State raises bar on chronic pain | Guest Column

By Dr. Michael Wingren

Washington State has issued a new set of guidelines for prescribing opioid (narcotic) drugs for non-cancerous chronic pain.

These guidelines went into effect Jan. 1 of this year, and they change many aspects of medical practice around chronic pain management.

This will, in turn, affect how patients receive care for their chronic pain conditions in local clinics and hospitals. This article will attempt to clarify some of the issues involved.

The main impetus for the new state guidelines has been an increase in prescription opioid drug overdoses and deaths in the state over the last 15 years.

Over this time, statistics showed a decrease in abuse and overdose from non-prescription opioids (heroin), but an increase in deaths from abuse of prescription opioids.

Deaths have occurred at nearly one per day in the state, and half of these deaths occur in Medicaid patients, for whom the state pays for the drug of abuse, overuse and death.

This period has coincided with increasing use of long-acting opioids such as oxycontin, to manage non-cancer pain.

Improper use of these medications, for example, chewing or smoking it, has been especially dangerous.

The new guidelines require a series of evaluations of patient characteristics before and during treatment. Before starting treatment with opioids, it is important to assess depression and other mood disorders, prior and concurrent substance abuse disorders, such as alcoholism, and prior treatment successes and side effects for the patient.

Regular clinical assessment of a patient’s improvement in function and pain control is required, as is regular urine toxicology screening for the drug used and others taken concurrently.

The guidelines also require specific action for those patients whose use of opioids exceeds the equivalent of 120 mg of morphine per day.

This means that patients taking more than the following daily doses of common medications will require consultation with pain specialists: 120 mg of MS Contin; 80 mg oxycodone or oxycontin; 120 mg of hydrocodone; or 50 mcg of fentanyl (duragesic) patches.

Though these are reasonably high doses, they are not uncommon, particularly in patients who take more than one medication concurrently for pain control.

The guidelines make an important shift in emphasis, from providing pain relief to improving — function. Use of written agreements or “contracts” with all chronic opioid users is now required.

Patients who overuse the medications beyond their contracted amounts will have to “go without” until their agreed-upon refill date. Patients who try to get additional medications from other doctors and pharmacies in the state will be easily tracked by an online data base. Long-acting pain medications will no longer be prescribed for acute pain, and will not be prescribed by emergency room physicians.

The goal of the new guidelines is to rationalize opioid use towards improving function and pain control while limiting overdose-related deaths.  Both the Inter Island Medical Center and San Juan Health Care Associates have adopted the new state guidelines.

Check with your primary care provider if you have more questions.


— Dr. Michael Wingren is a physician at Inter Island Medical Center.