1. Implementing HB 2976 Steps for clinics to take to prepare to implement the law June 7, 2011 UW Project ROAM1

2. 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 UW Project ROAM2

3. 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 UW Project ROAM3

4. ESHB 2876, rules CR-103P http://www.doh.wa.gov/hsqa/Professions/Pai nManagement/meetings.htm - site to access rules from all five boards of health http://www.doh.wa.gov/hsqa/Professions/Pai nManagement/meetings.htm UW Project ROAM4

5. 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 UW Project ROAM5

6. 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 UW Project ROAM6

7. Three levels of continuing education recommendations for Prescribers of long acting opioids Providers exempt from consultation Persons serving as pain management consultants UW Project ROAM7

8. Continuing Education for Prescribers Note: “should” WHOWHATWHEN Physicians WAC 248-919-858 4 hours CE on long acting opioids or methadone Once in a lifetime Osteopaths4 hours CE on long acting opioids or methadone Once in a lifetime Nurse Practitioners4 hours CE on long acting opioids or methadone Once in a lifetime Physician Assistants WAC 248-918-808 4 hours CE on long acting opioids or methadone Once in a lifetime Dentists4 hours CE on long acting opioids or methadone Once in a lifetime UW Project ROAM8

9. Continuing Education to be Exempt from Consultation (Accredited CE) WHOWHATWHEN Physicians WAC 248-919-858 12 hours CE with 2 hours on long acting opioids or methadone (Category 1) Within 2 years Osteopaths12 hours CE with 2 hours on long acting opioids or methadone Within 3 years Nurse Practitioners12 hours CE with 2 hours on long acting opioids or methadone Within 2 years Physician Assistants WAC 248-918-812 12 hours CE with 2 hours on long acting opioids or methadone and the sponsoring MD has CE Within 2 years Dentists12 hours CE 2 in opioids to include methadone Within 2 years 9

10. Continuing Education for Pain Management Specialists WHOWHATWHEN Physicians18 hours of CE in pain management Within last 2 years Nurse Practitioners18 hours of CE in pain management Within last 2 years Osteopaths18 hours of CE in pain management Within last 3 years Physician AssistantsNo definition as a specialist But sponsoring MD can be NA Podiatrist18 hours of CE in pain management With in last 2 years UW Project ROAM10

11. Examples of opportunities for education PCSS-B training on buprenorphine. http://www.pcssb.org/ (Physicians Clinical Support System). SAMSHA fundedhttp://www.pcssb.org/ American Academy of Pain Medicine http://www.painmed.org/CME/Calendar_MeetingsEvents.aspxhttp://www.painmed.org/CME/Calendar_MeetingsEvents.aspx (meetings from multiple org for multiple professions) American Academy of Family Practice Self study learning link series http://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 UW Project ROAM11

12. Project ECHO for Chronic Pain and Addiction: Discussion with UW Specialists and Community Providers and free CME

13. Other requirements for specialists beyond CE refer to the rules UW Project ROAM13 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

14. 14UW Project ROAM

15. 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 UW Project ROAM15

16. AMDG Guidelines Include tools and morphine equivalent dose calculator Computer will need excel software installed. www.agencymeddirectors.wa.gov/ 16UW Project ROAM

17. MED dose converter AMDG on-line tool www.agencymeddirectors.wa.gov – Lingua franca for Rx history: “Current MED is … Opioids used are:...” - Modify EMR to include this 17UW Project ROAM

18. 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 UW Project ROAM18

19. 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 UW Project ROAM19

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

21. Project ECHO Intake form with required elements 21UW Project ROAM

22. 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 UW Project ROAM22

23. 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 UW Project ROAM23

24. Sharing information Pharmacy Monitoring Program up by January. Emergency Room EDIE spreading UW Project ROAM24

25. 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 UW Project ROAM25

26. Consultation Suggested: pediatric visits, hx substance abuse, psych co-morbidities Mandatory consult when patients are on greater than 120 MED doses UW Project ROAM26

27. 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. UW Project ROAM27

28. Project Echo contact Kent Unruh ktunruh@uw.edu or mccatlin@uw.edu ktunruh@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! UW Project ROAM28