WASHINGTON STATE OPIOID GUIDELINES AND REGULATIONS

1. WASHINGTON STATE OPIOID GUIDELINES AND REGULATIONS Gary Franklin, MD, MPH Medical Director, WA Dept of Labor and Industries Chair, Washington State Agency Medical Directors Group Research Professor, Occupational and Environmental Health, Neurology, and Health Services, University of Washington 1

2. “To write prescriptions is easy, but to come to an understanding with people is hard.” – Franz Kafka, A Country Doctor 2

3. Change in National Norms for Use of Opioids for Chronic, Non-cancer Pain • By the late 1990s, at least 20 states passed new laws, regulations, or policies moving from near prohibition of opioids to use without dosing guidance • WA law: “No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed.” (WAC 246-919-830, 12/1999) • Laws were based on weak science and good experience with cancer pain • No dosing governor WAC Washington Administrative Code 3

4. Unintentional and Undetermined Intent Drug Overdose Death Rates by State, 2007 12.5 12.5 11.7 11.1 11.1 9.8 8.8 7.9 7.5 MD MA NH RI CT DE DC VT NJ Age-adjusted rate per 100,000 population National Vital Statistics System, http://wonder.cdc.gov 4

5. State mortality varies by regulatory environment Paulozzi and Stier, J Publ Health Pol 2010; 31: 422-32 • Per capita usage of opioids in NY 2/3 that in PA • Drug overdose deaths 1.6 fold higher in PA compared to NY • PDMP in NY better funded and uses serialized, tamperproof Rx forms But mortality rates probably not affected by mandatory education alone

6. Developed with clinical pain experts in 2006 Implemented April 1, 2007 First guideline to emphasize dosing guidance Educational pilot, not new standard or rule National Guideline Clearinghouse http://www.guideline.gov/content.aspx?id=23792&search=wa+opioids Washington Agency Medical Directors’ Group Opioid Dosing Guidelines 6 www.agencymeddirectors.wa.gov

7. Part I – If patient has not had clear improvement in pain AND function at 120 mg MED (morphine equivalent dose) , “take a deep breath” If needed, get one-time pain management consultation (certified in pain, neurology, or psychiatry) Part II – Guidance for patients already on very high doses >120 mg MED Washington Agency Medical Directors’ Opioid Dosing Guidelines 7 www.agencymeddirectors.wa.gov

8. Guidance for Primary Care Providers on Safe and Effective Use of Opioids for Chronic Non-cancer Pain • Establish an opioid treatment agreement • Screen for • Prior or current substance abuse • Depression • Use random urine drug screening judiciously • Shows patient is taking prescribed drugs • Identifies non-prescribed drugs • Do not use concomitant sedative-hypnotics • Track pain and function to recognize tolerance • Seek help if dose reaches 120 mg MED, and pain and function have not substantially improved http://www.agencymeddirectors.wa.gov/opioiddosing.asp MED, Morphine equivalent dosec 8

9. Washington State Primary Care Survey 2009: Adherence to State Guidelines Interim Evaluation of the Opioid Dosing Guidelines. http://www.agencymeddirectors.wa.gov 9

10. Open-source Tools Added to June 2010 Update of Opioid Dosing Guidelines • Opioid Risk Tool: Screen for past and current substance abuse • CAGE-AID screen for alcohol or drug abuse • Patient Health Questionnaire-9 screen for depression • 2-question tool for tracking pain and function • Advice on urine drug testing CAGE, “cut down” “annoyed” “guilty” “eye-opener” 10 http://www.agencymeddirectors.wa.gov/opioiddosing.asp#DC

11. ESHB 2876 (2010) and Washington State Opioid Treatment Regulations • Repeals older, permissive rules • Dosing guidance-120 mg/day consultation flag • Emphasize tracking patients for improved pain AND function • Emphasize widely agreed-upon best practices • Screening for substance abuse and other comorbidities • Prudent use of urine drug screens • Opioid treatment agreement • Single pharmacy and single prescriber • Encourage use of Prescription Monitoring Program and Emergency Department Information Exchange, when available • Implementation between 7/1/2011 and 1/2/2012 11

12. Improving Physician Access to Pain Specialists in Washington State • Issue • Moderate capacity problem: not enough pain specialists • Interventional anesthesiologists generally won’t see these patients to assist with opioid issues • Solution • Advanced training for primary care to increase proficiency • Have successfully “beta tested” telemedicine consults and webinar trainings with pain specialists and primary care physicians • Telephonic or video consultation with experts; Project ECHO • Public payers working on payment codes to incentivize these activities 12

13. Components Under Development for Community-based Treatment of Chronic Pain • Cognitive behavioral therapy • Graded exercise • Activity coaching • Interdisciplinary care • Care coordination 13

14. Average Daily Dosage for Opioids, Washington Workers’ Compensation, 1996–2010 96-Q1 96-Q3 97-Q1 97-Q3 98-Q1 98-Q3 99-Q1 99-Q3 00-Q1 00-Q3 01-Q1 01-Q3 02-Q1 02-Q3 03-Q1 03-Q3 04-Q1 04-Q3 05-Q1 05-Q3 06-Q1 06-Q3 07-Q1 07-Q3 08-Q1 08-Q3 09-Q1 09-Q3 10-Q1 10-Q3 Long-acting opioids Short-acting opioids Year/Quarter 14

15. THANK YOU! For electronic copies of this presentation, please e-mail Melinda Fujiwara vasudha@u.washington.edu For questions or feedback, please e-mail Gary Franklin meddir@u.washington.edu