Effective Date of Rule: July 1, 2011.

     Purpose: ESHB 2876 (chapter 209, Laws of 2010) directs the dental quality assurance commission to adopt new rules for the management of chronic noncancer pain. The adopted rules include the mandatory elements for dosing criteria, guidance on specialty consultations, guidance on tracking clinical progress, and guidance on tracking opioid use. The adopted rules also describe practitioner consultation exemptions.

     Statutory Authority for Adoption: RCW 18.32.785.

     Other Authority: RCW 18.32.0365.

      Adopted under notice filed as WSR 11-04-088 on February 2, 2011.

     Changes Other than Editing from Proposed to Adopted Version: The adopted rules include the following changes from the proposed rules published as WSR 11-04-088:

     •     Definitions, WAC 246-817-910.

          o     The terms "episodic care," "morphine equivalent dose," and "multidisciplinary pain clinic" are added to the definitions.

          o     The terms "physical dependence," "psychological dependence," and "tolerance" are deleted as these terms are not used in the rules.

     •     Written agreement for treatment, WAC 246-817-930(4), "or multidisciplinary pain clinic" and "or pharmacy system" are added.

     •     Long-acting opioids, including methadone, WAC 246-817-940, in the third sentence, after "one-time," "(lifetime)" is added.

     •     Consultation: Recommendations and requirements, WAC 246-817-950(2), "threshold for adults" is added to clarify the morphine equivalent dose (MED) threshold is for adults. The word "oral" is also added to clarify that the threshold is based on an "oral" dose. Language regarding pediatric patients is also added at the end of the paragraph: "Great caution should be used when prescribing opioids to children with chronic noncancer pain and appropriate referrals to a specialist is encouraged."

     •     Pain management specialist, WAC 246-817-965 (1)(d)(iii) and (3)(d), language is added to clarify that the current practice may also be in a multidisciplinary pain clinic setting.

     The adopted rules also include edits for grammar, punctuation, and formatting.

     A final cost-benefit analysis is available by contacting Jennifer Santiago, P.O. Box 47852, Olympia, WA 98504-7852, phone (360) 236-4893, fax (360) 236-2901, e-mail jennifer.santiago@doh.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 14, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 14, Amended 0, Repealed 0.

     Date Adopted: March 25, 2011.

Andrew A. Vorono, Chair

Dental Quality Assurance Commission

OTS-3816.4

PAIN MANAGEMENT
NEW SECTION
WAC 246-817-901   Pain management -- Intent.   These rules govern the use of opioids in the treatment of patients for chronic noncancer pain.

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     (1) The provision of palliative, hospice, or other end-of-life care; or

     (2) The management of acute pain caused by an injury or surgical procedure.

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     (1) "Acute pain" means the normal, predicted physiological response to a noxious chemical, thermal, or mechanical stimulus and typically is associated with invasive procedures, trauma, and disease. It is generally time-limited, often less than three months in duration, and usually less than six months.

     (2) "Addiction" means a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include:

     (a) Impaired control over drug use;

     (b) Craving;

     (c) Compulsive use; or

     (d) Continued use despite harm.

     (3) "Chronic noncancer pain" means a state in which noncancer pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.

     (4) "Comorbidity" means a preexisting or coexisting physical or psychiatric disease or condition.

     (5) "Episodic care" means medical care provided by a practitioner other than the designated primary care practitioner in the acute care setting, for example, urgent care or emergency department.

     (6) "Hospice" means a model of care that focuses on relieving symptoms and supporting patients with a life expectancy of six months or less. Hospice involves an interdisciplinary approach to provide health care, pain management, and emotional and spiritual support. The emphasis is on comfort, quality of life and patient and family support. Hospice can be provided in the patient's home as well as freestanding hospice facilities, hospitals, nursing homes, or other long-term care facilities.

     (7) "Morphine equivalent dose" means a conversion of various opioids to a morphine equivalent dose by the use of accepted conversion tables.

     (8) "Multidisciplinary pain clinic" means a clinic or office that provides comprehensive pain management and includes care provided by multiple available disciplines or treatment modalities, for example, medical care through physicians, physician assistants, osteopathic physicians, osteopathic physician assistants, advanced registered nurse practitioners, and physical therapy, occupational therapy, or other complementary therapies.

     (9) "Palliative" means care that improves the quality of life of patients and their families facing life-threatening illness. With palliative care particular attention is given to the prevention, assessment, and treatment of pain and other symptoms, and to the provision of psychological, spiritual, and emotional support.

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     (1) The patient's health history shall include:

     (a) Current and past treatments for pain;

     (b) Comorbidities; and

     (c) Any substance abuse.

     (2) The patient's health history should include:

     (a) A review of any available prescription monitoring program or emergency department-based information exchange; and

     (b) Any relevant information from a pharmacist provided to the dentist.

     (3) The initial patient evaluation shall include:

     (a) Physical examination;

     (b) The nature and intensity of the pain;

     (c) The effect of the pain on physical and psychological function;

     (d) Medications including indication(s), date, type, dosage, and quantity prescribed;

     (e) A risk screening of the patient for potential comorbidities and risk factors using an appropriate screening tool. The screening should address:

     (i) History of addiction;

     (ii) Abuse or aberrant behavior regarding opioid use;

     (iii) Psychiatric conditions;

     (iv) Regular concomitant use of benzodiazepines, alcohol, or other central nervous system medications;

     (v) Poorly controlled depression or anxiety;

     (vi) Evidence or risk of significant adverse events, including falls or fractures;

     (vii) Receipt of opioids from more than one prescribing practitioner or practitioner group;

     (viii) Repeated visits to emergency departments seeking opioids;

     (ix) History of sleep apnea or other respiratory risk factors;

     (x) Possible or current pregnancy; and

     (xi) History of allergies or intolerances.

     (4) The initial patient evaluation should include:

     (a) Any available diagnostic, therapeutic, and laboratory results; and

     (b) Any available consultations.

     (5) The health record shall be maintained in an accessible manner, readily available for review, and should include:

     (a) The diagnosis, treatment plan, and objectives;

     (b) Documentation of the presence of one or more recognized indications for the use of pain medication;

     (c) Documentation of any medication prescribed;

     (d) Results of periodic reviews;

     (e) Any written agreements for treatment between the patient and the dentist; and

     (f) The dentist's instructions to the patient.

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     (a) Any change in pain relief;

     (b) Any change in physical and psychosocial function; and

     (c) Additional diagnostic evaluations or other planned treatments.

     (2) After treatment begins the dentist should adjust drug therapy to the individual health needs of the patient. The dentist shall include indications for medication use on the prescription and require photo identification of the person picking up the prescription in order to fill. The dentist shall advise the patient that it is the patient's responsibility to safeguard all medications and keep them in a secure location.

     (3) Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment.

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     (1) The patient's agreement to provide biological samples for urine/serum medical level screening when requested by the dentist;

     (2) The patient's agreement to take medications at the dose and frequency prescribed with a specific protocol for lost prescriptions and early refills;

     (3) Reasons for which drug therapy may be discontinued (e.g., violation of agreement);

     (4) The requirement that all chronic pain management prescriptions are provided by a single prescriber or multidisciplinary pain clinic and dispensed by a single pharmacy or pharmacy system;

     (5) The patient's agreement to not abuse alcohol or use other medically unauthorized substances;

     (6) A written authorization for:

     (a) The dentist to release the agreement for treatment to local emergency departments, urgent care facilities, and pharmacies; and

     (b) Other practitioners to report violations of the agreement back to the dentist.

     (7) A written authorization that the dentist may notify the proper authorities if he or she has reason to believe the patient has engaged in illegal activity;

     (8) Acknowledgment that a violation of the agreement may result in a tapering or discontinuation of the prescription;

     (9) Acknowledgment that it is the patient's responsibility to safeguard all medications and keep them in a secure location; and

     (10) Acknowledgment that if the patient violates the terms of the agreement, the violation and the dentist's response to the violation will be documented, as well as the rationale for changes in the treatment plan.

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     (1) During the periodic review, the dentist shall determine:

     (a) Patient's compliance with any medication treatment plan;

     (b) If pain, function, or quality of life have improved or diminished using objective evidence, considering any available information from family members or other caregivers; and

     (c) If continuation or modification of medications for pain management treatment is necessary based on the dentist's evaluation of progress towards treatment objectives.

     (2) The dentist shall assess the appropriateness of continued use of the current treatment plan if the patient's progress or compliance with current treatment plan is unsatisfactory. The dentist shall consider tapering, changing, or discontinuing treatment when:

     (a) Function or pain does not improve after a trial period;

     (b) There is evidence of significant adverse effects;

     (c) Other treatment modalities are indicated; or

     (d) There is evidence of misuse, addiction, or diversion.

     (3) The dentist should periodically review information from any available prescription monitoring program or emergency department-based information exchange.

     (4) The dentist should periodically review any relevant information from a pharmacist provided to the dentist.

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     (2) Episodic care practitioners should avoid providing opioids for chronic pain management. However, if opioids are provided, the practitioner should limit the use of opioids for a chronic noncancer pain patient to the minimum amount necessary to control the pain until the patient can receive care from a primary care practitioner.

     (3) Prescriptions for opioids written by an episodic care practitioner shall include indications for use or the International Classification of Diseases (ICD) code and shall be written to require photo identification of the person picking up the prescription in order to fill.

     (4) If a patient has signed a written agreement for treatment and has provided a written authorization to release the agreement under WAC 246-817-930(6) to episodic care practitioners, then the episodic care practitioner should report known violations of the agreement back to the patient's treatment practitioner who provided the agreement for treatment.

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     (2) The mandatory consultation threshold for adults is one hundred twenty milligrams morphine equivalent dose (MED) (oral). In the event a dentist prescribes a dosage amount that meets or exceeds the consultation threshold of one hundred twenty milligrams MED (orally) per day, a consultation with a pain management specialist as described in WAC 246-817-965 is required, unless the consultation is exempted under WAC 246-817-955 or 246-817-960. Great caution should be used when prescribing opioids to children with chronic noncancer pain and appropriate referrals to a specialist is encouraged.

     (a) The mandatory consultation shall consist of at least one of the following:

     (i) An office visit with the patient and the pain management specialist;

     (ii) A telephone consultation between the pain management specialist and the dentist;

     (iii) An electronic consultation between the pain management specialist and the dentist; or

     (iv) An audio-visual evaluation conducted by the pain management specialist remotely, where the patient is present with either the dentist or a licensed health care practitioner designated by the dentist or the pain management specialist.

     (b) A dentist shall document each mandatory consultation with the pain management specialist. Any written record of the consultation by the pain management specialist shall be maintained as a patient record by the specialist. If the specialist provides a written record of the consultation to the dentist, the dentist shall maintain it as part of the patient record.

     (3) Nothing in this chapter shall limit any person's ability to contractually require a consultation with a pain management specialist at any time. For the purposes of WAC 246-817-901 through 246-817-965, "person" means an individual, a trust or estate, a firm, a partnership, a corporation (including associations, joint stock companies, and insurance companies), the state, or a political subdivision or instrumentality of the state, including a municipal corporation or a hospital district.

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     (1) The patient is following a tapering schedule;

     (2) The patient requires treatment for acute pain which may or may not include hospitalization, requiring a temporary escalation in opioid dosage, with expected return to or below their baseline dosage level;

     (3) The dentist documents reasonable attempts to obtain a consultation with a pain management specialist and the circumstances justifying prescribing above one hundred twenty milligrams morphine equivalent dose (MED) per day without first obtaining a consultation; or

     (4) The dentist documents the patient's pain and function is stable and the patient is on a non-escalating dosage of opioids.

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     (1) The dentist is a pain management specialist as described in WAC 246-817-965; or

     (2) The dentist has successfully completed, within the last two years, a minimum of twelve continuing education hours on chronic pain management approved by the profession's continuing education accrediting organization, with at least two of these hours dedicated to long acting opioids, to include methadone; or

     (3) The dentist is a pain management practitioner working in a multidisciplinary chronic pain treatment center, or a multidisciplinary academic research facility; or

     (4) The dentist has a minimum three years of clinical experience in a chronic pain management setting, and at least thirty percent of his or her current practice is the direct provision of pain management care.

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     (1) If a physician or osteopathic physician:

     (a) Board certified or board eligible by an American Board of Medical Specialties-approved board (ABMS) or by the American Osteopathic Association (AOA) in physical medicine and rehabilitation, rehabilitation medicine, neurology, rheumatology, or anesthesiology; or

     (b) Has a subspecialty certificate in pain medicine by an ABMS-approved board; or

     (c) Has a certification of added qualification in pain management by the AOA; or

     (d) A minimum of three years of clinical experience in a chronic pain management care setting; and

     (i) Credentialed in pain management by an entity approved by the Washington state medical quality assurance commission for physicians or the Washington state board of osteopathic medicine and surgery for osteopathic physicians; and

     (ii) Successful completion of a minimum of at least eighteen continuing education hours in pain management during the past two years; and

     (iii) At least thirty percent of the physician's or osteopathic physician's current practice is the direct provision of pain management care or is in a multidisciplinary pain clinic.

     (2) If a dentist: Board certified or board eligible in oral medicine or orofacial pain by the American Board of Oral Medicine or the American Board of Orofacial Pain.

     (3) If an advanced registered nurse practitioner (ARNP):

     (a) A minimum of three years of clinical experience in a chronic pain management care setting;

     (b) Credentialed in pain management by a Washington state nursing care quality assurance commission-approved national professional association, pain association, or other credentialing entity;

     (c) Successful completion of a minimum of at least eighteen continuing education hours in pain management during the past two years; and

     (d) At least thirty percent of the ARNP's current practice is the direct provision of pain management care or is in a multidisciplinary pain clinic.

     (4) If a podiatric physician:

     (a) Board certified or board eligible in a specialty that includes a focus on pain management by the American Board of Podiatric Surgery, the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, or other accredited certifying board as approved by the Washington state podiatric medical board; or

     (b) A minimum of three years of clinical experience in a chronic pain management care setting; and

     (c) Credentialed in pain management by a Washington state podiatric medical board-approved national professional association, pain association, or other credentialing entity; and

     (d) Successful completion of a minimum of at least eighteen hours of continuing education in pain management during the past two years, and at least thirty percent of the podiatric physician's current practice is the direct provision of pain management care.

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