HOUSE BILL REPORT

HB 1339

As Reported by House Committee On:

Health Care & Wellness

Title: An act relating to restrictions on prescriptions for opioid drugs.

Brief Description: Providing for restrictions on prescriptions for opioid drugs.

Sponsors: Representatives Cody, Harris, Jinkins, Johnson, Kagi, Lovick, Ormsby and Slatter.

Brief History:

Committee Activity:

Health Care & Wellness: 2/1/17, 2/17/17 [DPS].

Majority Report: The substitute bill be substituted therefor and the substitute bill do pass. Signed by 13 members: Representatives Cody, Chair; Macri, Vice Chair; Schmick, Ranking Minority Member; Clibborn, DeBolt, Harris, Jinkins, Riccelli, Robinson, Rodne, Slatter, Stonier and Tharinger.

Minority Report: Do not pass. Signed by 4 members: Representatives Graves, Assistant Ranking Minority Member; Caldier, MacEwen and Maycumber.

Staff: Alexa Silver (786-7190).

Background:

Prescriptive Authority.

It is unlawful to possess, deliver, or dispense a legend drug except pursuant to a prescription issued by a health care provider who has prescriptive authority under Washington law. Providers with prescriptive authority include allopathic and osteopathic physicians and physician assistants, advanced registered nurse practitioners, dentists, naturopaths, optometrists, podiatric physicians, and veterinarians.

Prescriptions must be for a legitimate medical purpose and within the provider's scope of practice. Depending on the profession, restrictions may apply. For example, optometrists may not prescribe a controlled substance for more than seven days in treating a patient for a single trauma, episode, or condition.

Pain Management Rules and Guidelines.

In 2011 the Medical Quality Assurance Commission, Board of Osteopathic Medicine and Surgery, Podiatric Medical Board, Dental Quality Assurance Commission, and Nursing Care Quality Assurance Commission were required to adopt rules on chronic, noncancer 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 opioids 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 opioids at the lowest possible effective dose.

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Summary of Substitute Bill:

By January 1, 2018, disciplining authorities must adopt rules establishing requirements for prescribing opioid drugs. The rules must be consistent with the Interagency Guideline for Prescribing Opioids for Pain developed by the Washington State Agency Medical Directors' Group. A practitioner who violates the rules commits unprofessional conduct under the Uniform Disciplinary Act.

To prescribe an opioid drug, a practitioner must annually complete one hour of continuing education regarding best practices in the prescribing of opioid drugs. A disciplining authority may adopt additional continuing education requirements related to prescribing opioid drugs.

"Opioid drug" means any substance having an addiction-forming or addiction-sustaining liability similar to morphine or being capable of conversion into a drug having addiction-forming or addiction-sustaining liability. It excludes opioid overdose medications and medications approved by the Food and Drug Administration for treating opioid use disorder. A "practitioner" is any licensed health professional who is authorized to prescribe opioid drugs. A "disciplining authority" is the agency, board, or commission that has authority to take disciplinary action against a practitioner.

Substitute Bill Compared to Original Bill:

The substitute bill strikes the underlying provisions of the bill, which limited prescriptions for opioids drugs issued to a patient for the first time for outpatient use, and adds the continuing education and rulemaking requirements.

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Appropriation: None.

Fiscal Note: Available. New fiscal note requested on February 17, 2017.

Effective Date of Substitute Bill: The bill takes effect 90 days after adjournment of the session in which the bill is passed.

Staff Summary of Public Testimony:

(In support) Opioid use disorder is rampant in this state, and the problem has partly been created by physicians. Humans have an excellent pain system, but taking opioids cheats this system. If opioids are taken for too long a period of time, people may become addicted; quitting is hard because of the withdrawal symptoms. Physicians take an oath to do no harm, but prescribing opioids for a long duration causes harm.

(Opposed) Arbitrary limits do not comport with real world pain management. Only the treating practitioner can best determine a patient's medical needs. The bill would add barriers to patients seeking appropriate care, create undue burdens for physicians, and add waste and inefficiencies to the health care delivery system. The seven-day limit is ambiguous, and it is unclear what would be a legitimate documentation of an exception. In other states that have passed similar bills, patients are hoarding their pills.

Washington has taken significant steps to reduce the opioid epidemic, and deaths from prescription drug overdoses have been steadily declining. Before the 1990s, doctors did not prescribe opioids for pain because they were considered too addictive, but then pain was recognized as the fifth vital sign, extended release opioid drugs were released to the market, and intractable pain laws were enacted. This bill swings the pendulum too far back in the other direction. The best practices in this bill may not always be considered best practices.

Better solutions are to encourage patients and practitioners to be engaged on pain strategies, create awareness about removing excess drugs from homes, develop guidelines, and encourage voluntary continuing education programs. Dentists have approved a resolution to reduce opioid abuse, which establishes and promotes prescribing protocols. Dentists should check the prescription monitoring program and take online training.

Even with major reconstructive surgery performed by a dentist, a patient could only get a three-day supply. This would cause confusion, because some practitioners have both a dental license and a medical doctor license.

(Other) In rural areas, advanced registered nurse practitioners have had patients who had dental surgery prior to the weekend and then run out of medication over the weekend.

Persons Testifying: (In support) Asif Khan.

(Opposed) Katie Kolan and Kent Hu, Washington State Medical Association; Scott Kennedy, Washington State Hospital Association; Craig Neal, Washington State Society of Oral and Maxillofacial Surgeons; and Amy Cook, Washington Dental Association.

(Other) Leslie Emerick, Advanced Registered Nurse Practitioners United.

Persons Signed In To Testify But Not Testifying: None.