Frequently Asked Questions (FAQs) for Practitioners
Background
Will these rules impact all types of pain management?
Why is the state doing rules?
Why is this important?
What professions must comply with the rules?
What boards or commissions must adopt rules?
When are the rules effective?
What about existing rules?
What about other professions that also prescribe?
What was the process to create these rules?
Why did the workgroup contain just these professions?
Rule Content – General
Why is “should” used sometimes and “shall” used at other times?
Will there be a “grace” period or delayed effective date for the rules?
Consultation – Exempt Practitioner, Pain Specialist
Why is there a requirement to consult a pain specialist?
Are there practitioner exemptions for the consultation requirement?
For my patient who has been on a dosage regimen higher than 120 mg MED, do I have to consult with a pain specialist?
Will I receive a certificate to show that I am an exempt practitioner or a pain specialist?
Who is going to pay for a required consultation with a pain specialist?
Is there a list available of the pain specialists in the state?
There are not enough pain specialists in the state. How is this going to work?
Why aren’t face-to-face consultations required?
Why is an adult registered nurse practitioner (ARNP) listed as a pain specialist; but a physician assistant is not included in the list?
Continuing Education
Is there a grace period to obtain the continuing education required to be exempt or a specialist?
Will the CE be monitored?
If I took continuing education on pain management three years ago, do I have to take it again in the next 3-4 years?
How much CE is required and how often?
Morphine Equivalent Dosage (MED)
Why do the rules set a morphine equivalent dosage (MED) amount?
What table should I use to determine the daily morphine equivalency dose (MED)?
Is there a separate MED for children?
If I prescribe below 120mg MED for a patient, do I need to consult a pain specialist?
If a patient has been at 140mg MED for several years, do I need to consult a pain specialist?
Are there exemptions to the consultation requirement?
Prescription Monitoring Program (PMP)
Do the rules include a prescription monitoring program (PMP)?
Other Questions
I would like to have a conversation with someone about these rules. Who can I contact?
Will the state monitor or audit individual practices?
How can I stay informed about these rules?
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Background
Will these rules impact all types of pain management?
No. The rules do not apply to the treatment of chronic cancer pain or acute pain caused by an injury or a surgical procedure. The rules also do not apply to palliative, hospice, and other end of life care.
Why is the state doing rules?
The 2010 legislation requires five boards and commissions that regulate seven professions to adopt new rules related to chronic pain management. Three boards and commissions must also repeal current pain management rules. These boards and commissions have separate disciplining and rulemaking authority. The legislation requires rules for each profession. Rules are enforceable, unlike guidelines that are suggestions.
Why is this important?
Pain management is a dynamic and challenging area of medical care. This care often includes the use of opioids. Overdose deaths and hospitalizations involving prescription pain medicine have increased in Washington State over the last 16 years. In 2009 there were 17 times more deaths and 7 times more hospitalizations than in 1995. The legislature is concerned about the health risks of managing chronic, long-term pain and in 2010 passed
Engrossed Substitute House Bill 2876 in response to these concerns.
What professions must comply with the rules?
The professions include: Physicians and physician assistants, osteopathic physicians and osteopathic physician assistants, advanced registered nurse practitioners, dentists, and podiatrists.
What boards or commissions must adopt the rules?
The legislation specifically names the Medical Quality Assurance Commission (MQAC), Nursing Care Quality Assurance Commission (NCQAC), Board of Osteopathic Medicine and Surgery (BOMS), Dental Quality Assurance Commission (DQAC), and Podiatric Medical Board (PMB).
When are the rules effective?
The rules for osteopathic physicians, osteopathic physician assistants, dentists, advanced registered nurse practitioners, and podiatrists are effective July 1, 2011. The BOMS, DQAC NCQAC, and PMB are the boards and commissions that adopted these rules.
The rules for physicians and physician assistants are effective January 2, 2012. The MQAC
is the commission that adopted these rules.
What about existing rules?
Three boards and commissions (MQAC, BOMS, and PMB) must repeal existing pain management rules. The repeal effective dates for each of the boards and commission are the same as the effective dates for the new rules.
What about other professions who also prescribe?
There are other professions with prescribing or dispensing authority, such as optometrists, veterinarians, and pharmacists. The 2010 legislation did not require those professions to adopt rules on this subject.
What was the process to create these rules?
The five named boards and commissions each appointed two representatives to form a workgroup. The workgroup developed pattern rules for consideration by each of the boards and commissions. The workgroup conducted five open public meetings and provided opportunities for the public to provide comments.
Each of the five boards and commissions considered the draft pattern rules and filed proposed rules in January and February, 2011. Five public rule hearings were held in March and April, 2011. Each board and commission adopted final rules after their hearing.
Why did the workgroup contain just these professions?
The workgroup was comprised of representatives from the five boards and commissions required to adopt rules. The 2010 legislature did not require other professions to adopt rules on chronic pain management. The workgroup and the department did recognize the very important role that pharmacists and other professions have in this subject matter and input was sought from other professions and stakeholders.
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Rule Content – General
Why is “should” used sometimes and “shall” used at other times?
The law requires that the rules contain certain mandatory elements and provide guidance for other elements. For this reason the rules have requirements for some areas and guidance or recommendations for others. “Shall” is used to mean “has a duty to,” that is, to require the performance of the act. “Should” is used to mean a recommendation or guidance for the act.
Is there a grace period before practitioners must comply with the rules?
No. The requirements begin when the rules are effective
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Consultation – Exempt Practitioner, Pain Specialist
Why is there a requirement to consult a pain specialist?
The law has several requirements for the rules that are built around consultation with a pain specialist. These include a dosage amount that must not be exceeded without consulting a practitioner specializing in pain management, circumstances when this dosage amount may be exceeded without the consultation, and rules regarding consultation with a practitioner specializing in pain management.
Are there practitioner exemptions for the consultation requirement?
Yes. The rules describe the specific criteria to be an exempt practitioner or to be considered a pain specialist. You are encouraged to consult your legal counsel for practice-specific questions.
For my patient who has been on a dosage regimen higher than 120 mg MED, do I have to consult with a pain specialist?
Not necessarily. The rules provide exemptions for exigent and special circumstances. You must document adherence to all standards of practice defined in the rules for your profession and the patient is following a tapering schedule, or requires treatment for acute pain, or you document your reasonable attempts to obtain a consultation, or you document that your patient’s pain and function is stable and the patient is on a nonescalating dosage opioids.
Will I receive a certificate to show that I am an exempt practitioner or a pain specialist?
No. The rules do not require that you submit proof to anyone that you are exempt or a pain specialist. The rules only require that you meet the required criteria. Practitioners should always retain documentation that shows they meet education, training, or CE requirements.
Who is going to pay for a required consultation with a pain specialist?
The boards and commissions do not have jurisdiction or authority over insurance coverage or who will pay for care. The rules do not address this topic.
Is there a list available of the pain specialists in the state?
No. Licenses are issued by profession and not by specialty. The department does not have a list of pain specialists.
There are not enough pain specialists in the state. How is this going to work?
This is a concern for the boards and commissions. For this reason, the rules contain options and exemptions related to the consultation requirement.
Why aren’t face-to-face consultations required?
The boards and commissions understand the challenges that patients and practitioners in rural areas face when attempting to obtain care. The rules intend to provide for flexibility for patients and practitioners in rural or remote locations. The law requires that the rules minimize the burden on practitioners and patients. Requiring only face-to-face consultations would have placed a greater burden on practitioners and patients.
Why is an advanced registered nurse practitioner (ARNP) listed as a pain specialist; but a physician assistant is not included in the list?
ARNPs are independent practitioners. PAs are not independent practitioners and work under a supervising physician or osteopathic physician. The rules do not restrict PAs from providing pain management care under the supervision of a pain specialist.
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Continuing Education
Is there a grace period to obtain the continuing education required to be exempt or a specialist?
No. The boards and commissions determined that the required CE is attainable within a short period of time.
Will the CE be monitored?
No. But, the disciplinary authorities do conduct random audits on practitioners to ensure the continuing education (CE) requirements are met. You may be asked to provide copies of completed CE and should always retain these records.
If I took continuing education on pain management three years ago, do I have to take it again in the next 3-4 years?
Yes. The continuing education must be completed within the last two years for physicians, dentists, ARNPs, and podiatrists. Osteopathic physicians must complete the CE every three years which is the CE cycle for this profession.
How much CE is required and how often?
It depends upon your profession.
- All of the professions included in the rules require 12 hours within the last two years in order to be exempt from the consultation requirement. At least two of these hours dedicated to long acting opioids.
- Osteopathic physicians have a 3-year CE cycle. They may complete 18 hours within the last three years.
- The rules suggest a one-time (lifetime) completion of at least four hours of CE related to long-acting opioids or methadone. This is included in the rules because the boards and commissions believe it is important that practitioners who prescribe opioids should be familiar with its risks and use.
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Morphine Equivalent Dosage – Med
Why do the rules set a morphine equivalent dosage (MED) amount?
The law requires that the rules must contain dosing criteria to include a dosage amount that must not be exceeded unless the practitioner either consults with a practitioner specializing in pain management or the prescriber or patient are exempt. An MED is used because one drug is not necessarily the same as another. One drug may need a higher dosage amount than another to achieve the same result.
What table should I use to determine the daily morphine equivalency dose (MED)?
The rules include a generally accepted definition for MED. The boards and commissions determined to not include a conversion table in the rules. Technology, knowledge, and medication changes occur frequently. Conversion tables could quickly become outdated. The boards and commissions believe practitioners should be able to decide which conversion table to
use. The Washington State Agency Medical Director’s Group (AMDG) provides information on dosing guidelines. Please see the pain management web page for resources like the AMDG.
Is there a separate MED for children?
No. The legislation does not specify any specific patient population. The rules were clarified to indicate that the 120 mg MED is for adults and based on an oral dose. The rules further indicate that great care should be used with prescribing opioids to children and that appropriate referral to a specialist is encouraged.
If I prescribe below 120mg MED for a patient, do I need to consult a pain specialist?
No. The mandatory consultation threshold for adults is 120mg MED. A consultation with a pain specialist is required if the prescribed dosage amount exceeds 120mg MED orally per day, unless the consultation is exempted. The exemptions are listed in the rules.
If a patient has been at 140 mg MED for several years, do I need to consult a pain specialist?
No. For a patient with stable pain and function, on a non-escalating dosage of opioids, the consultation requirement would not be required as long as the practitioner documents these items.
Are there exemptions to the consultation requirement?
Yes. The exemptions are listed in the rules under two sections: Consultation – Exemptions for exigent and special circumstances; and Consultation – Exemptions for the (specific practitioner profession named), for example “dentist”, “physician”, etc.
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Prescription Monitoring Program (PMP)
Do the rules include a prescription monitoring program (PMP)?
No. The pain management legislation requires the boards and commissions to include guidance on tracking the use of opioids. In 2007 the legislature authorized the Department of Health (department) to develop and implement a PMP when funding is available. The department recently received a grant and is developing a PMP. The rules include references to the use of any available PMP or emergency department-based information exchange.
Other Questions
I would like to have a conversation with someone about these rules. Who can I contact?
We encourage you to review the rules and the FAQs. If you have general questions, please email them to
painmanagement@doh.wa.gov. You can also call 360-236-4997. You may also send technical profession questions to us and we will direct them to the appropriate board or commission.
For situation specific questions related to your practice, we encourage you to speak with your legal counsel.
Will the state monitor or audit individual practices?
No.
How can I stay informed about implementation of these rules?
We have created a
pain management listserv and
website to keep people informed. You can join this listserv, or the listserv for one of the named professions, to receive regular emails about the pain management. You may send questions to
painmanagement@doh.wa.gov.
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