Opioid Clinical Guidance

A message from the WSMA president on HCA’s new Medicaid opioid clinical policy
HCA webinars on new clinical opioid policy
What you need to know about House Bill 1427
Joint Opioid Safe Practices Task Force
Gov. Inslee's executive order
FAQs on managing pain and treating addiction
AMA call to action
Prescription monitoring program
Prescription guidelines
Compliance
Continuing education
Pain management and safe prescribing
Opioid addiction and abuse
Closure of Seattle Pain Centers



A message from the WSMA president on HCA’s new Medicaid opioid clinical policy

Aug. 25, 2017

Dear Colleagues,

As physicians, many of us see firsthand the tragic toll the opioid crisis is taking on patients, families and communities. Here in Washington, we’ve made some strides, including reducing prescription overdose deaths. However, we also know that more must be done to fully address the epidemic of opioid misuse and addiction. To continue to move us forward, the WSMA has joined with the Washington State Hospital Association and the state Health Care Authority to develop community-based solutions, informed by clinician expertise, with the health of our patients of paramount concern.

This week, the Health Care Authority announced its new clinical policy on opioid prescribing for Apple Health (Medicaid). The new policy includes provisions that:

  • Establish pill limits for management of acute pain: Initial prescriptions are limited to a total of three days for pediatric patients and seven days for adult patients.
  • Define the transition from acute to chronic: Use of any opioid for more than 42 days within a 90-day period is considered chronic use of opioids.
  • Establish pill limits for management of chronic pain.

It’s important to note that if a provider feels these limits are not appropriate for their patients, they need only write “exempt” on the prescription and document in their records the reason. No prior authorization, no extra paperwork. This exemption is the result of WSMA’s successful advocacy: Upon learning that an earlier version of the policy would have implemented strict prior authorization for all opioid prescriptions, the WSMA negotiated a broad exemption that allows physicians to exercise their clinical judgement and provides the necessary flexibility to ensure patients will receive appropriate treatment for their pain while minimizing administrative burden on clinicians.

Also note that patients who are already on chronic opioids will be grandfathered under the policy, and will not be subject to these limits or to prior authorization. Visit the Health Care Authority website to read the new policy. The guidelines will take effect on Nov. 1.

The policy represents an initial step forward in this unique partnership between the state and providers. In the months to come, we will have more information on other collaborative efforts, such as an opioid feedback reporting program and training on administering medication-assisted treatment for opioid dependence and addiction. With physician-led, evidenced-based approaches, we believe we can change the culture of opioid prescribing and end the epidemic of opioid misuse and overdose deaths, while avoiding blunt “one-size-fits-all” strategies that result in legislation or other hard mandates that don’t contain the flexibilities found in this new policy, and that could potentially prevent patients from accessing clinically appropriate treatments.

In the coming weeks, we will work with the Health Care Authority and provider community to educate physicians, providers and patients on the new prescribing policy. For more information on the new policy, visit the Health Care Authority website.

Sincerely,

Shane Macaulay, MD
WSMA President



New HCA clinical opioid policy

On Oct. 1, 2017, a new Health Care Authority clinical policy pertaining to opioid prescriptions takes effect for Apple Health (Medicaid), both through managed care organizations and fee-for-service.

For more information on the new prescribing policy and provider exemption, see this message from WSMA President Shane Macaulay, MD and visit the Health Care Authority website.



Free webinar: What you need to know about House Bill 1427

HB 1427, passed during the 2017 legislative session, represents a successful effort by the WSMA, the Washington State Hospital Association and the Department of Health to support medical group practices' ability to identify and help prevent drug abuse and overdose by leveraging data in the prescription monitoring program.

Watch a recording of our webinar presented on July 27, 2017 covering the new law and how to prepare your practice for its implementation, or view PDFs of the webinar slides here.



Joint Opioid Safe Practices Task Force

The WSMA has convened and is leading a task force to address prescription drug opioid abuse, addiction and overdose in Washington state. Joined by our partners at the Washington State Hospital Association, the task force will begin working on solutions to reverse a crisis facing our state and nation, with an eye toward ways physicians and hospitals can play a more active role in tackling this issue (read the press release, issued July 6).

Task force members

WSMA

  • Ray Hsiao, MD, past president, child psychiatrist and addiction specialist at Seattle Children's Hospital
  • Tom Schaaf, MD, 1st vice president, family physician and hospitalist at Providence Medical Group in Spokane
  • Nathan Schlicher, MD, JD, secretary treasurer, emergency physician at St. Joseph's Medical Cetner in Tacoma

WSMA staff

  • Kathryn Kolan, director of legislative and regulatory affairs
  • Jeb Shepard, 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

WSHA staff

  • Ian Corbridge, policy director, clinical issues


Gov. Inslee's executive order

Gov. Inslee issues press release announcing executive order to combat the opioid epidemic. WSMA/WSHA issue press release in support (Oct. 7, 2016).



FAQs on managing pain and treating addiction

With the assistance of WSMA member Michael Schiesser, MD, internist and addiction specialist at EvergreenHealth, the WSMA is now offering two sets of FAQs for physicians and practices navigating the complexities of pain management in the face of an unfolding opioid crisis. The following guidance documents—one for physicians and one for practice administrators—offer sound, useful advice and links to critical resources for those seeking to create new or improve current pain management care plans.

Physician FAQ on Managing Pain and Treating Addiction During the Opioid Epidemic (Updated Nov. 2016)
Practice Administrator FAQ on Assisting Clinicians and Patients During the Opioid Epidemic (Updated Nov. 2016)

While potentially challenging at first, a sincere effort to bring about change can transform how your clinic manages pain and result in life-changing medical treatment for patients in your community. The two FAQs will be updated periodically as new information and updates become available.

Dr. Schiesser provides peer guidance and training to manage risks from prescribed narcotics as the course director of A Leader’s Guide: Eliminating Problems due to Prescribed Narcotics in your Primary Care Clinic. A Leader’s Guide is a shared effort delivered by ControlRx LLC, on behalf of Physician’s Insurance A Mutual Company and its wholly owned subsidiary, Experix LLC.



AMA call to action

In February 2016, AMA President Steven J. Stack, MD called on physicians to take action to confront an unfolding opioid epidemic.

Dr. Stack urged physicians to take five steps:

  1. Register for and use prescription drug monitoring programs if you prescribe controlled substances.
    Find out more about Prescription Review, Washington state’s prescription monitoring program.

  2. Enhance education and training about safe prescribing.
    Updated prescribing guidelines are listed below as well as education and resources on safe prescribing practices.

  3. Co-prescribe naloxone to patients at risk of overdose.
    In 2015, the WSMA helped pass legislation making it easier to obtain the overdose reversal drug in our state. Find more information on naloxone in our opioid abuse and addiction section.

  4. Get training to provide medication-assisted treatment for substance use disorders.
    More physicians need to be trained to recognize patients with substance use disorder, and more physicians need to become certified to increase access to treatment. Find more information on medication-assisted treatment for substance use disorders in our opioid abuse and addiction section.

  5. Speak out against stigma.
    Patients in pain deserve care and compassion, not judgement. Treating pain is among the most difficult—and most common—reasons patients come to us. As physicians, we are often under pressure to “satisfy a patient’s pain.” Sometimes this requires prescribing an opioid. But caring also means sometimes saying no and recommending an alternative course of treatment—no matter how difficult that may be. Read an editorial on stigma and substance use disorder from the AMA Task Force to Reduce Opioid Abuse in cooperation with WSMA.


Prescription monitoring program

Prescription Review

Prescription Review is Washington state’s prescription monitoring program, a crucial tool in helping to stem the frequency of medication abuse and overdose. Started in 2011 and run through the Department of Health, the 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.

Get started setting up your account with Prescription Review.

Did you know?
Responding to physician concerns regarding the program’s usability, the WSMA helped pass legislation in 2016 making it easier for facilities and physician groups to access Prescription Review. For more detailed information on the improvements being made to Prescription Review—including easier, expanded access—review Confronting the Opioid Epidemic: Appropriately Treating Pain While Stopping Abuse, a WSMA/WSHA/DOH webinar originally aired on June 10. Find the webinar and slides on the WSHA website.



Prescribing guidelines

CDC Guideline for Prescribing Opioids for Chronic Pain

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

  • American Medical Association response
  • American College of Emergency Physicians response
  • American Academy of Family Physicians response
  • American Academy of Pain Management response

AMDG 2015 Interagency Guideline on Prescribing Opioids for Pain

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.

Visit the WSMA Legal Resource Center for information on the 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.



Compliance

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.

State of Washington Medical Quality Assurance Commission (MQAC)

Understanding state regulations as they pertain to the practitioner's management of non-cancer pain.

Visit the MQAC website for information on pain management rules.

Washington State Pharmacy Quality Assurance Commission (PQAC)

The Pharmacy Quality Assurance Commission regulates the practice of pharmacy, and the distribution, manufacturing and delivery of pharmaceutical within and into the state. The commission protects and promotes public health and safety by issuing licenses, registrations and certifications to qualified persons and entities and responding to complaints or reports of unprofessional conduct.

Visit the PQAC website.



Continuing education

Category 1, non-expired (i.e. up-to-date) topics within pain management, opioid prescribing and opioid addiction. The CME listed are sponsored by organizations other than pharmaceutical manufacturers. This list is not meant to be comprehensive. For more education and resources, see the pain management and safe prescribing and the opioid abuse and addiction sections of this page. Providing the following list of available continuing education does not imply endorsement by the WSMA.

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Pain management and safe prescribing

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.

ER/LA Opioids: Achieving Safe Use while Improving Patient Care
Developed by the Collaborative for REMS Education (CO*RE) for physicians or physician assistants who prescribe extended-release and long-acting opioid analgesics, this free course offers best-practice strategies and skills to improve therapy adherence and reduce harm. CO*RE—a collaboration between 13 health care professional organizations—was founded in 2010, prior to the release of the Food and Drug Administration's ER/LA Opioid REMS Blueprint. Visit the CO*RE website to access the course online or search for upcoming in-person events. This activity has been approved for AMA PRA Category 1 Credit™.

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.

Pain Medication Safety Guidelines in the Emergency Department
This patient resource for emergency departments was created to help reduce the recent rise in abuse, addiction, overdose, and death from prescription pain medication

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

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 | Opioid Abuse, Dependence, and Addiction in Pregnancy
Committee Opinion | Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician-Gynecologist
Committee Opinion | Nonmedical Use of Prescription Drugs
American Congress of Obstetricians and Gynecologists

Healthcare Brief | Medication-Assisted Treatment for Opioid Addiction
Office of National Drug Control Policy 




Closure of Seattle Pain Centers

A call on physicians to provide care to Seattle Pain Center patients (WSMA DocTalk blog, Sept. 26, 2016)

Update on provider and patient support related to closure of Seattle Pain Centers (WSMA Membership Memo, August 10, 2016)

Provider alert: Update on closure of Seattle Pain Centers | Treating patients and reminder on pain management rules (WA DOH, Washington State Medical Commission and Washington State Health Care Authority, August 1, 2016)

Guidance for physicians treating patients affected by state action against Seattle Pain Centers (WSMA Membership Memo, July 27, 2016)

The WSMA announces joint task force with the Washington State Hospital Association to address growing opioid crisis. Read the press release, issued July 6, 2016.