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Update on Opioid Prescribing

Gail McGaffick, JD

            The following is an update on opioid prescribing. It includes information on anticipated modifications to the Podiatric Medical Board’s (PMB) opioid rules, as well as information concerning legislation impacting opioid prescribing that is being considered by the 2019 Legislature.

            Podiatric Medical Board. Opioid prescribing rules for DPMs were effective on November 1, 2018. The rules are now found online with all the WACs governing podiatry. The opioid prescribing WACs are 246-922-660 through 790. A detailed summary of the opioid rules is available on WSPMA’s web site.

            At the time the PMB rules were being considered, the PMB required a check of the prescription monitoring program (PMP) for a second refill for an acute pain prescription, unless the DPM was working in a practice setting that integrated their EHR with the PMP. In that case, checking the PMP for every opioid prescription for acute pain is required (WAC 246-922-790). The PMB decision was based on a recommendation of the Opioid Task Force.

            Now that opioid prescribing rules for the various professions have been adopted, it’s become clear that the podiatry rules are an “outlier.” Other professions require checking the PMP for every opioid prescription or at least at the time of the first refill for acute pain. As a result, the PMB has made the decision to move forward and match the MD’s rules by requiring checking the PMB for the first refill for acute pain. WSPMA expects this change to be effective sometime in 2019.

            Another change that we expect the PMB will consider is requiring DPMs to document if a patient does not want to receive an opioid for any reason. There are anecdotal stories of some patients having been given an opioid prescription, when they did not want one due to previous issues with opioids, or perhaps fear of taking opioids. Bottom line, WSPMA expects that DPMs as well as other opioid prescribers will be asked to have that conversation if legislation including that requirement passes.

            Legislation impacting opioid prescribing. You would have thought that with all the focus on opioid prescribing, that there would be a pause before more legislation was considered. However, the Governor had other ideas. While much of the Governor’s request legislation (SB 5380) is very important to assure that Washingtonians have appropriate treatment for substance use disorder, WSPMA has concerns about Section 21 of the legislation.

Section 21 focuses on driving more integration of electronic health records (EHRs) with the PMP. This push is happening because the opioid rules require more frequent checks of the PMP if a prescriber works in a practice setting that integrates the EHR with the PMP. In other words, our rules are being used against us.

Section 21 contains a study of how to improve integration options, as well as explore federal and state funding. Oregon recently used federal and states funds to create a system for all providers to easily connect their EHRs with the PMP. There is no reason that Washington can’t do the same. WSPMA supports this study.

Unfortunately, Section 21 also includes a requirement that by July 1, 2020 groups of more than 10 providers must integrate their EHRs with the PMP. While integration of EHRs into the PMP is a worthy goal, the challenge is how to do it in a way that avoids being punitive to providers. What works for virtually all other states that mandate PMP checks does not work in Washington State. We have a unique system based on our OneHealthPort Health Information Exchange. As a result, while integration is occurring in large health care delivery systems because they can absorb the cost of creating the “one off” type of interface needed for Washington State, smaller providers have lagged behind because of concerns over cost.

Another portion of Section 21 places restrictions on EHR vendors who have fully integrated with the PMP. These restrictions include limits on fees they can charge. While well intended, there are questions as to whether this subsection is legally enforceable. Of additional concern is that EHR vendors may chose to leave the state rather than adhere to these limits. If that happens, providers will have to find new EHR vendors at considerable expense. WSPMA opposes inclusion of this subsection.

WSPMA is working with WSMA to support an amendment that would keep the study, but delete the other provisions of Section 21. WSPMA believes that there should not be any requirement to integrate an EHR with the PMP because of cost considerations. Requiring that the PMP be checked is one thing; requiring how it is checked is something else and WSPMA cannot support it.

Comments or questions concerning this article may be directed to [email protected].