Implementing HB 2976

Steps for clinics to take to prepare to implement the law

June 7, 2011

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Disclosures

• Mary Catlin has no financial disclosures that would constitute a conflict of interest

• There will be no unannounced discussion of off label use of FDA approved drugs or devices

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Objective of the legislation is to reduce suffering and to save lives

• Review what the legislation asks of you• Propose steps your facility can take to

implement the law

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ESHB 2876, rules CR-103P

• http://www.doh.wa.gov/hsqa/Professions/PainManagement/meetings.htm - site to access rules from all five boards of health

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Medical Preamble: “don’t worry be happy”

– “These rules..are not inflexible rules or rigid practice requirements and are not intended…to establish a legal standard of care outside of the context of the medial quality assurance jurisdiction.” “ …A reasonable course of action”

– A practitioner who differs from the rules should document justifications

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Implementing the Rules implies

• Continuing Education• Determining if your practitioners or site are

pain management specialists/clinic • A system for identifying and tracking patients• Forms and tools • Documentation template• A way to seek consultations

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Three levels of continuing education recommendations for

• Prescribers of long acting opioids• Providers exempt from consultation• Persons serving as pain management

consultants

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Continuing Education for Prescribers Note: “should”

WHO WHAT WHEN

PhysiciansWAC 248-919-858

4 hours CE on long acting opioids or methadone

Once in a lifetime

Osteopaths 4 hours CE on long acting opioids or methadone

Once in a lifetime

Nurse Practitioners 4 hours CE on long acting opioids or methadone

Once in a lifetime

Physician AssistantsWAC 248-918-808

4 hours CE on long acting opioids or methadone

Once in a lifetime

Dentists 4 hours CE on long acting opioids or methadone

Once in a lifetime

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Continuing Education to be Exempt from Consultation (Accredited CE)

WHO WHAT WHEN

PhysiciansWAC 248-919-858

12 hours CE with 2 hours on long acting opioids or methadone (Category 1)

Within 2 years

Osteopaths 12 hours CE with 2 hours on long acting opioids or methadone

Within 3 years

Nurse Practitioners 12 hours CE with 2 hours on long acting opioids or methadone

Within 2 years

Physician AssistantsWAC 248-918-812

12 hours CE with 2 hours on long acting opioids or methadone and the sponsoring MD has CE

Within 2 years

Dentists 12 hours CE 2 in opioids to include methadone

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Continuing Education for Pain Management Specialists

WHO WHAT WHEN

Physicians 18 hours of CE in pain management

Within last 2 years

Nurse Practitioners 18 hours of CE in pain management

Within last 2 years

Osteopaths 18 hours of CE in pain management

Within last 3 years

Physician Assistants No definition as a specialistBut sponsoring MD can be

NA

Podiatrist 18 hours of CE in pain management

With in last 2 years

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Examples of opportunities for education

• PCSS-B training on buprenorphine. http://www.pcssb.org/ (Physicians Clinical Support System). SAMSHA funded

• American Academy of Pain Medicinehttp://www.painmed.org/CME/Calendar_MeetingsEvents.aspx (meetings

from multiple org for multiple professions)• American Academy of Family Practice Self study learning link serieshttp://www.aafp.org/online/en/home/cme/selfstudy/learninglink/pain1.html#Parsys66612• MQAC is preparing videos, webinars, fliers and extensive educational

material that will be available soon

• Project ECHO Telemedicine Clinics with UW specialists Contact Kent Unruh for more information ktunruh@uw.edu

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Project ECHO for Chronic Pain and Addiction: Discussion with UW Specialists and

Community Providers and free CME

Other requirements for specialists beyond CE refer to the rules

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• Board certified, eligible, sub-specialty, certificate OR

• Credentialed AND • Work in multi-disciplinary pain clinic or academic

research facility AND• Three years of experience AND • 30% of patients chronic pain• AND or OR varies by profession; PA not

specialists but NP can be

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Forms to have on hand

• Pain agreement – include your fax/phone as last page so ED, and recipients can inform you easily

• Release of information meets CRF 42 Part 2 plus HIPPA (examples on Project Roam website)

• Pain guidelines or clinical pathway (AMDG)• List of EDs, urgent care facilities and pharmacies,

acceptable pain specialists • Morphine equivalent dose calculator

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AMDG Guidelines

Include tools and morphine equivalent dose calculator

Computer will need excel software installed.

www.agencymeddirectors.wa.gov/

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MED dose converter

AMDG on-line toolwww.agencymeddirectors.wa.gov

– Lingua franca for Rx history:• “Current MED is …

Opioids used are: ...”

- Modify EMR to include this

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Forms to have on-hand cont.

• Taper protocols or resources– Opioids – Benzodiazepines

• Patient education sheets-Informed consent materials-How to safe guard medications-Photo ID needed to pick up medications-Copy of patient agreement

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Forms: Review visit template• “Review visit” note contents from the WAC

– Change in pain relief, physical and psychosocial function, quality of life using standardized tools (AMDG)

– Compliance with prescribed meds and the MED– (Practical Note: Urine tests)– Opioid Risk Tool and aberrant behaviors – Escalating doses– Decision to continue, taper, stop, or change meds– Diagnosis – Plan– Efforts to seek consultation or other therapies

Review visit – automatic scheduler

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http://www.cpain.com/20UW Project ROAM

Project ECHO Intake form with required elements

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Pain Agreement

• Rules say use for high risk – simpler to use for all or define high risk? – One prescriber, one pharmacy– Agree to urine/serum testing– Take medications as prescribed, safe guard them– No early refills– Agree not to use alcohol or “other medically

unauthorized substance”– Violations may result in tapering, or dc of medication

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Authorizations to share information

• Agree to share AGREEMENT with ED, urgent care and pharmacies

• Agree that other practitioners should report violations

• Physician may notify authorities of illegal acts

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Sharing information

• Pharmacy Monitoring Program up by January. • Emergency Room EDIE spreading

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If you don’t have EDIE

• Need to have a way of easily informing providers that their patient has been seeking pain medication.

• Prescription Monitoring Program will help

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Consultation

• Suggested: pediatric visits, hx substance abuse, psych co-morbidities

• Mandatory consult when patients are on greater than 120 MED doses

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Exemption from Consultation

• Patient is being tapered• Acute pain in a person on chronic opioid therapy• Pain and function are stable, dose not escalating• You tried! Document reasonable attempt to get a

consultation and why they are on 120 MED or more.

• But you can call into Project ECHO every Wed and alternate Fridays for a free consult.

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Project Echo contact Kent Unruh ktunruh@uw.edu or mccatlin@uw.edu

• PI Dr. John Scott• Specialists include Dr. Joe Merrill, Addiction

Medicine Specialist, Pain Specialist Dr. David Tauben, Psychiatrists Dr. Christina Flores, Dr. Mark Sullivan and others

• Addiction focus every other Friday and pain central focus every Wednesday.

• Grant funded research project. Try it it’s free!

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