Prescribing prognosis mostly positive

While many health experts hail state's new rules on pain medication, one local legislator says changes are needed

By Marissa Harshman, Columbian health reporter

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photoDr. Mimi Pattison

The state's new, tougher stance on opioid prescribing, although initially unpopular, now has many doctors and health officials hailing a better and safer system. The concerns that pain patients would be left in a world of hurt went unrealized, health officials say.

But one local legislator claims the state was guilty of overkill when it adopted the new pain-management rules. And Rep. Paul Harris, R-Vancouver, plans to take his skepticism, and a few ideas of his own, to Olympia this year.

Standing by the rules

In 2010, Washington lawmakers approved a bill, sponsored by state Rep. Jim Moeller, D-Vancouver, calling for new rules concerning the management of chronic pain not caused by cancer. The purpose of the legislation was to improve opioid prescribing and rein in prescription drug abuse and misuse.

The rules require for each patient an evaluation and complete history of pain treatment, a written treatment plan and a written agreement for treatment. The rules also require prescribers of long-acting opioids or methadone to have completed at least four hours of specialized training.

In addition, the rules require, for the first time, consultations with pain specialists for patients who reach an established threshold (120 mg of a morphine equivalent per day) of pain medication.

The rules went into effect for physicians and physician assistants on Jan. 2, 2012, and for all other fields on July 1, 2011.

One of the biggest fears expressed by providers, patients and pain advocates revolved around the consultation requirement. Many worried the state's pain specialists would be overwhelmed and unable to handle the larger caseload created by the rules.

But the rules allow for consultation exemptions for providers who complete extra education or cannot get their patients an appointment with specialists. That's why the specialist consultation fears went unrealized, said James McLaughlin, attorney for the state's Medical Quality Assurance Commission.

"I think that was sort of a bigger issue early on, a panic about a bottleneck of pain specialists," McLaughlin said. "Once people learned the rules, they learned the panic was overstated."

The same has proven true for other concerns, said Dr. Mimi Pattison, chairwoman of the medical commission and a member of the state group that crafted the prescribing rules.

"In general, I would say it has been a 180-degree turn in attitude from a year ago," Pattison said.

A year ago, physicians were afraid of the rules, she said. Many hadn't read the rules or didn't understand them. Instead, they reacted to hearsay, Pattison said.

"Once physicians have been educated, probably the most common response we've gotten … is thank you," she said.

In the last year, the commission has not received a single complaint about physicians not prescribing enough opioids, Pattison said. The commission has received inquiries about the rules from patients whose physicians have reduced their pain medications but no formal complaints have been filed, she said.

"We are pleased with where we are today," Pattison said.

As a result, the state has no plans, at this point, to modify the rules, she said.

Rep. Moeller won't be proposing any changes to the rules either.

"Most of the providers have been thankful they have a maximum they can prescribe (without a specialist consultation)," Moeller said.

Moeller's office has received calls from patients whose providers have stopped treating pain patients. Those providers direct angry patients to Moeller, indicating the rules he introduced are behind the decision to drop patients, Moeller said. In reality, the providers are using it as an excuse to stop seeing difficult patients, he said.

Patients have also inquired about who's responsible for paying the pain specialist consultation bill, Moeller said.

"If that's an issue of insurance companies not paying for consultations, then we need to address that," he said. "But I haven't heard that, generally."

Unintended consequences

Camas resident Paul Mulwitz is among those who received an unexpected bill as a result of the rules.

Mulwitz has had a prescription for narcotic pain medication for about 10 years. In August, for the first time, Mulwitz's provider required a compliance test to make sure he was following his treatment plan, he said.

Mulwitz's insurance wouldn't cover the entire $500 bill for the visit, but he was able to negotiate the cost. He ultimately paid about $320 for the visit.

The compliance test, Mulwitz said, was expensive, unnecessary and assumes a person is guilty until proven innocent. But his hands were tied. If he didn't take the test, his provider wouldn't write him another prescription.

"It's picking on people that are already at a big disadvantage," he said.

Rep. Harris has heard several similar stories.

Harris estimates 10 people have contacted his office about the pain rules. Many of those people are chronic pain patients, like Mulwitz, who are suddenly required to have a urinalysis once, or in some cases twice, a year. Those patients are already saddled with expensive medical bills. Adding the cost of the test is just another burden, Harris said.

The rules don't address who is responsible for the cost of a consultation, and the state boards and commissions don't have the authority to require insurance companies foot the bill, according to the state health department.

Harris has also heard of practitioners deciding not to treat pain patients, leaving those patients to find another doctor and endure another expense.

"It's actually making some of the good people, the good players who aren't abusing, get caught up in the system, and it's costing all of us," Harris said.

The legislation was well-intended, Harris said, but the unintended consequences have revealed the state is overregulating.

Harris, who is a member of the House Health Care and Wellness Committee, wants to take a closer look at the rules. He hopes a meeting with medical teams and providers will reveal how well the rules are working and what the impact has been.

Harris isn't planning any legislation just yet, but he does have a couple ideas for possible fixes to the rules. Those ideas include eliminating annual urinalysis tests, raising the threshold for consultations and making it less cumbersome for general practitioners to treat pain patients.

"We're making access to care, once again, more difficult," he said.

Providers see improvements

But some local providers who treat pain patients believe the new rules have helped, not hindered, chronic pain care.

Dr. Ben Platt, a pain specialist for PeaceHealth Southwest Interventional Pain Clinic, said the rules are helping to balance the pendulum between overprescribing and underprescribing.

"Like most things in life, it has been a bell-shaped curve," he said. "The majority are, for the most part, interpreting (the rules) mostly correctly. A smaller percentage are interpreting them perfectly, and a similar smaller percentage are using them as an attempt to not take care of patients on pain medications."

"Overall, I would say they have improved, and not hindered, pain care," he added.

As a pain specialist, Platt is busier than ever, but he doesn't believe the system is completely overwhelmed. After the initial rush, requests for consultations have decreased to a manageable flow, he said.

The required consultations have created learning opportunities for patients and providers that wouldn't likely exist without the rules, Platt said. That, he said, has improved the quality of pain care being provided.

Some providers and health care groups have used the rules as a launching point to create their own rules and protocols for treating pain patients.

The PeaceHealth Medical Group, for example, has created a systemwide protocol its providers follow when treating chronic pain patients, in addition to following the state rules, said Dr. Jon Dykstra, who works in family practice for the medical group in Vancouver.

Most patients understand the need for the new rules but some have complained, he said. For example, the new guidelines don't allow providers to prescribe narcotics on a patient's first visit. That rule, in particular, has frustrated patients who don't want to make multiple appointments or who are low on pain medication, Dykstra said.

Urine drug tests are also standard procedure now. Before, physicians administered the tests as a reaction to red flags. Now, all patients can expect to be tested at least once a year and up to four times a year, Dykstra said.

Before implementing the urinalysis requirements, PeaceHealth conducted a drug screening pilot project where providers asked numerous patients to come in for drug tests. The project revealed 25 percent of patients had abnormalities, which could include unexpected drugs or too much of a drug in one' s system, Dykstra said.

"That's a pretty high percentage from my standpoint," he said. "That brought it home for me that we need to be doing this."

The only complaint Dykstra has heard from his colleagues is the time commitment. Following the system procedures and state rules take extra time, which can be a strain on busy providers, he said.

"But we've decided as a group that this is important," Dykstra said.

"We need to be doing this," he added. "This all revolves around patient safety."

Marissa Harshman: 360-735-4546; http://twitter.com/col_health;http://facebook.com/reporterharshman;marissa.harshman@columbian.com.