Washington State: The Fine Print

Much has been made of the public policy initiatives of the state of Washington in the area of prescription narcotics.  To quote from a workcompcentral article (subscription required) this week: “The CDC held out Washington as an example of a state that is aggressively tackling problems with excessive opioid prescriptions.  Five medical boards and commissions passed measures requiring a provider to perform a full assessment of a patient’s health history and past treatment of pain when prescribing opioids.  Doctors are required to prepare a treatment plan, and also seek a consultation for any prescription that exceeds the equivalent of a 120 mg dose of orally administered morphine per day.”

And another article appears to indicate that the state’s 2007 dosage guidelines may, in fact, have led to a drop in both the dosage levels and overdose deaths associated with opioids. 

I applaud these efforts as a necessary step toward mitigating the public health crisis of prescription drug over-utilization.  In particular, I’m appreciative of the efforts of Dr. Gary Franklin, Medical Director for the Washington State Department of Labor and Industries, who has served as a voice of reason on this issue. 

But I also want to make sure we collectively understand the fine print on the new rules, effective January 2, 2012.  For instance:

• Washington is a single payer state (i.e., the state essentially operates as a monopolistic work comp carrier).  This is a well-known fact and not exactly “fine print”, but it’s important to note because this makes translating public policy initiatives to other, non-monopolistic states a potentially more complicated proposition. 
• The rules provide for an exemption from the mandatory consultation requirement for the following: pain management specialists, doctors who have completed at least 12 hours of CE in chronic pain management (with at least 2 hours focused on long acting opioids), physicians who are “pain management practitioners” working in a multidisciplinary pain program or academic medical center, or any physician with at least 3 years of experience in a chronic pain management setting with at least 30% of current care being delivered in the area of chronic pain management.  Did you get all that?  In our experience, the presumption that “pain management specialists know better” is a dangerous one. 
• The rules do not require doctor/patient narcotics contracts unless the patient is deemed “at high risk for medication abuse, or has a history of substance abuse, or psychiatric comorbidities.”  This conflicts with the ACOEM guidelines, which suggest initiation of such a contract for any patient being prescribed an opioid for chronic non-cancer pain.      
• And what happens if a doctor doesn’t follow these rules?  The commission goes out of its way to state, within rule set itself (WAC 246-919-850), that “physicians should not fear disciplinary action from the commission for ordering, prescribing, dispensing, or administering controlled substances, including opioid analgesics, for a legitimate medical purpose…”  Until the commission intervenes with punitive action for non-compliant physicians, I’m not convinced the rules will have their intended (and much needed) effect. 

I don’t mean to be overly critical.  These rules are an excellent start and a good step in the right direction.  But for employers and insurers in other states waiting for legislation to fix the problem of opioid abuse in work comp, don’t hold your breath.  Get to work on a market-driven solution. 

Michael
On Twitter @PRIUM1