WSR 25-05-091
PERMANENT RULES
DEPARTMENT OF HEALTH
(Washington Medical Commission)
[Filed February 18, 2025, 3:01 p.m., effective March 21, 2025]
Effective Date of Rule: Thirty-one days after filing.
Purpose: General provisions for opioid prescribing and tapering rules for allopathic physicians and physician assistants. The Washington medical commission (commission) has adopted amendments to the commission's opioid prescribing rules to exclude patients with sickle cell disease, to clarify tapering considerations, and to clarify the use of biological specimen testing. The rules amend WAC 246-918-801 Exclusions, 246-918-870 Periodic review—Chronic pain, 246-918-900 Tapering considerations—Chronic pain for physician assistants, 246-919-851 Exclusions, 246-919-920 Periodic review—Chronic pain, and 246-919-950 Tapering considerations—Chronic pain for allopathic physicians.
Citation of Rules Affected by this Order: Amending WAC 246-918-801, 246-918-870, 246-918-900, 246-919-851, 246-919-920, and 246-919-950.
Adopted under notice filed as WSR 24-18-091 on August 30, 2024.
A final cost-benefit analysis is available by contacting Amelia Boyd, P.O. Box 47866, phone 360-918-6336, TTY 711, email medical.rules@wmc.wa.gov, website wmc.wa.gov.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 6, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 6, Repealed 0.
Date Adopted: October 11, 2024.
Kyle S. Karinen
Executive Director
Washington Medical Commission
OTS-5085.2
AMENDATORY SECTION(Amending WSR 22-22-039, filed 10/25/22, effective 11/25/22)
WAC 246-918-801Exclusions.
WAC 246-918-800 through 246-918-935 do not apply to:
(1) The treatment of patients with cancer-related pain;
(2) The treatment of patients with sickle cell disease;
(3) The provision of palliative, hospice, or other end-of-life care;
(((3)))(4) The provision of procedural medications;
(((4)))(5) The treatment of patients who have been admitted to any of the following facilities for more than 24 hours:
(a) Acute care hospitals licensed under chapter
70.41 RCW;
(b) Psychiatric hospitals licensed under chapter
71.12 RCW;
(c) Nursing homes licensed under chapter
18.51 RCW and nursing facilities as defined in WAC 388-97-0001;
(d) Long-term acute care hospitals as defined in RCW
74.60.010; or
(e) Residential treatment facilities as defined in RCW
71.12.455; or
(((5)))(6) The treatment of patients in residential habilitation centers as defined in WAC 388-825-089 when the patient has been transferred directly from a facility listed in subsection (((4)))(5) of this section.
AMENDATORY SECTION(Amending WSR 18-23-061, filed 11/16/18, effective 1/1/19)
WAC 246-918-870Periodic review—Chronic pain.
(1) The physician assistant shall periodically review the course of treatment for chronic pain. The frequency of visits, biological testing, and PMP queries in accordance with the provisions of WAC 246-918-935, must be determined based on the patient's risk category:
(a) For a high-risk patient, at least quarterly;
(b) For a moderate-risk patient, at least semiannually;
(c) For a low-risk patient, at least annually;
(d) Immediately upon indication of concerning aberrant behavior; and
(e) More frequently at the physician assistant's discretion.
(2) During the periodic review, the physician assistant shall determine:
(a) The patient's compliance with any medication treatment plan;
(b) If pain, function, and quality of life have improved, diminished, or are maintained; and
(c) If continuation or modification of medications for pain management treatment is necessary based on the physician assistant's evaluation of progress towards or maintenance of treatment objectives and compliance with the treatment plan.
(3) Periodic patient evaluations must also include:
(a) History and physical examination related to the pain;
(b) Use of validated tools or patient report from reliable patients to document either maintenance or change in function and pain control; and
(c) Review of the Washington state PMP at a frequency determined by the patient's risk category in accordance with the provisions of WAC 246-918-935 and subsection (1) of this section.
(4) If the patient violates the terms of the agreement, the violation and the physician assistant's response to the violation will be documented, as well as the rationale for changes in the treatment plan.
(5) Biological specimen testing should not be used in a punitive manner but should be used in the context of other clinical information to inform and improve patient care. Physician assistants should not dismiss patients from care on the basis of a biological specimen test result alone.
AMENDATORY SECTION(Amending WSR 18-23-061, filed 11/16/18, effective 1/1/19)
WAC 246-918-900Tapering considerations—Chronic pain.
Not all chronic pain patients will need their opioid prescriptions tapered. Relying on medical decision making and patient-centered treatment, the physician assistant shall consider tapering or referral for a substance use disorder evaluation when:
(1) The patient requests;
(2) The patient experiences a deterioration in function or pain;
(3) The patient is noncompliant with the written agreement;
(4) Other treatment modalities are indicated;
(5) There is evidence of misuse, abuse, substance use disorder, or diversion;
(6) The patient experiences a severe adverse event or overdose;
(7) There is unauthorized escalation of doses; or
(8) The patient is receiving an escalation in opioid dosage with no improvement in their pain or function.
OTS-5086.2
AMENDATORY SECTION(Amending WSR 22-22-039, filed 10/25/22, effective 11/25/22)
WAC 246-919-851Exclusions.
WAC 246-919-850 through 246-919-985 do not apply to:
(1) The treatment of patients with cancer-related pain;
(2) The treatment of patients with sickle cell disease;
(3) The provision of palliative, hospice, or other end-of-life care;
(((3)))(4) The provision of procedural medications;
(((4)))(5) The treatment of patients who have been admitted to any of the following facilities for more than 24 hours:
(a) Acute care hospitals licensed under chapter
70.41 RCW;
(b) Psychiatric hospitals licensed under chapter
71.12 RCW;
(c) Nursing homes licensed under chapter
18.51 RCW and nursing facilities as defined in WAC 388-97-0001;
(d) Long-term acute care hospitals as defined in RCW
74.60.010; or
(e) Residential treatment facilities as defined in RCW
71.12.455; or
(((5)))(6) The treatment of patients in residential habilitation centers as defined in WAC 388-825-089 when the patient has been transferred directly from a facility listed in subsection (((4)))(5) of this section.
AMENDATORY SECTION(Amending WSR 18-23-061, filed 11/16/18, effective 1/1/19)
WAC 246-919-920Periodic review—Chronic pain.
(1) The physician shall periodically review the course of treatment for chronic pain. The frequency of visits, biological testing, and PMP queries in accordance with the provisions of WAC 246-919-985, must be determined based on the patient's risk category:
(a) For a high-risk patient, at least quarterly;
(b) For a moderate-risk patient, at least semiannually;
(c) For a low-risk patient, at least annually;
(d) Immediately upon indication of concerning aberrant behavior; and
(e) More frequently at the physician's discretion.
(2) During the periodic review, the physician shall determine:
(a) The patient's compliance with any medication treatment plan;
(b) If pain, function, and quality of life have improved, diminished, or are maintained; and
(c) If continuation or modification of medications for pain management treatment is necessary based on the physician's evaluation of progress towards or maintenance of treatment objectives and compliance with the treatment plan.
(3) Periodic patient evaluations must also include:
(a) History and physical examination related to the pain;
(b) Use of validated tools or patient report from reliable patients to document either maintenance or change in function and pain control; and
(c) Review of the Washington state PMP at a frequency determined by the patient's risk category in accordance with the provisions of WAC 246-919-985 and subsection (1) of this section.
(4) If the patient violates the terms of the agreement, the violation and the physician's response to the violation will be documented, as well as the rationale for changes in the treatment plan.
(5) Biological specimen testing should not be used in a punitive manner but should be used in the context of other clinical information to inform and improve patient care. Physicians should not dismiss patients from care on the basis of a biological specimen test result alone.
AMENDATORY SECTION(Amending WSR 18-23-061, filed 11/16/18, effective 1/1/19)
WAC 246-919-950Tapering considerations—Chronic pain.
Not all chronic pain patients will need their opioid prescriptions tapered. Relying on medical decision making and patient-centered treatment, the physician shall consider tapering or referral for a substance use disorder evaluation when:
(1) The patient requests;
(2) The patient experiences a deterioration in function or pain;
(3) The patient is noncompliant with the written agreement;
(4) Other treatment modalities are indicated;
(5) There is evidence of misuse, abuse, substance use disorder, or diversion;
(6) The patient experiences a severe adverse event or overdose;
(7) There is unauthorized escalation of doses; or
(8) The patient is receiving an escalation in opioid dosage with no improvement in their pain or function.