health program that introduced new pill limits for all opioid prescriptions written for the treatment of acute pain.
  • Prescriber discretion. The initiative established a non-burdensome process for automated exemption that allows the prescribing clinician to overrule those limits if it’s in the best interest of their patient by simply documenting in the medical record and indicating the exemption on the prescription. Importantly, this approach avoids the additional paperwork and administrative burden that accompany similar policies adopted in other states and that can take time away from patient care.
  • Physician-led feedback program. The initiative introduced Washington Opioid Reports, a feedback reporting program that provides data compiled from the state’s prescription monitoring program to physicians and other prescribing providers allowing them to see how their opioid prescribing practices compare to others in their health care system and specialty.

Getting results

Better Prescribing, Better Treatment's data-driven and data-sharing approach is working. The initiative, now encompassing 17,000+ prescribers at more than 20 health systems and groups in the state, has reduced opioid prescriptions exceeding the new Apple Health guidelines by nearly 70 percent since its inception in late 2017.

How to enroll

If you see Medicaid patients and your organization has yet to enroll to receive Washington Opioid Reports, simply email opioidreportsadmin@wsma.org to enroll. Minimal resources and administrative burden required.

Statewide opioid feedback program

Plans are underway to expand Better Prescribing, Better Treatment's data-leveraging strategy to all opioid prescribers in Washington state. We anticipate this expanded statewide opioid feedback program to be available in the first quarter of 2019.

Prescription Monitoring Program

Learn more about Washington state’s prescription monitoring program.

Washington state's prescription monitoring program, Prescription Review, is a crucial tool in helping to stem the frequency of medication abuse and overdose. Started in 2011 and run through the Department of Health, Prescription Review uses a secure platform to allow a prescribing physician to access crucial patient information before prescribing, such as duplicate prescribing, misuse, drug interactions and other potential concerns. This information can help to determine appropriate medical treatment and referral needs. As physicians, you play a crucial role in protecting your patients' health and safety.

Register with Prescription Review

To get started setting up your account with Prescription Review, visit this DOH webpage for step-by-step instructions, including video tutorials.

Medical groups and health systems: Integrating your EHR with the state prescription monitoring program

Group and health system executives: As leaders in your communities, the WSMA and the Washington State Hospital Association encourage you to provide as many tools as possible to your physicians and other prescribers to combat the opioid crisis. This includes low-barrier access to real-time state prescription monitoring program data by integrating your electronic health record with the PMP database.

Integrating PMP data directly into your EHR is an important tool to addressing the opioid crisis and the right thing to do for Washington patients. Allowing physicians and providers real-time access to patients’ prescriptive history supports optimal clinical decision-making within the time constraints of a patient encounter. Also, there are new PMP mandates in the opioid prescribing rulemaking that resulted from House Bill 1427 (passed by the Washington State Legislature in 2017). Many of these mandates are set to go into effect in 2019. Integrating your hospital or group’s medical record with the PMP will help ensure your physicians and other providers are able to meet new state requirements while minimizing disruption to patient care*.

If your EHR vendor is Epic®, NextGen®, Cerner®, or AllScripts®, we encourage you to:

  • Contact your vendor and express your desire to integrate PMP data.
  • Prioritize the integration of PMP data to your EHR with your IT department.
  • Work with your vendor to install the update for the PMP connection.
  • Work with our statewide health information exchange, OneHealthPort, to connect the PMP data to your vendor.

Technical guidance for practice IT departments and vendors please visit the Department of Health’s PMP webpage or see below**.

Unfortunately, not all EHR vendors offer an integration pathway. For those vendors that have not yet developed an integration pathway, consider urging them to develop a Washington-compliant interface as soon as possible. The DOH website provides technical guidance for providers and hospitals; technical guidance for your vendor is available from OneHealthPort.

We understand resources are required to integrate these platforms, and the WSMA and WSHA will continue to advocate for reasonable regulatory policies and funding opportunities to help offset the costs of integrating EHRs with the PMP.

*Note that under the Washington Medical Commission rules, physicians and other providers working at organizations that have integrated their EHR with the PMP must review the patient’s information in the database before prescribing opioids.

**Washington state has built a non-proprietary, open-source connection for the PMP to integrate with certified EHR systems. This connection is based on a standard that all certified EHRs already use. The first hospital in Washington went live with their EHR connection with Epic® last year. Since that first connection, 17 other medical entities representing over 900 hospitals and clinics across the state have connected their EHR systems to the PMP database. Six more medical organizations are actively testing connections or exploring implementation. We have seen tremendous growth in 2018. In January 2018, there were roughly 200,000 queries of the PMP and by September 2018 there were over 1.5 million queries as a result of these connections.

State Opioid Prescribing Rules

Information on new state rules for physicians and physician assistants.

New opioid prescribing rules for Washington state's prescribing professions, prompted by House Bill 1427 from 2017, have been adopted by the state’s regulatory bodies.

For allopathic physicians and physician assistants, the new prescribing rules go into effect Jan. 1, 2019; new rules for osteopathic physicians and PAs went into effect Nov. 1, 2018. (For more on the differing requirements between Washington Medical Commission and the Board of Osteopathic Medicine and Surgery rulemaking, see this Table of Differences from the Department of Health.)

The comprehensive rules represent a significant change in how opioids are prescribed. Key provisions applicable to all prescribing physicians and PAs include:

  • A seven-day pill limit for acute prescriptions and 14 days for acute operative pain, with an exemption to these limits when clinical judgment is documented in the medical record.
  • A specific care plan and documentation requirements for each phase of pain.
  • Mandated registration and targeted checks of the prescription drug monitoring program.
  • Required continuing medical education on opioid prescribing.

How to prepare

  • Register to attend WSMA’s free one-hour webinar, Understanding New State Opioid Prescribing Rules, on Wednesday, Dec. 19, noon–1 p.m., designed to help you understand how to comply with the new requirements. Register for the webinar online. This activity has been approved for AMA PRA Category 1 Credit™. Attendance will fulfill the new state requirement for continuing medical education on opioid prescribing.
  • Set up your account with Washington state’s prescription monitoring program, Prescription Review. Prescription Review uses a secure platform to allow a prescribing physician to access crucial patient information before prescribing, such as duplicate prescribing, misuse, drug interactions, and other potential concerns. Don’t wait until the last minute—get started today setting up your account. The DOH website has a section with instructions for physicians, including video tutorials.

The WSMA has joined the Washington State Hospital Association to reach out to hospital and health system leaders, encouraging them to work with their IT departments to build edits and prompts into electronic health records that assist clinicians with compliance under the rules.

Preparing your practice

The WSMA wants to help prepare your practice, regardless of size. Our staff experts are producing a customizable PowerPoint presentation template to educate your practice's care teams on the new rules. This presentation should be available in December.

More information on the new rules

The Washington State Department of Health opioid prescribing webpage.

The Washington Medical Commission rules overview and resources and rule text.

Board of Osteopathic Medicine and Surgery rules overview and resources and rule text.

Prescribing Guidelines

Opioid prescribing guidelines from the CDC, the Washington State Agency Medical Directors’ Group and more.

CDC opioid prescribing guidelines

Released March 2016, the Centers for Disease Control and Prevention's Guideline for Prescribing Opioids for Chronic Pain provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care. The guideline addresses: 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use.

Information for physicians on the CDC guideline.

Related
Physician groups respond to CDC guidelines

AMDG 2015 Interagency opioid prescribing guidelines

Washington state was one of the first states to respond to the opioid epidemic. The first edition of the Washington State Agency Medical Directors' Group opioid guidelines, published in 2007, was the first attempt in the U.S. to reduce prescribing of high doses of opioids associated with unintentional overdose.

In 2015, the AMDG published the third edition of its Interagency Guideline on Prescribing Opioids for Pain. This edition expands focus to include opioid use in acute, subacute, and perioperative pain phases and in special populations; includes sections on tapering and opioid use disorder.

AMDG medical treatment guidelines are published as an educational tool for medical providers caring for patients of state agency programs.

Information for physicians on the AMDG guideline, third edition.

Related
Opioid dose calculator
Use in conjunction with the AMDG guideline to calculate the total daily morphine equivalent dose for prescribed opioids (this calculator should not be used to determine doses when converting a patient from one opioid to another). This Web-based tool works on smart phones, tablets and PCs/Macs.

Assessment tools
Documents and tools found in the AMDG 2010 Opioid Dosing Guideline for Chronic Non-Cancer Pain.

MQAC rules for management of chronic non-cancer pain

The Medical Quality Assurance Commission's final rules for management of chronic non-cancer pain became effective Jan. 2, 2012. The rules apply to physicians who treat patients with opioids for chronic non-cancer pain (as defined in the rules). The rules do not apply to physicians providing palliative care, hospice care, or other forms of end-of-life care. The rules also do not apply to the management of acute pain related to an injury or surgical procedure.

Learn more about the MQAC rules.

Related
MQAC technical assistance letter to providers regarding pain rules (Updated: Oct. 19, 2016)
To help allay legitimate concerns from physicians regarding fear of state sanction for treatment of patients on opioids, the Medical Quality Assurance Commission has issued, at the request of the WSMA, a technical assistance letter which addresses three points: the intent of the MQAC pain rules; opioid prescribing levels, and; what counts as a consultation requirement. We'll update this link as additional guidance from MQAC becomes available.

Washington State Department of Health pain management resources. Includes:

  • FAQ on MQAC's 2012 pain rules
  • Patient resources
  • Professional resources
  • Legal resources

Group Health: Patients on Chronic Opioid Therapy for Chronic Non-Cancer Pain Safety Guideline

Updated September 2016, the recommendations in this guideline apply to adult patients who are already on chronic opioid therapy for the treatment of chronic non-cancer pain. Group Health's guideline is consistent with the regulations, and providers adhering to the guideline will be compliant with the law. The guidelines are intended to provide a MINIMUM standard of care, and are based on the legal requirements defined by Washington State Administrative code (WAC).

Find the guidelines on the Group Health website. (Scroll down to Chronic Opioid Therapy for Chronic Non-Cancer Pain)

Group Health has adopted the recommendations of the 2015 Agency Medical Directors' Group (AMDG) Interagency Guideline on Prescribing Opioids for Pain.

This guideline does not apply to patients receiving palliative, hospice, or other end-of-life care.

U.S. Drug Enforcement Administration (DEA)

Information from the U.S. Drug Enforcement Administration to assist physicians authorized to prescribe, dispense and administer controlled substances in their understanding of the Federal Controlled Substances Act and its regulations as they pertain to the practitioner's profession.

Overdose Notification

Giving physicians timely information to coordinate prescribing, support treatment interventions, and stop overdose deaths.

The WSMA, the Washington State Department of Health and the Washington State Hospital Association have partnered with Collective Medical (developers of the Emergency Department Information Exchange, or EDIE) to launch an overdose notification program, with a statewide roll out expected in 2019.

This new system, currently being piloted in Clallam and Jefferson counties, will notify a primary care physician or any other prescribing provider when their patient is brought to a hospital emergency department and confirmed to have experienced an overdose. The goal of this program is to give providers timely information to coordinate prescribing, support treatment interventions, and stop overdose deaths.

Learn more

Opioid overdose pilot program designed to save lives (WSMA article, Aug. 31, 2018)

Pain Management and Safe Prescribing

Resources to assist clinicians in treating pain appropriately and safely.

WSMA/WSHA education

Confronting the opioid epidemic: Appropriately treating pain while stopping abuse (webinar presented by WSMA, WSHA and the DOH, July 20, 2016)

Education

Physicians Insurance/Experix online continuing medical education on pain management
These activities has been approved for AMA PRA Category 1 Credit™.

A Leader's Guide
A Leader's Guide is a shared effort delivered by ControlRx on behalf of Experix, a wholly owned subsidiary of Physicians Insurance A Mutual Company. Your course director is Michael Schiesser MD, an internist and addiction medicine specialist practicing in the state of Washington.

MQAC's 2012 pain management rules and 2015 AMDG Interagency Guideline CME package
MQAC offers an educational program on the 2012 pain rules, which includes a video the commission has produced which can be part of a free four CME offering available through L&I. This activity has been approved for AMA PRA Category 1 Credit™.

UW TelePain Sessions
The University of Washington Division of Pain Medicine offers weekly UW TelePain sessions, audio and video-based conferences to assist community providers (both primary and specialty) in the management of complex and challenging chronic pain problems. The sessions include:

  • Didactic presentations from the UW Pain Medicine curriculum for primary care providers
  • Case presentations from community clinicians
  • Interactive consultations for providers with an interprofessional panel of specialists
  • The use of measurement-based clinical instruments to assess treatment effectiveness and outcomes for individuals and larger populations

UW TelePain Sessions take place each Wednesday from noon-1:30 p.m. for community health care providers.

Military and VA providers are encouraged to join a special session of UW TelePain focused on military and veterans' health care on Thursdays from noon-1:30 p.m.

Weekly didactic presentations for primary care providers occur between noon-12:30 p.m. during each broadcast followed by a brief question and answer period. Slides, articles, and references from these presentations are made available to participants.

This activity has been approved for AMA PRA Category 1 Credit™.

ROAM and ECHO: Defeating Opiate Addiction in Rural Washington
Two initiatives to help providers grapple with the disparate problems of addiction and pain management. ROAM (the Rural Opiate Addiction Management) Collaborative, launched by UW Medicine and Washington State University, seeks to help manage the widespread issue of opiate addiction in rural Washington. COPE (Collaborative Opioid Prescribing Education), launched by UW Medicine is an online educational tool that helps providers communicate to patients about how best to manage treatment of chronic, non-cancer-related pain.

Resources

UW Pain Medicine Provider Toolkit
The University of Washington has developed a provider toolkit, which brings together a number of useful, informative, and important resources regarding the treatment of chronic pain and MQAC's 2012 pain rules.

Risk Evaluation and Mitigation Strategy (REMS) for Extended-Release and Long-Acting Opioids
On July 9, 2012, FDA approved a risk evaluation and mitigation strategy (REMS) for extended-release (ER) and long-acting (LA) opioid medications.

ER/LA opioids are highly potent drugs that are approved to treat moderate to severe persistent pain for serious and chronic conditions. The misuse and abuse of these drugs have resulted in a serious public health crisis of addiction, overdose and death.

The REMS is part of a multi-agency federal effort to address the growing problem of prescription drug abuse and misuse. The REMS introduces new safety measures to reduce risks and improve safe use of ER/LA opioids while continuing to provide access to these medications for patients in pain.

Opioid Abuse and Addiction

Find information on medication-assisted treatment for substance use disorders and more in this section.

WSMA/WSHA education

What physicians need to know about recent federal policy changes,including the Comprehensive Addiction and Recovery Act (CARA) of 2016 (Updated Nov. 2016)
With passage of CARA, and changes made by the Substance Abuse and Mental Health Services Administration's final rule, Congress and the White House have made a number of policy changes to combat the opioid epidemic-some of which physicians can leverage immediately. To bring members up to speed, the WSMA has prepared this guidance document, which contains information on federal policy changes, particularly those that address medication-assisted treatment (MAT)-the use of medications together with behavioral therapy to treat substance use disorders. The guidance includes new information on patient limits, which practitioners can prescribe buprenorphine, and partial prescription fills for controlled substances.

Education

Physicians Insurance/Experix online continuing medical education on addiction and pain management
These activities has been approved for AMA PRA Category 1 Credit™.

A Leader's Guide
A Leader's Guide is a shared effort delivered by ControlRx on behalf of Experix, a wholly owned subsidiary of Physicians Insurance A Mutual Company. Your course director is Michael Schiesser MD, an internist and addiction medicine specialist practicing in the state of Washington.

ROAM and ECHO: Defeating Opiate Addiction in Rural Washington
Two initiatives to help providers grapple with the disparate problems of addiction and pain management. ROAM (the Rural Opiate Addiction Management) Collaborative, launched by UW Medicine and Washington State University, seeks to help manage the widespread issue of opiate addiction in rural Washington. COPE (Collaborative Opioid Prescribing Education), launched by UW Medicine is an online educational tool that helps providers communicate to patients about how best to manage treatment of chronic, non-cancer-related pain.

SAMHSA (Substance Abuse and Mental Health Services Administration) opioid courses and buprenorphine training
SAMHSA is the agency within the U.S. Department of Health and Human Services that leads public health efforts to reduce the impact of substance abuse and mental illness.

Webinar | Addiction, Stigma and Discrimination: Implications for Treatment and Recovery
Providers' Clinical Support System for Medication Assisted Treatment

CME | Stigma in Methadone and Buprenorphine Maintenance Treatment
Providers' Clinical Support System for Medication Assisted Treatment

Webinars & Activities | Substance Use Disorders
The American Psychiatric Association

CME | Featured Courses on MAT and Pain Management
The American Psychiatric Association

CME | DATA 2000 8 Hour Waiver Qualifying Buprenorphine Training
The American Society of Addiction Medicine

CME | Buprenorphine Waiver Training
The American Academy of Addiction Psychiatry

Webinar | MAT Office-Based Treatment of Opioid Dependence
Providers' Clinical Support System for Medication Assisted Treatment Self Study at the American Osteopathic Academy of Addiction Medicine

Resources

Recommendations on co-prescribing naloxone
The AMA offers recommendations for when you should consider co-prescribing naloxone to your patients.

Barriers to Treatment
Providers' Clinical Support System for Medication Assisted Treatment

National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
American Society of Addiction Medicine

Committee Opinion | Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician-Gynecologist
American Congress of Obstetricians and Gynecologists

Joint Opioid Safe Practices Task Force

Supporting efforts to reduce and treat opioid-related abuse, addiction and overdose, at all points on the care continuum, is a priority for the WSMA and its opioid safe practices task force, formed jointly with the Washington State Hospital Association.

Task force members

WSMA

Ray Hsiao, MD, child psychiatrist and addiction specialist at Seattle Children's Hospital
Tom Schaaf, MD, family physician and hospitalist at Providence Medical Group in Spokane
Nathan Schlicher, MD, JD, emergency physician at St. Joseph's Medical Center in Tacoma
Kathryn Kolan, JD, WSMA's director of legislative and regulatory affairs
Jeb Shepard, WSMA's associate director of legislative and regulatory affairs

WSHA

Scott Kennedy, MD, chief medical officer at Olympic Medical Center in Port Angeles
Sean Dobbin, pharmacy director at Sacred Heart Medical Center in Spokane
Tom Staiger, MD, chief medical officer at UW Medical Center in Seattle
Ian Corbridge, WSHA's policy director, clinical issues

Join or renew your membership today