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New Rules For Pain

Patricia Murphy

The statistics around opiate abuse in Washington state are striking. Overdose deaths now outpace the number of people killed in car accidents. Dr. Gary Franklin is medical director for the State Department of Labor and Industries (L & I).

Franklin: "I don't think most people realize how severe the problem is in the community with regard to people getting into trouble with high dose opiates that are prescribed to them."

In an effort to combat the problem, the Legislature passed a bill requiring the state's five medical boards and commissions to adopt new rules for prescribing opiates like OxyContin for chronic non–cancer pain.

The workgroup has its final meeting Monday. But there is fear that the rules, which take effect in June, will create new problems for an already vulnerable population of patients who use opiates to treat chronic pain. KUOW's Patricia Murphy reports.


By definition, chronic pain is pain that lasts more than six months. Treatment for the condition is as complex as the people who live with it. Integrated care for pain patients usually includes access to alternative therapies like biofeedback and acupuncture. But The American Pain Foundation's Elin Bjorling says these therapies simply aren't an option for some patients.

Bjorling: "A lot of people don't have access to those resources. Most people have access to a primary care provider. Most people don't have access to alternative medicine options."

So a lot of people with chronic pain depend on opiates to help them function. The drugs are tricky. Under the best circumstances, patients can develop tolerance; they can require escalating doses of the drugs to get the same level of relief.

Franklin: "The evidence that increasing the dose actually makes people better is really very flimsy." L&I's Dr. Gary Franklin says if there's no improvement, often that's a yellow flag that opiates aren't working well for a patient.

So to combat the potential for that scenario, Franklin says new rules will require doctors and nurse practitioners to track the progress of their patients on long–term opiates. They'll have to chart how well the drugs are working by tracking pain level and function.

It seems simple enough, at the bare minimum a physician can ask a couple of questions and have the answer. But the next part of the law has some people really worried.

If a doctor wants to prescribe opiates above a certain dose they'll have to consult with a so–called pain specialist before doing so.

Dr. Alex Cahana heads the University of Washington's Pain Clinic which specializes in providing patients integrated, cutting edge care.

Cahana: " If you have a patient and they're complaining of pain and you're escalating their doses and they're not getting better, when should you ask for help? Ask for help at that threshold. You wanna ask for help before? Ask for help before! Not a problem. But not later."

Elin Bjorling disagrees. She says setting a dosing threshold could mean patients are left in pain.

Bjorling: "We're guessing that many, many providers are just going to view that as a cut off rather than a threshold and just say I'm not going to go above that level. That we may see practices who say: this is the level for the threshold, we don't have the time, funding, ability to go into that, you know, to go over that issue. So we're just going to have a blanket policy where we just don't go over that level."

Franklin says currently between Workers Comp, Medicaid, and the state's Uniform health plan, more than 10,000 people regularly take enough opiates to exceed that dose level. Which leads to a bigger issue: How will doctors gain access to pain specialists?

Dr. Franklin says yes, this is a problem, but it's also is an opportunity for doctors and nurse practitioners to use things like telemedicine to fulfill the required consultation.

Franklin: "There aren't that many pain experts in the community. We do have a capacity problem but the state is working very hard with the University of Washington to improve and increase the capacity."

He says that could include giving some doctors specialty training to function as pain specialists in their locations. But all of this additional care costs money. And there are still questions over whether these new requirements will actually be reimbursed by insurers.

Dr. Cahana says if all the critics are right and there are problems with the new rules, he's confident they will be corrected. But if the rules are successful, he believes this is the starting point for providing better pain care in Washington.

Cahana: "There is very little that one can accomplish if one takes a stance of 'what if.' What if this creates this negative effect? What if this creates that negative effect? You do not get very far. Letting ourselves be part of what we know is poor care has to stop. And the bill roadmaps conditions where, I don't know if it will stop bad care, but it will make it much more difficult to continue and do that."

The rules go into effect in June. Representatives from the medical boards named in the bill have their final workgroup meeting today. A public comment period begins in March.

I'm Patricia Murphy, KUOW News.

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