DEPARTMENT OF HEALTH

(Podiatric Medical Board)

[Filed March 18, 2020, 11:14 a.m.]

Preproposal statement of inquiry was filed as WSR 19-18-018.

Title of Rule and Other Identifying Information: WAC 246-922-700 Acute perioperative pain, 246-922-780 Coprescribing of opioids for patients receiving medication assistant treatment, and 246-922-790 Prescription monitoring program—Required registration, queries, and documentation. The podiatric medical board (board) is proposing amendments to the requirements for checking the prescription monitoring program (PMP) when prescribing opioids, as well as correcting other typographical errors.

Hearing Location(s): On April 30, 2020, at 1:00 p.m. In response to the coronavirus disease 2019 (COVID-19) public health emergency, the podiatric medical board will not provide a physical location for this hearing to promote social distancing and the safety of the citizens of Washington state. A virtual public hearing, without a physical meeting space, will be held instead.

To access the meeting online https://global.gotomeeting.com/join/458100637.

You can also dial-in using your phone: Call in: +1 (646) 749-3122, Access Code: 458-100-637.

Date of Intended Adoption: April 30, 2020.

Submit Written Comments to: Susan Gragg, P.O. Box 47852, Olympia, WA 98504-7852, email https://fortress.wa.gov/doh/policyreview, by April 24, 2020.

Assistance for Persons with Disabilities: Contact Susan Gragg, phone 360-236-4941, TTY 711, email podiatric@doh.wa.gov, by April 24, 2020.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The podiatric medical board (board) is proposing amendments regarding the requirement for podiatric physicians to check the PMP when prescribing opioids; the proposed rule would change the requirement from the second refill or renewal to the first refill or renewal.

In addition, the board is proposing three typographical error corrections: WAC 246-922-700 Acute perioperative pain, when the board initially adopted this rule section to implement ESHB 1427, it was discovered after adoption that a cut-and-paste error had occurred. The board intended to state "a three day supply or less will often be sufficient; more than a fourteen-day supply will rarely be needed." This language is almost identical to language in WAC 246-922-695 for acute nonoperative pain; however, the verbiage in WAC 246-922-695 stated "a seven-day supply will rarely be needed." The copy-and-paste error was made in that the seven-day supply verbiage was not updated to a fourteen-day supply for WAC 246-922-700. The proposed rule amendment will correct that error.

WAC 246-922-780 Coprescribing of opioids for patients receiving medication assistant treatment, it was discovered that the title incorrectly says "medical assistant treatment" when is [it] should be "medication assisted treatment." This proposed rule amendment will correct that error.

WAC 246-922-790 Prescription monitoring program—Required registration, queries, and documentation, it was also discovered that a reference in subsection (8) referred to WAC 246-922-755 but should have referred to WAC 246-922-775. This proposed rule amendment will also correct that error.

Reasons Supporting Proposal: In 2017, the legislature passed ESHB 1427 (chapter 297, Laws of 2017) directing the board, along with four other health profession boards and commissions, to adopt rules establishing requirements for prescribing opioid drugs for seven health professions.

The board participated in a workgroup task force with those boards and commissions to develop model rules that each board and commission would then customize to align with the specific practice areas to which they would be applied. With an effective date of November 1, 2018, the board held one of the first rule adoption hearings and adopted rule language that closely mirrored the task force model rules. The other boards and commissions subsequently modified the model rule language with more restrictive PMP query requirements.

The board is considering amendments to more closely align their PMP query requirement with the other board and commissions. In addition, after the effective date, it was discovered there were typographical errors in three section[s] of the adopted rules. The board will consider correcting these errors, as well as consider changes to the PMP query requirement.

Statutory Authority for Adoption: RCW 18.22.015 and 18.22.800.

Statute Being Implemented: RCW 18.22.800.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Washington state podiatric medical board, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Susan Gragg, 111 Israel Road S.E., Tumwater, WA 98501, 360-236-4941.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Susan Gragg, P.O. Box 47852, Olympia, WA 98504-7852, phone 360-236-4941, TTY 711, email podiatric@doh.wa.gov.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The proposed rules do not impose any costs on businesses. Minor costs may be imposed on individual providers.

Randy Andersen, DPM, Chair

Podiatric Medical Board

AMENDATORY SECTION(Amending WSR 18-20-085, filed 10/1/18, effective 11/1/18)

WAC 246-922-700Acute perioperative pain.

The podiatric physician shall comply with the requirements in this section when prescribing opioid analgesics for perioperative pain and shall document completion of these requirements in the patient record:

(1) The podiatric physician, or his or her authorized designee, shall conduct queries of the PMP in accordance with the provisions of WAC 246-922-790 and document their review and any concerns in the patient record.

(2) If the podiatric physician prescribes opioids for effective pain control, such prescription must not be in a greater quantity than needed for the expected duration of pain severe enough to require opioids. A three-day supply or less will often be sufficient; more than a ((seven-day))fourteen-day supply will rarely be needed. The podiatric physician shall not prescribe beyond a fourteen-day supply from the time of discharge without clinical documentation in the patient record to justify the need for such a quantity. For more specific best practices, the podiatric physician may refer to clinical practice guidelines including, but not limited to, those produced by the agency medical directors' group, the Centers for Disease Control and Prevention, or the Bree Collaborative.

(3) The podiatric physician shall reevaluate the patient who does not follow the expected course of recovery. If documented improvement in function or pain control has not occurred, the podiatric physician shall reconsider the continued use of opioids or whether tapering or discontinuing opioids is clinically indicated.

(4) Follow-up visits for pain control should include objectives or metrics to be used to determine treatment success if opioids are to be continued. This may include:

(a) Change in pain level;

(b) Change in physical function;

(d) Additional planned diagnostic evaluations or other treatments.

(5) If the podiatric physician elects to prescribe a combination of opioids with a Schedule II-V medication listed in WAC 246-922-775 or prescribes opioids to a patient known to be receiving a medication listed in WAC 246-922-775 from another practitioner, such prescribing must be in accordance with WAC 246-922-775.

(6) If the podiatric physician elects to treat a patient with opioids beyond the six-week time period of acute perioperative pain, the podiatric physician shall document in the patient record that the patient is transitioning from acute pain to subacute pain. Rules governing the treatment of subacute pain in WAC 246-922-705 and 246-922-710 shall apply unless there is documented improvement in function or pain control and there is a documented plan and timing for discontinuation of all opioid medications.

AMENDATORY SECTION(Amending WSR 18-20-085, filed 10/1/18, effective 11/1/18)

WAC 246-922-780Coprescribing of opioids for patients receiving medication ((assistant))assisted treatment.

(1) Where practicable, the podiatric physician providing acute nonoperative pain or acute perioperative pain treatment to a patient known to be receiving MAT shall prescribe opioids for pain relief either in consultation with the MAT prescribing practitioner or a pain specialist.

(2) The podiatric physician shall not discontinue MAT medications when treating acute nonoperative pain or acute perioperative pain without documentation of the reason for doing so, nor shall these medications be used to deny necessary operative intervention.

AMENDATORY SECTION(Amending WSR 18-20-085, filed 10/1/18, effective 11/1/18)

WAC 246-922-790Prescription monitoring program—Required registration, queries, and documentation.

(1) The podiatric physician shall register to access the PMP or demonstrate proof of having registered to access the PMP if the podiatric physician prescribes opioids in Washington state.

(2) The podiatric physician is permitted to delegate performance of a required PMP query to an authorized designee in accordance with WAC 246-470-050.

(3) At a minimum, the podiatric physician shall ensure a PMP query is performed prior to the prescription of an opioid at the following times:

(a) Upon the ((second))first refill or renewal of an opioid prescription for acute nonoperative pain or acute perioperative pain;

(b) The time of transition from acute to subacute pain; and

(4) For chronic pain management, the podiatric physician shall ensure a PMP query is performed at a minimum frequency determined by the patient's risk assessment, as follows:

(a) For a high-risk patient, a PMP query shall be completed at least quarterly.

(b) For a moderate-risk patient as determined using the risk assessment tool described in WAC 246-922-715, a PMP query shall be completed at least semiannually.

(c) For a low-risk patient as determined using the risk assessment tool described in WAC 246-922-715, a PMP query shall be completed at least annually.

(5) The podiatric physician shall ensure a PMP query is performed for any chronic pain patient immediately upon identification of aberrant behavior.

(6) The podiatric physician shall ensure a PMP query is performed when providing episodic care to a patient who the podiatric physician knows to be receiving opioids for chronic pain, in accordance with WAC 246-922-770.

(7) For the purposes of this section, the requirement to consult the PMP does not apply when the PMP or the electronic medical record (EMR) cannot be accessed by the podiatric physician due to a temporary technological or electrical failure.

(8) If the podiatric physician is working in a practice, group, or institution that integrates access to the PMP into the workflow of the EMR, the podiatric physician shall ensure a PMP query is performed for all prescriptions of opioids and coprescribed medications listed in WAC ((246-922-755))246-922-775(1) for acute pain.

(9) Pertinent concerns discovered in the PMP must be documented in the patient record.