Background: Pain Management Rules and Guidelines. In 2011, the Medical Quality Assurance Commission, the Board of Osteopathic Medicine and Surgery, the Podiatric Medical Board, the Dental Quality Assurance Commission, and the Nursing Care Quality Assurance Commission were required to adopt rules on chronic, non-cancer pain management. The rules do not apply to palliative, hospice, or end-of-life care, or to the management of acute pain caused by an injury or surgical procedure. The rules contain:

dosing criteria, including a dosage amount that may not be exceeded without consultation with a pain management specialist, and special circumstances under which the dosage may be exceeded without a consultation;
guidance on when to seek specialty consultation and ways in which electronic specialty consultation may be sought;
guidance on tracking clinical progress by using assessment tools; and
guidance on tracking the use of opioids.

Separately, the Agency Medical Directors' Group has adopted guidelines on prescribing opiates for pain. The guidelines contain recommendations applicable to all pain phases, as well as recommendations specific to different types or phases of pain. Generally, they recommend prescribing opiates at the lowest possible effective dose.

Health Care Authority (HCA) Action. In 2017, HCA implemented an opiate prescription policy for Apple Health that went into effect on November 1, 2017. Under the policy, opiate prescription limits for first-time, non-cancer pain patients are:

no more than 18 doses—approximately a three-day supply—for patients age 20 or younger.

no more than 42 doses—approximately a seven-day supply—for patients age 21 or older.

On January 2, 2018, the same policy went into effect for public employees and retirees enrolled in the Uniform Medical Plan (UMP).

Summary of Bill: Prescription limits and requirements. For first-time patients, health care practitioners must limit opiate prescriptions for outpatient use to a seven-day supply for patients 21 years old or older; and a three-day supply for patients 20 years old or younger.

When issuing a prescription for an opiate for more than a three-day supply to a first-time patient, a practitioner must discuss:

the risks of addiction with the patient;
the increased risk of addiction and overdose for patients with mental illness or a history of alcohol or substance abuse; and
the dangers of taking opiates with benzodiazepines, alcohol, or other central nervous system depressants.

The practitioner must also obtain signed written consent from the patient that includes:

the name and quantity of the opiate being prescribed and the amount of the initial dose;
a statement indicating that a controlled substance is a substance that the United States drug enforcement administration has identified as having potential for abuse; and
a statement that the practitioner discussed the risks of addiction with the patient.

Exceptions. The above limits do not apply to the treatment of pain associated with cancer, or for palliative, hospice, or other end-of-life care. The patient's medical record must indicate the condition triggering the opiate prescription in excess of the limits.

If a practitioner, in their professional medical judgment, believes an opiate supply of more than three or seven days is necessary to treat the patient's condition, the practitioner may issue a prescription for no greater quantity that is needed for the expected duration of pain. The practitioner must document the patient's condition triggering the prescription in the patient's medical record, and indicate that an alternative treatment was not appropriate.

Staff Summary of Public Testimony: PRO: The bill combats over-prescribing and would reduce the number of unused pills in the community. It would also allow patients to make more informed decisions after discussing addiction risks. The prescription limits are evidence-based and consistent with the Center for Disease Control guidelines. The legislative process is the proper vehicle to address the opioid crisis because rulemaking is uncertain and cannot produce rules in time to address the immediate need.

CON: Prescription limits should be addressed through the rulemaking process, not legislation. Rulemaking allows for more thoughtful decision making and the rulemaking body has the proper expertise to address the issue. Rulemaking will also allow more flexibility in the future to adjust requirements as necessary. It is too difficult to change legislation once it is enacted. Statutorily limiting access to opiates will hurt the people who really need them.

OTHER: Prescription limits should be addressed through rulemaking, not legislation.

Persons Testifying: PRO: Senator Annette Cleveland, Prime Sponsor; Michelle Braun, citizen; Kelly Richburg, Senior Policy Analyst, Office of the Attorney General; Bob Ferguson, Washington Attorney General; Lori Grassi, Washington State Chiropractic Association. CON: Katie Kolan, Washington State Medical Association; Lisa Thatcher, Washington State Hospital Association; Nathan Schlicher, Washington State Medical Association; Charles Hoenhous, citizen; Cyndi Hoenhous, citizen; Leslie Emerick, ARNPS United of Washington. OTHER: Mellani McAleenan, Washington State Dental Association; Gary Franklin, Agency Medical Director's Group.