Overview of the New Washington State Prescribing Requirements

The Opioid Crisis

Hundreds of people in Washington State die from opioid overdoses each year, both from prescription drugs and from other narcotics such as heroin. The problem is a public health crisis. Many who survive overdoses are still prescribed opioids after the overdose. In October 2016, Gov. Jay Inslee issued an executive order calling opioid use disorder “a devastating and life-threatening medical condition.” His order called for action to curb opioid misuse and abuse.

Legislative Response

In 2017, the legislature passed a law that focuses on improving opioid prescribing and on monitoring prescriptions. The law requires five healthcare professional boards and commissions to adopt new rules for prescribing opioid drugs:

* Medical Commission

* Board of Osteopathic Medicine and Surgery

* Nursing Commission

* Dental Quality Assurance Commission

* Podiatric Medical Board

Implementation Dates

The new requirements for advanced registered nurse practitioners, osteopathic physicians, osteopathic physician assistants, and podiatric physicians became effective on November 1, 2018.

The requirements for medical doctors and allopathic physician assistants and will become effective January 1, 2019.

Exclusions

The new opioid prescribing rules do not apply when treating patients with cancer-related pain, palliative, hospice, end-of -life care, inpatient and observation hospital patients, or procedural pre-medications.

New Opioid Prescribing Limits

Acute Pain (0-6 weeks ): Seven-day limit for acute non-operative and fourteen-day limit for acute perioperative unless clinically documented.

Subacute Pain (6-12 weeks): Fourteen-day limit unless clinically documented.

Chronic Pain (12+ weeks):

* Mandatory pain consultation when prescribing over 120 MED (morphine equivalents per day).

* Complete a written agreement for treatment

* Confirm or provide naloxone when prescribing opioids to a high risk patient or as clinically indicated (ARNP requirement for naloxone when 50 MED or above)

ARNP’s are also required to provide an ICD-10 code on all opioid prescriptions.

Prescription Monitoring Program (PMP)

Providers must also complete a PMP query when prescribing opioids. In 2007, Washington passed RCW 70.225 which created Washington’s PMP also known as Prescription Monitoring Program. The program was created with the purpose to improve patient care and stop prescription drug misuse by collecting dispensing records for Schedule II, III, IV and V drugs and making the information available to medical providers and pharmacists as a patient care tool. Program rules, WAC 246-470, took effect August 27, 2011. The program started data collection from all dispensers October 7, 2011.

Any provider who intends to prescribe an opioid in Washington State must individually register with the Prescription Monitoring Program. The frequency of PMP queries required varies depending on prescriber type.

For example, ARNP’s are required to complete a PMP query at:

* First opioid prescription

* First opioid prescription refill or renewal

* At each pain transition treatment phase (acute to subacute and subacute to chronic)

* Periodic intervals for patient with chronic non-cancer pain

Co-Prescribing

Due to the increased risk of side effects, opioids shall not be prescribed with the following medications without documentation in patient record, discussion of risks, and consultation with prescribers of other medications for patient care plan or consideration of tapering:

· Benzodiazepines

· Barbiturates

· Sedatives

· Carisoprodol

· Non-benzodiazepine hypnotics (Z drugs)

Possible side effects include sedation, altered sleep pattern, fall risk, decreased respiration, constipation, confusion, and delirium.

Please refer to https://www.doh.wa.gov/opioidprescribing for detailed prescribing requirements and provider toolkits.